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Witness Testimony of Paul Bockelman, Director, Veterans Integrated Service Network (VISN) 11, Veterans Health Administration, U.S. Department of Veterans Affairs

WRITTEN STATEMENT OF
PAUL BOCKELMAN
VISN 11 DIRECTORVETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
SUBCOMMITTEE ON HEALTH
COMMITTEE ON VETERANS’ AFFAIRS
U.S. HOUSE OF REPRESENTATIVES

AUGUST 27, 2014

    Good morning, Chairman Benishek, Ranking Member Brownley  Thank you for the opportunity to discuss rural health care and health care specifically for American Indian Veterans within the Veterans Integrated Service Network (VISN) 11.  I am accompanied today by Ms. Peggy Kearns, Director of the Aleda E. Lutz VA Medical Center (VAMC) and Mr. James Rice, Director of the Oscar G. Johnson VAMC.  

VISN 11 and Aleda E. Lutz VA Medical Center (VAMC) Overview
The employees of VISN 11 proudly provide patient-centered care to the approximately 386,000 Veterans living in portions of Michigan, Ohio, Indiana, and Illinois.  VISN 11 consists of 30 Community-Based Outpatient Clinics (CBOC) and
7 health care system main campuses located in:  Ann Arbor, Battle Creek, Detroit, and Saginaw in Michigan; Indianapolis and Ft. Wayne in Indiana; and Danville in Illinois.
 With a budget exceeding $2.1 billion, we are in a position to provide our Nation’s heroes with high quality care through traditional and innovative methods.  VISN 11 also has a collaborative relationship with the Vet Centers located in Macomb County, Dearborn, Detroit, Escanaba, Grand Rapids, Saginaw, and Traverse City.
The Aleda E. Lutz VAMC, located in Saginaw, Michigan, is accredited by the Joint Commission and consists of the Medical Center with a Community Living Center (CLC) and Annex in Saginaw and CBOCs in Alpena, Bad Axe, Cadillac, Cheboygan County (Mackinaw City), Clare, Gaylord, Grayling, Oscoda, and Traverse City.  These facilities provide care to Veterans in the 35 counties of Central and Northern Michigan’s Lower Peninsula.  On April 21, 2014, the Aleda E. Lutz VAMC was awarded Planetree Bronze Recognition for Meaningful Progress in Patient-Centered Care.  The Aleda E. Lutz VAMC is the first health care organization in Michigan to be awarded Bronze-level recognition since Planetree first introduced the recognition level in 2012.
The Aleda E. Lutz VAMC provides primary and specialty medical services, ambulatory surgical services, mental health services, inpatient medical care, rehabilitation, dentistry, audiology, optometry, blind rehabilitation, pain management, geriatrics, and extended care.
Expanded mental health programs include:  Operation Enduring Freedom/
Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) case outreach, Mental Health Intensive Case Management (MHICM), Posttraumatic Stress Disorder (PTSD) Clinical Care, Home-Based Primary Care (HBPC) psychology services, Compensated Work Therapy (CWT), recovery-based programs, suicide prevention, outpatient substance abuse programs, evidenced-based therapies, VA Caregiver Support, and Homeless Veterans Program, including Veterans Justice Outreach.  

Focus on Access
No Veteran should have to wait for the care and services that they deserve.  We remain committed to ensuring Veterans have access to the highest quality care that they have earned through their service to this country.  Patients at the Aleda E. Lutz VAMC can consistently access primary care, specialty, and mental health services within thirty days.  Access is monitored daily to assure availability.  
The Aleda E. Lutz VAMC has implemented the Accelerating Care Initiative along several different tracks.  Approaches to assure timely access include:  
1.    Increasing the use of Non-VA care;
2.    Use of Saturday clinics;
3.    Hiring a substitute provider (known as a locum tenens provider) for Primary Care, and;
4.    Ongoing recruitment of staff.  
There have been reductions in the number of patients waiting both on the Electronic Wait List (EWL) and the New Enrollee Appointment Request (NEAR) list. From May 15, 2014, to August 1, 2014, the Aleda E. Lutz VAMC EWL dropped from 61 to 34.  From June 1, 2014 to August 1, 2014 its NEAR list dropped from 110 to 9.  .  
As part of our commitment to transparency, VA is posting regular data updates showing progress on our efforts to accelerate access to quality health care for Veterans who have been waiting for appointments.  These access data updates are posted at the middle and end of each month at the following link:  http://www.va.gov/health/access-audit.asp.

