STATEMENT OF WM. TED GALEY, MD DIRECTOR, VETERANS INTEGRATED SERVICE NETWORK 20 ON VETERANS CARE IN VISN 20 BEFORE THE COMMITTEE ON VETERANS’ AFFAIRS, SUBCOMMITTEE ON HEALTH BOISE VETERANS AFFAIRS MEDICAL CENTER JUNE 30, 1998
Mr. Chairman and members of the Subcommittee, welcome to the Northwest Network. The Northwest Network (NWNW), VISN 20, covers the states of Alaska, Oregon and Washington, and most of the state of Idaho (Exhibit 1.a.). Its six medical centers, one independent domiciliary, one independent outpatient clinic served approximately 115,000 unique veterans (about 10% of the 1.1 million veterans within our geographic area of responsibility) in FY1997. Included within these facilities are 7 nursing home care units, three homeless domiciliaries, and 15 readjustment counseling centers. Six currently approved, 2 currently proposed and 14 planned Community Based Outpatient Clinics (CBOCs) will significantly improve access to northwest veterans and increase the unique patients served between now and 2002 (Exhibit 2). The Northwest Network has an operating budget of $622M and employs 7300 people. The Network has a research budget of approximately $24M, and is involved in national research programs with the Northwest Health Systems Research & Development program in Seattle, WA, the Environmental Hazards Research Center (Gulf War veteran’s illnesses), the Office of Regeneration Research and the newly awarded Center for Rehabilitative Auditory Research at Portland, OR. Further, research, education and clinical care in Mental Health, Geriatrics and Epidemiology are enhanced by a Mental Illness Research, Education, and Clinic Center (Boise, Portland and Puget Sound Health Care System [PSHCS]), a Geriatric Research, Education and Clinical Center (PSHCS), the Oregon Geriatric and Education Center (Portland) and the Epidemiologic Research and Information Center (PSHCS). In support of our education mission, Network facilities have a total of 292 affiliation arrangements with both regional and national academic institutions. The Network covers approximately 788,500 square miles, 72% of which is the state of Alaska. Most facilities are 150 to 500 miles apart; Anchorage is 2,500 land miles and 1,500 air miles from the nearest VA facility (Exhibit 1 b). The geographic spread, mountainous terrain, and hazardous winter weather conditions offer special challenges for the Network in developing an integrated delivery system.
Mission, Vision and Key Initiatives The mission of the Northwest Network is to share our resources and talents to produce the best possible outcomes for our patients, the best education for future health providers, and to discover new knowledge. Our vision is to be a leader in the community and in the VA, providing integrated, managed and appropriate care for veterans. We will be a national model for VA networks. Our major five-year goal is to become an integrated health service delivery system (IHS) providing customer–focused care. An IHS is a network of organizations that provide or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population served. Key initiatives in support of our major goal are:
Now, I will highlight some of these goals and plans to achieve them and conclude with a discussion of the Veteran’s Equitable Resource Allocation model and it’s effect on the Northwest Network now and in the future. Primary Care Model Our plan will rearrange the delivery of primary care services in an effort to make care more patient centered and customer focused. Additionally, we have designed a system that bestows responsibility upon Primary Care Providers for both the quality of medical care and the cost-effective management of resources. We envision a multidisciplinary team approach to delivering care; one that assures continuity with a primary provider as well as other team members over time and location of care. If the Primary Care Teams are to be effective, a number of system changes must occur. The way we provide urgent care, admit patients to the hospital, and obtain specialty consultation will be re-engineered to ensure that Primary Care providers can in fact coordinate care for their patients. It is the reorganization of our delivery system, improving coordination and eliminating redundancy, that will improve the quality and cost-effectiveness of care, and patient satisfaction. VA owned and operated delivery sites will remain a significant component of our Primary Care Network. To improve access and customer service, however, we will contract with other public and private sector providers, where financially feasible and to the extent allowed by law. The expansion of our Primary Care Network will be planned in a way that controls growth, yet addresses barriers to access. These barriers may be mountain ranges or inner city congestion. The Primary Care Network of the future is likely to be a diverse set of arrangements that create a virtual primary care delivery system, a system that will always deliver value to the veteran. Coordinated Mental Health Services Because significant proportions of our clients have mental health concerns, the design of our mental health delivery system is also paramount. We are well along in implementing changes for a system of Coordinated Mental Health Services. We have implemented a multidisciplinary team approach to mental health care. These teams ensure continuity of services throughout the spectrum, from the ambulatory setting through long-term care. Case management of patients with chronic mental illness is the cornerstone of our model. The system changes cited above will also support the role of the Primary Mental Health Provider. Additionally, we have created teams of both psychiatric and medical providers to care for those patients with significant medical problems complicated by chronic mental illness. Network-wide planning for mental health services will focus on population based resource allocation, shifting care to residential and ambulatory settings, and evaluating a product line management strategy. Northeastern Psychiatric Education Center data suggest that our utilization of acute inpatient services is significantly below the national average. We believe this is, in part, due to the lack of resources in eastern Washington. To correct this, we have recently opened a temporary in-patient psychiatric ward at the Spokane VAMC. We will be building an acute psychiatry ward at the Spokane VAMC with an anticipated opening of April 1999. As a consequence, we anticipate minimal transfer of patients to Boise or the Puget Sound area for acute psychiatric care.
