VA Testimony of Michael W. Murphy, Ph.D. before Congress on June 1, 2000

United States Department of Veterans Affairs

STATEMENT OF
MICHAEL W. MURPHY, PH.D.
DIRECTOR, VA NORTHERN INDIANA HEALTH CARE SYSTEM (NIHCS)
VETERAN INTEGRATED SERVICE NETWORK (VISN) 11
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES

June 1, 2000

Mr. Chairman and members of the Committee I have been invited to discuss the VA Northern Indiana Health Care System (NIHCS). NIHCS is dedicated to serving America’s veterans and ensuring that they receive the medical care benefits they deserve.

The integration of the VA Medical Centers in Fort Wayne and Marion IN into the VA Northern Indiana Health Care System was announced in March 1995. VAMC Fort Wayne was a primary and secondary medical and surgical facility, with an outpatient clinic and nursing home, located in the second largest city in Indiana. The primary service area (PSA) served 19 counties in the northern third of Indiana along with 7 counties in northwest Ohio, with an estimated veteran population of 150,224 (1994 data). VAMC Marion was a psychiatric and long term care facility with primary medical services and an outpatient clinic, and served as the neuropsychiatric referral facility for the entire state of Indiana. The computer databases were merged and NIHCS commenced operations as an integrated facility on October 1, 1995.

Upon integration the veteran catchment area for NIHCS was redefined to include 28 counties in Indiana and 7 counties in Ohio. The Marion campus serves as the neuropsychiatric referral facility for Indiana. The two campuses are separated by 60 miles and provide complementary services. Medical and surgical services are available at the Fort Wayne campus, psychiatry and extended care are provided at the Marion campus. Primary care clinics and nursing home care units are available at both campuses. Inpatient services are provided in the 243 authorized hospital beds and 180 nursing home care beds. A Community-Based Outpatient Clinic (CBOC) was opened in the South Bend-Elkhart area in April 1998, extending care to the state’s largest population of under served veterans. In August 1999 a second NIHCS CBOC was opened in Muncie, providing area veterans convenient access to primary care services.

NIHCS also provides administrative support to a veteran’s readjustment counseling center (Vet Center) in Fort Wayne and to the Marion National Cemetery.

Although the Marion campus is well over 100 years old and the Fort Wayne campus was constructed in the 1950’s, recently completed renovation and construction, in addition to projects currently under way, ensure a modern and attractive state-of-the art healthcare environment. A 240 bed geropsychiatry building was occupied at the Marion campus in July of 1997 and a 100 bed general psychiatry building is scheduled to be activated in the fall of 2000. A new ambulatory care addition was opened in November of 1998 at the Fort Wayne campus.

NIHCS is fully accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in the Hospital Accreditation Program (HAP), Home Health Care, Long Term Care Program, and Behavioral Health Care. Our most recent cyclic survey in 1997 resulted in scores of 89, 90, 91, and 98 respectively, Two random unannounced JCAHO surveys in the spring of 1999 resulted in our scores being raised to 94, 94, 94, and 98. We are also fully accredited by the College of American Pathologists (CAP), the Commission on Accreditation of Rehabilitation Facilities (CARF), and the Nuclear Regulatory Commission (NRC).

A Combined Assessment Program (CAP) Review by the Office of Inspector General (OIG), Department of Veterans Affairs was conducted at NIHCS March 6-10, 2000. During the exit interview and subsequent conference calls, the IG made a number of recommendations for improvement, including the need to review staffing levels; review specific patient care programs in terms of reprogramming or relocation of current programs and development of new programs, e.g. dementia unit; improve safety features; and, improve medication management and security. We have concurred with all recommendations and some corrective actions have been completed, with implementation plans being developed for all others. We have discussed these actions and plans with two members of the review team.

Our emphasis continues to be on providing high quality health care services for all veterans in the appropriate clinical setting. We have expanded our efforts in serving homeless veterans by partnering with a provider in the Anderson area, through the Homeless Provider Grant and Per Diem Program. Additionally we work closely with the Homeless Task Force of Fort Wayne in supporting "stand downs" and other essential homeless services. Our Home Based Primary Care (HBPC) program provides in-home primary medical care services to home-bound veterans with chronic diseases and terminal illnesses. Our Adult Day Health Care program provides maintenance and rehabilitation services to veterans in an outpatient setting. Our Respite Care program provides care givers brief periods of needed relief from the responsibility of providing 24 hour care to their loved ones.

The shift in emphasis at NIHCS, from a hospital-based healthcare system to an ambulatory care, outpatient focused system, has resulted in many changes in the delivery of quality health care for our veterans. This shift is consistent with the current delivery paradigm in the private sector and more specifically within the VA in medical, surgical, psychiatric and mental health care.