VA Rural Health Care Program – State of Michigan
    There are approximately 660,800 Veterans in the state of Michigan, of which an estimated 31 percent or 207,200 live in rural areas.  Approximately 227,400 Veterans in Michigan are enrolled in VA, and 43 percent or 97,300 enrolled Veterans live in rural areas.  An estimated 34 percent of all Veterans living in Michigan are enrolled in the VA health care system.
In addition to funding allocated to VISN 11 through the Veterans Equitable Resource Allocation (VERA) system for Veterans’ healthcare, in Fiscal Year (FY) 2014, VISN 11 received $8 million from the Veterans Health Administration’s (VHA) Office of Rural Health to support 25 projects and programs to increase access to care for rural Veterans.  The programs specific to Michigan include our Mobile Prosthetics Van, which brings prosthetic services typically found only at the main campus to the CBOCs; clinical training opportunities for providers in rural locations; telehealth; and HBPC which currently serves around 300 Veterans.  Since the telehealth and HBPC services are co-located within the community Veterans Service Office, such as the American Legion building, in Ludington, MI, we are able to facilitate Veterans’ needs by working closely on Veterans Benefits Administration and claims issues and providing community-based services.  This program is made available to Veterans in the Mason, Lake, Newaygo, Mecosta, and Oceana counties by the Battle Creek VAMC Northern Rural Expansion Team.
We continue to look for opportunities to expand our care via telehealth technology.  VHA is in the early stages of developing a collaborative effort with community providers to be able to exchange health information.  We now have the capability to provide Clinical Video Telehealth (CVT) in the home, which will improve access to care for rural Veterans and mitigate the need for travel to a VHA site of care.  We are also establishing additional Mental Health services via telehealth to Veterans at the Patriot House in Gaylord in 2014.  
The Battle Creek VAMC has taken the lead on several Veteran outreach projects in the rural areas of Michigan.  To address low utilization rates, the Battle Creek VAMC signed a Memorandum of Understanding (MOU) with local Veteran Service Organizations, such as Veterans of Foreign War (VFW) and American Veterans (AMVETS), to allow VA to use their space to deliver care to rural Veterans.  Additionally, the facility started delivering care in Veterans’ homes.  The care provided included access to a nurse practitioner, psychologist, social worker, registered nurse, pharmacist, occupational therapist, registered dietitian and a telehealth clinical technician.  The use of home telehealth, as well as utilization of tele-dermatology and tele-retinal services, has been incorporated into this team.  
These services enable rural Veterans to access VA care without long drives to one of the Battle Creek CBOCs.  The psychologist has initiated some mental health groups in addition to utilizing clinical video telehealth to connect Veterans with other providers at the main medical center.  To date, this motivated team of Federal employees has provided VA services and care to over 560 Veterans, with the numbers growing weekly.  

Rural Health Outreach Transportation Program
The Aleda E. Lutz VAMC’s Rural Health Transportation Program is well developed, averaging nearly 1,200 patients per year, over 80 percent of whom reside in rural communities.  Patient satisfaction has increased with this program.  Many of the users of the transportation program may not otherwise get to appointments and are repeat customers.  Veterans requiring transportation assistance have pick-up sites in Gaylord, Grayling, West Branch, and Standish.  Transportation is provided to the Aleda E. Lutz VAMC, as well as the Ann Arbor and Detroit Medical Centers.  