Access to Surgical, Specialty and Ambulatory Care Services A major challenge for the NWNW is providing access to veterans’ health services throughout a relatively sparsely populated large geographic area. With input from stakeholders, attention to population based need, to both VHA and non-VHA resource availability and to maintenance of high value (value = quality + customer satisfaction + economy/efficiency) service availability is being expanded. We are currently implementing plans for core surgical service and core specialty services at all our NWN medical centers. In addition, we are in the process of implementing a multi-year plan for the development of Community Based Outpatient Clinics (CBOCs) (Exhibit 2). Core Surgical Services: In late 1996 a Surgical Advisor Group (SAG) for the NWNW was appointed and found that many patients were travelling long distances for relatively routine surgical consultation and minor procedures. The SAG defined by specialty a set of services that it thought should be provided locally, if at all possible. The list of specialty services that the SAG recommended should be provided locally included: General Surgery* Ophthalmology* Orthopedic Surgery* Urology* Otolaryngology (ENT) Gynecology Hand Surgery The four specialties indicated by asterisks were ones that were designated to be true "core" services that should be provided locally if at all possible. The SAG recommended that all facilities should ideally be able to offer local consultation and ambulatory procedures in the above specialties. These services could be provided by VA FTEE, by contract or fee-basis arrangements, or by sharing agreements depending on volume of need, cost, and/or availability. On the other hand, the SAG recommended those patients requiring hospitalization for procedures in the above specialties ought to be referred to VA facilities with in-patient programs because these procedures could be accommodated with existing FTEE and resources. Importantly, these cases are often complex surgeries, are often carried out on patients with multiple co-morbidities and, thus require programs with the volume experience and the extensive support services found only in the major medical centers. To date, the network has distributed $2.79M to network facilities, including $233K annually recurring and $33K non-recurring funds to Boise, to hire or purchase core services as noted above. With a few exceptions (e.g., Orthopedics in the Boise and Roseburg areas) centers have been able to hire or purchase these services. The results have been to decrease patient travel to receive services, to improve timeliness of services and to decompress the traditionally overcrowded clinics in these specialties in Seattle and Portland, which usually had long waits for new patient tertiary consultation.
Core Medical Specialty Services: In early 1997 an analogous Medical Specialties Committee (MSC) was commissioned to define core medical specialty services for essentially the same reasons as noted for surgical services above. The group identified eight core medical services that if possible should be available locally for ambulatory care, minor procedures and in-patient services within the capability of the available support, technical and professional services. These are: Audiology Cardiology Dermatology Gastroenterology Infectious Disease Neurology Oncology Pulmonology The MSC has recommended that $3.70M recurring funds to be distributed to the facilities for use in the same manner noted above to provide these services locally when possible. This recommendation will be acted upon in the June Executive Leadership Council and it is anticipated that it will be accepted. Boise VAMC is slated to receive $457K annually to accomplish these goals. In the interim tertiary centers have been able to send specialists in some of these fields to the less complex centers and the network has made available funds to hire staff in these specialties prior to ELC approval when good opportunities have become apparent. Both patients and staff have been very pleased with local availability and value of service they have received. Objective measurement of improved service and maintenance of quality will be sought. Community Based Outpatient Clinics: (See Exhibit 2) Veterans who live in the population centers along the major Northwest Interstate Highways have in general had better access to VHA health services. However, in the more rural parts of the Northwest, which accounts for the bulk of the landmass in this region, veterans often travel great distances, over difficult terrain and often in inclement weather to reach a VHA facility for even basic primary care services. A major initiative in the NWNW is to develop and put into operation CBOCs that are strategically placed throughout the Northwest. To date a total of six CBOCs have been approved (one in Twin Falls, ID), three are operational and two additional have been proposed and are awaiting congressional clearance. Fourteen are in the planning stages with the intent to activate nine in FY 1999 (one to serve Moscow, ID/Pullman, WA) and five in FY 2000.It is our goal by 2002 to have primary care services available within a 30-mile distance for the majority of Northwest veterans.