From FY96 through FY99, total inpatient bed days of care (BDOC) decreased more than 33.8%, (from 190,450 to 125,950 respectively).
The average length of stay (ALOS) in acute medicine has reduced from 8.25 days in FY96 to 5.70 days in FY99. Adjusted for age and diagnosis, our ALOS is comparable to that in the private sector.
From FY96 to FY99, the number of outpatients treated per year increased by over 20.6% (from 12,445 to 15,014 veterans served). Thus far in FY00 we are up more than 20% over FY99 and expect to see over 17,000 veterans this fiscal year. This will represent an increase in the number of veterans being served by NIHCS of approximately 36.6% from FY96, the first year of integration.
In FY96 NIHCS saw 6,013 veterans in outpatient primary care clinics, by FY99 the number of veterans seen in primary care had risen to 10,281, an increase of over 70%.
Surgeries performed in an ambulatory setting increased from 64.5% of all surgeries performed in FY96 to approximately 89.3% in FY99.
As a result of workload shifts and program changes, employment (FTEE) at NIHCS has decreased from 1,283.4 in FY96 to 1,064.5 at the end of FY99.
Our inpatient substance abuse treatment program (SATP) converted to an outpatient model early in FY99. Federal and private health care studies have revealed that more successful outcomes are obtained in outpatient treatment models that emphasize patient commitment and provider support compared to those obtained in the traditional inpatient setting. The SATP professional team carefully monitors patient care and provides care management; coordinating services with veterans, families and community providers. By shifting our emphasis from inpatient to outpatient treatment we are able to increase the number of veterans we serve, while achieving cost efficiencies. Alternative living arrangements were developed for those veterans who were homeless or who could not commute daily to this treatment program.
Our combat veterans treatment program (CVTP) for patients diagnosed with post traumatic stress disorder (PTSD) was converted to an outpatient program for those patients not otherwise requiring hospital care. Those patients in need of inpatient psychiatric care are admitted to an existing psychiatry unit with their PTSD treatment being provided in the Mental Health Clinic. As with the substance abuse program, alternative living arrangements have been made for those veterans that are homeless or otherwise cannot commute from home while participating in the PTSD program.
An Intensive Psychiatric Community Care (IPCC) program was started in FY 1999 in an effort to return patients to a community setting. The driving force of this program is to improve the quality of life and the quality of care for those veterans whose psychiatric care does not require that they be treated in an institutional setting.
NIHCS has opened two CBOCs to improve the access to care for veterans. These CBOCs reduce the distance veterans travel to receive their outpatient primary medical care.
In 1997 the City of Marion entered into a Memorandum of Understanding with NIHCS to provide fire suppression services to the VA allowing us to close our VA fire department and thereby, achieve cost efficiencies and reprogram resources into patient care.
In 1996 NIHCS began reviewing our aging laundry plant to determine whether it was more cost effective to replace this facility or to contract for laundry services. The cost of equipment replacement alone was estimated at $3 million. The network’s new consolidated laundry at VAMC Battle Creek had excess capacity and it was determined the workload from NIHCS could be accommodated at that facility. The network’s consolidated laundry was already providing services to all four Lower Michigan VA medical centers and had some experience in managing inventory and transportation. In 1999 NIHCS decided to close the existing laundry facility and obtain laundry services from the VISN 11 consolidated laundry. It is recognized there continue to be some operational issues as this consolidated laundry strives to meet the needs of many facilities, most notably the handling of patient personal clothing, but we are working to correct these problems with the Laundry Plant Manager and the Network Laundry Oversight Board.
Since 1996 NIHCS has closed approximately 12 buildings at the Marion campus. Most of these buildings were nearing or over 100 years old and were very inefficient to operate and maintain. The estimated annual saving on the utilities and maintenance from these closures is $227,000. Some of the closures were made possible by the reduction in the bed days of care for inpatients, which allowed us to consolidate buildings and wards; other closures resulted from the opening of the new geropsychiatry facility (Building 172) in the summer of 1997. Additional building closures and program consolidations will be possible when we activate the 100 bed general psychiatry building in September 2000.

NIHCS supports the Veterans Health Administration, and VISN 11 in developing programs for veterans consistent with the six nationally adopted domains of value: Quality, Cost, Access, Satisfaction, Functional Outcomes and Community Health. We are committed to providing America’s veterans the highest quality health care in the most cost effective manner and in the least restrictive setting. We have an equivalent commitment to our employees to improve communication and participation in implementing new programs. The many changes that have taken place at NIHCS and that will be necessary in the future have a significant impact on employees in terms of how they do their jobs, the settings where care is provided, the skills sets necessary to do the quality work we all strive for, and overall job satisfaction.