Beaver Island Outreach Project
The Aleda E. Lutz VAMC, the VISN 11 Rural Health Consultant, and the VISN 11 Planner have worked with the Beaver Island Rural Health Clinic to bring VA health care services to Beaver Island Veterans using non-VA Care authorizations.  This partnership enables eligible Veterans to receive primary care, laboratory, and general radiology services from the Beaver Island Rural Health Center instead of traveling to a VA facility.  To be eligible for services, Veterans must be enrolled in the VA Health Care System and meet VA eligibility requirements.  VA and the Beaver Island Rural Health Clinic held a VA Day on June 13, 2014, to provide information for Beaver Island Veterans on VA health care as well as listen for additional opportunities to meet their health care needs.  As a result of the information collected, we will establish a VA telehealth clinic to provide these Veterans access to VA health care.  This service will be established by
October 1, 2014.

Readjustment Counseling Service
VA’s Vet Centers present a unique service environment—a personally engaging setting that goes beyond the medical model—in which Veterans, Servicemembers, and their families receive professional and confidential care in a convenient and safe community location.  Vet Centers are community-based counseling centers, within Readjustment Counseling Service (RCS), that provide a wide range of social and psychological services including professional readjustment counseling to eligible Veterans, Servicemembers, and their families; military sexual trauma counseling; and bereavement counseling for eligible family members who have experienced an
active-duty death.  
The Saginaw and Traverse City Vet Centers, like those throughout the country, also provide community outreach, education, and coordination of services with community agencies to link Veterans and Servicemembers with other VA and non-VA services.  A core value of the Vet Center is to promote access to care by helping those who served and their families overcome barriers that may impede them from using those services.  All Vet Centers have scheduled evening and/or weekend hours to help accommodate the schedules of those seeking services.

VISN 11 Telehealth Clinic Expansion in FY 2013  
In FY 2013, VISN 11’s Telehealth program conducted 109,806 visits using telehealth modalities, reaching 12.4 percent of Veterans in VISN 11 who use the VA system.  The Aleda E. Lutz VAMC led VISN 11 in telehealth performance targets.  In the past 12 months, this VAMC  has achieved a 20 percent increase in virtual visits and 28 percent increase in the number of Veterans using telehealth programs.   
Recognizing the Aleda E. Lutz VAMC is not a tertiary health care site, VISN 11 is developing virtual capabilities to link Veterans with specialty care found in our tertiary facilities in Ann Arbor and Detroit, including care for substance abuse; and also provide pharmacy clinical video health services to a Veteran’s home.  Utilizing telehealth for follow-up care helps eliminate travel and ensures Veterans receive the appropriate follow-up consultation.  The Aleda E. Lutz VAMC is also working with the National Telemental Health Center to provide mental health services for patients with chronic pain – an area of growing demand and concern.
The Battle Creek VAMC expanded their health care reach by placing telehealth equipment at the rural Volunteers of America (VOA) site.  Telehealth equipment was purchased for the VOA site in Lansing to provide telehealth services for homeless Veterans.  Some of the services for homeless Veterans include, telemental health counseling, substance abuse treatment, and case management.  Future services to be provided will be primary care basic visits, diagnostic visits, mental health visits, and mental health case management.  We are in the planning stages for a project that will allow for small, county mental health offices to have telehealth equipment to connect with providers located within the Battle Creek VAMC.
Obesity is a significant problem impacting the health care of many in the United States.  VA has enthusiastically engaged in weight management programs, such as our MOVE!® weight management program.  We have and continue to expand these services by adding TeleMOVE! ® to our CBOCs.  The goal of the TeleMOVE! Program is to assist with weight management in the comfort and convenience of the Veterans home through a home messaging device. Time spent with our registered dietitians assisting and motivating Veterans has proven to be an effective component –of a Veterans weight loss plan.
FY 2014 Expansion Goals
As we learn about additional opportunities or tools related to telehealth we have been aggressive in investigating them for utilization within VA.  We still have opportunities to expand mental health programs in such areas as OEF/OIF/OND case outreach, outpatient substance abuse programs, evidence-based therapies, the VA Caregiver Support Program, telehealth for the homeless Veteran, and the Veterans Justice Outreach.  Aleda E. Lutz VAMC is participating in a VA national tele-spirometry project to provide spirometry testing to patients at the CBOCs.  We know that addressing hearing aid deficiencies is a big need for Veterans.  We have learned there are components of such care that we can provide virtually through tele-audiology.  We will be expanding this program in four additional CBOCs in Michigan.