Integrated Information System In August 1997 the NWNW hosted a retreat of nearly 100 multidisciplinary providers, managers and leaders at Bogus Basin, Idaho. The intent was to look at our accomplishments as a network to date and determine the major strategic areas that we needed to focus on to develop an integrated system of health services for veterans. We broke up into groups for a day and came back to present our findings to a plenary session. In each instance the common major need identified for the major elements of an IHS was a user friendly, accurate, fast, accessible information management system. Providers noted a critical need for electronic access to the complete patient record, including consultations and diagnostic studies available anytime and anywhere the patient chooses to access the system. Managers and leaders identified the need for traditional management data and information, but also identified a need for interrelational data base capability. These are crucial to monitor quality, utilization, and stewardship of resources and for the capacity to model systems and their responses to fluctuating variables. Data and information in aggregate, and specifically by provider, by group practices, by unit, etc., are necessary for identifying best and aberrant practice, to monitor efficiency and effectiveness and for professional practice evaluation and improvement. Finally, the value of Telemedicine Technology was greatly emphasized. The ability to evaluate patients and their diagnostic studies "real time" with discipline specific consultants was noted as an essential for this rural part of the country. Exhibit 3 is a menu of the developments in information technology and management in the NWNW during FY 1997 and continuing into FY 1998. We have focused on making information systems technology available to our providers throughout the network by providing work stations and access points throughout our systems (Hardware Procurement, Common VISTA Access and Consult Tracking). We have invested heavily in the infrastructure to support the demands of a sophisticated information and communications system (Telecommunication Infrastructure Project, PBX Replacement and Asynchronous Transfer Mode). We are among the national leaders in developing a system wide electronic medical record (Computerized Patient Record System, Network Health Exchange, and Clinical Information Resource Network). We are also among the leaders of all health systems in the implementation and use of Telecommunications and Telemedicine technology (Telemedicine, VISTA Imaging System, and VISN-Wide Videoconferencing System). Lastly, our largest centers and several of our smaller centers are entering current data into the Decision Support System (DSS). This information management and modeling program is a very sophisticated tool to objectively audit and account costs and utilization. It allows evaluation of data sets in numerous ways (DRG Specific, discipline specific, procedure specific, provider specific, group practice specific, etc.) It is also a sophisticated systems modeling tool. The system required that all of the databases be retrospectively built and populated, a several year process which is coming to fruition. The network facilities will be using this data increasingly in management decision-making and change toward more efficient and effective care services.
Provider Profiling (PP), Consumer Health Information and Performance Set (CHIPS) and the Balanced Scorecard (BSC) The new VHA is an organization of exceptional accountability. The Provider Profiling Project and the Balanced Scorecard are objective measurement and accounting tools that are applied at a provider (practice) specific level or at a system or facility level respectively. Provider (practice) profiling is an analytic tool that uses epidemiological methods to compare providers on various dimensions by focusing on patterns of care for defined populations of patients over time rather than on individual occurrences of care. Provider Profiling is one of several practice management tools that can be used to improve the quality and efficiency of healthcare. Provider profiling serves several purposes. It serves to link individual performance to organizational performance goals in order to improve the five domains of healthcare value (technical quality, patient satisfaction, functional outcomes, access, and cost). It enables leaders to clarify expectations and performance accountability at the provider and team level. Most importantly, it enables providers and teams to learn about their practices and opportunities for improvement, and facilitates learning and performance oriented culture. The Balanced Scorecard serves the same purposes for a facility or an IHS that Provider Profiling serves for the provider or practice. In addition, it is balanced because it is constructed in such a way that performance improvement in one area can not be achieved by sacrificing performance in another area. By evaluating the interrelated parts of a system and setting steady state or improvement goals for the component system parts, balanced improvement can be achieved. Exhibit 3.a. demonstrates the concept of a Balanced Scorecard. Multiple weighted objective measures reside under each of the five domains noted in the left-hand column with Access being the first. The relationship between Access, Cost, Quality, and Satisfaction is well known with each inexorably linked. When one is out of balance, too high or too low, one or more of the others suffer. The several elements present under each domain allow for fine-tuning and improvement of the system. This tool allows facilities, or systems to make decisions about where to put various energy levels to achieve specific desirable goals. Examining Exhibit 3.b. for VISN 20 reveals that we perform well against our peers with this methodology, but none-the-less, there are areas like end of life planning and performing Addiction Severity Indices where we need improvement. On going periodic progress reports are shared with providers, teams and facilities. On a regular basis members of the VISN Executive Leadership Council receive interim data about their performance against these standards. At the ELC the results are examined from the view of an integrated system with the recognition that we are responsible to one another for our collective performance and that our respective performance affects the success of each of the other elements. These tools are used to identify areas for improvements that are data based. The results of action taken can be measured against an objective out come. The system encourages cooperation and support for those elements that are lagging behind and creating issues of performance for the entire organization. Using this system the NWNW has seen an overall performance improvement of 148%, since FY 1996. Effect of the Veteran’s Equitable Resource Allocation Model On VISN 20 In FY1997, VISN 20 gained 5.96% in resources when compared to FY1996. The uncapped gain should have been 15%, but VERA was delayed for 6 months, and losses were capped by VISN. Four VISNs (1, 2, 3, and 12) lost more than 1.0%, plus they had to absorb inflation for FY1997. Our percent gain was double the national average experience. In FY1998, VISN 20 gained 4.82% when compared to FY1997. This limited gain was again as a result of the losses being capped in some VISNs. The uncapped gain should have been 8.33%. Nationally, VISN 20 had the 5th highest percent change in resources from FY1997 to FY1998. FY1999 VERA projections have not been released. We anticipate gaining another 2.5%, if past projections hold. If this FY1999 estimate is accurate, we will have to absorb approximately 2.5% in inflation, plus provide additional services from cost-saving measures. Summary: FY1996 Base: $587 Percent Increase FY1997 Allocation: $622 million 5.96% FY1998 Allocation: $652 million 4.82% The increases in VERA have allowed the Northwest Network to increase the number of veterans served by 11% over two years: from 115,228 in FY1996 to a projected 127,960 in FY1998. As noted above, we have expanded and upgraded outpatient clinics in several facilities, including the Boise VAMC. We have increased availability of surgical subspecialties at several facilities, and established an inpatient psychiatric unit at Spokane. We have invested heavily to upgrade medical equipment such as CT Scanners (Boise’s replaced last year), MRIs, and cardiac catheterization units. We have improved information management systems, including fiber optics and servers within facilities, replaced telephone systems, and began implementing computerized medical records. We will be implementing Teleradiology within the Network starting in FY1998. Beginning in FY 98 and extending into FY 1999 we will be investing primarily recurring funds in staff and contracting for services to provide core medical specialty services in all our medical centers. We will continue to open CBOCs primarily by redirection of existent resources. Summary The Northwest Network is becoming an integrated health services delivery system. We are rapidly moving away from a hospital-based system to one based on Primary Care, continuity, collaboration and connectivity throughout the system. We are reorienting our resources to fund information management and communications infrastructure to assist in the smooth flow of veterans and their patient care information through the system. We are increasing access to core surgical and medical specialty services by investing in VA providers and staff or will be purchasing services where it is more economically feasible. We are further increasing access by opening a number of CBOCs in the NWNW and by the development of a Telemedicine capacity to remote sites. We strive to be an accountable health care system, using data, information, and objective measurement of performance and change to continually identify opportunities to improve. With sound management, attention to best practices, and applying Primary Care and VA Care principles of wellness and disease prevention and care management of chronic disease, VISN 20 has the human and financial resources to continually improve the access to and the quality of health services for veterans now and in the foreseeable future. Thank you for the opportunity to address you today. Northwest Network, VISN 20,
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