Homeless Veterans and the Veterans Justice Outreach Programs
Homelessness is not just an urban issue – homeless Veterans are in rural areas too.  We provide direct help daily through our homeless staff and programs such as HUD-VASH wherein HUD provides Housing Choice vouchers and VA provides case management services.  We also recognize that it is important to create and maintain access points within Veterans Affairs Offices and/or local community partners where the homeless congregate.  Our goal is to identify homeless Veterans and introduce them into the continuum of care we have available to serve them.  We continue to combat homelessness proactively by working to identify Veterans who are incarcerated or at risk for incarceration and working with the court systems to intercede where possible.  Working proactively before an incarcerated Veteran is released has been instrumental in avoiding Veterans instantly becoming homeless.  We have Veterans Justice Outreach Coordinators located throughout the state and have strong relationships with seven Veterans Courts in Michigan.  We have experience with utilizing telehealth to link our Veterans and the judges involved with their care and we look forward to expanding this capability where possible.

VISN 11 American Indian/Alaskan Native Veterans Overview
The VA and Indian Health Service (IHS) Memorandum of Understanding was signed in 2010 to increase access and quality of care for American Indian and Alaskan Native Veterans across the Nation.  VISN 11 has done extensive outreach to all
13 tribes in Lower Michigan, particularly with the Little Traverse Bay Bands of Odawa, Grand Traverse Bay of Ottawa and Chippewa Indians, and the Pokagon Band of Potawatomi in Dowagiac, Michigan.  
Over the past 3 years, VHA personnel attended Pow Wows, American Indian health fairs, annual meetings with IHS, and VHA presentations at tribal chair meetings.  
In April 2014, Battle Creek VAMC entered into MOUs with the Pokagon Potawatomi and the Nottawasippi Huron Potawatomi to provide telemental health for tribal Veterans at the Tribal offices via telehealth technology through the Battle Creek VAMC.  The MOUs provide for a part-time VA Tribal Outreach Worker for each tribe location to assist in connecting tribal Veterans to VA’s mental health providers.  This new telemental health project currently has a small number of newly-enrolled, younger American Indian Veterans utilizing their VA benefits for their health care needs.  It is anticipated that 130 Tribal Veterans within the Nottawaseppi Huron and Pokagon Band of the Potawatomi Nation will benefit from this project to bring access to mental health services to them in a location that is easily accessible and acceptable for them.
In addition, the Grand Traverse Bay Band of Ottawa and Chippewa Indians and VA are working on a Reimbursement Agreement, under which VA will reimburse the tribe for direct care services provided by the tribe to eligible American Indian Veterans. Aleda E. Lutz VAMC will be representing VHA at health fairs held during 2014 at the Little Traverse Bay Bands of Odawa Indians and Grand Traverse Bay Band of Ottawa and Chippewa Indians.   In addition, the Aleda E. Lutz VAMC is beginning a new partnership collaboration with Little River Band of Ottawa Indians and will be attending the Veterans’ Warrior Society meeting in August to expand outreach to tribal Veterans.

American Indian Outreach Tribal Veteran Representative (TVR) Training
The Battle Creek VAMC and Aleda E. Lutz VAMC, along with VISN 12’s Oscar G. Johnson VAMC, held the third annual Tribal Veteran Representative (TVR) Training.  VISN 11 also conducted two TVR Trainings in 2013 for tribal members and another was held July 21-24, 2014, in Farwell, Michigan.  
TVR training in Michigan promotes the practice of having an American Indian TVR in Federally recognized tribes throughout Michigan.  The representative assists Veterans in understanding how to access benefits while also allowing VA to develop positive relationships with American Indian tribes in Michigan.  The value in tribal members participating in the training is that many tribal customs are shared during discussions.  This enhances the health care team members’ cultural understanding and appreciation of American Indian Veterans’ contributions to our country.
 
Conclusion
    VHA, VISN 11, the Aleda E. Lutz VAMC, and the Battle Creek VAMC are committed to providing the high-quality care that our Veterans have earned and deserve.  We appreciate the opportunity to appear before you today, and we appreciate the resources Congress provides VA to care for Veterans.   We are prepared to answer questions you may have for us.