VA Testimony of Michael W. Murphy, Ph.D. before Congress on September 5, 2001

United States Department of Veterans Affairs

STATEMENT OF
MICHAEL W. MURPHY, PH.D.
DIRECTOR, VA NORTHERN INDIANA HEALTH CARE SYSTEM (NIHICS)
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

September 5, 2001

Mr. Chairman and members of the Committee I have been invited to discuss, access, enrollment, funding/budget, recruitment and retention, and program changes. The VA Northern Indiana Health Care System ( NIHICS) is dedicated to serving America's veterans and ensuring that they receive the medical care benefits they deserve.

The VA Northern Indiana Health Care System is comprised of VA Medical Centers in Fort Wayne and Marion, Indiana, and Community Based Outpatient Clinics (CBOC) in South Bend and Muncie, Indiana. VAMC Fort Wayne is a primary and secondary medical and surgical facility, with an outpatient clinic, located in the second largest city in Indiana. VAMC Marion is a psychiatric and long-term care facility with an outpatient clinic, and serves as the neuropsychiatric referral facility for the entire state of Indiana.

The veteran catchment area for NIHICS includes 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 are available at both campuses. Inpatient services are provided in the 243 authorized hospital beds and 180 nursing home care beds. A contracted Community-Based Outpatient Clinic (CBOC) was opened in the South Bend-Elkhart area of Indiana, in April 1998. This contract was re-bid in the spring of 2001 with a new contractor taking over this past May. In August 1999, a second NIHICS CBOC was opened in Muncie, Indiana, providing area veterans convenient access to primary care services. We are providing basic mental health services at both CBOCs, through a contractor at South Bend, and VA personnel at Muncie. Both CBOC operations have an enrollment of approximately 3500 veterans, and are attracting over 100 new enrollees per month.

NIHICS 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 projects ensure a modern and attractive state-of-the art healthcare environment. A 240- bed gero-psychiatry building was occupied at the Marion campus in July of 1997 and a 100-bed general psychiatry building was activated in the fall of 2000. A new ambulatory care addition was opened in November of 1998 at the Fort Wayne campus.

NIHICS 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, and Behavioral Health Care. Our most recent cyclic JCAHO survey in December 2000 resulted in scores of 86, 97, 97, and 100 respectively. 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 NIHICS, March 6-10, 2000. The OIG made a return visit in October 2000 to review our progress and the status of actions taken. As of May 2, 2001, the OIG closed the report based upon our responses and information provided concerning actions taken on their recommendations. We invited an outside consultant, Dr. Andrea Conti-Wyneken, faculty member Indiana University School of Medicine, Chief of PM&RS, Indianapolis VAMC, and a surveyor for the Commission on Accreditation for Rehabilitation Facilities (CARF), to come in and review our Sub-Acute Rehabilitation program. Her report offered some suggestions to improve our program, but did not recommend any consolidations or realignments. Our Nursing Home Care Unit operations were reviewed by the Boston HSR&D, Management Decision and Research Center (MDRC). Their report recommended that all NIHICS Nursing Home Care operations be consolidated at the Marion campus. We have discussed this issue with stakeholders and have received VACO approval and have implemented the change to provide all inpatient Nursing Home services at the Marion campus.

The inpatient medicine unit at the Marion campus has been experiencing a decreasing average daily census (ADC) over the past few years; it was 5.9 in FY00 and is 6.0 through July of FY01. After reviewing patient needs, options for inpatient medical care, costs, and the need to maintain staff competencies we have decided to close that unit. The targeted closure date is October 1 of this year. Stakeholders have been informed and VACO approval has been obtained. Veterans presenting at the Marion campus in need of inpatient medical care will be transferred to Fort Wayne, Indianapolis VAMC, or the local community hospital, as appropriate.

The emphasis at NIHICS 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 psychosocial health care services and rehabilitation 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. We are working closely with the Indianapolis VAMC Psychosocial Residential Rehabilitation Treatment Program to identify and return long term psychiatric inpatients to a community setting.

The shift in emphasis at NIHICS, from a hospital-based healthcare system to an ambulatory care, outpatient focused system, has resulted in improvements in the access and 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. Recruitment of nurses, pharmacists, and certain types of medical technicians has become increasingly difficult due to nationwide shortages and increased competition for these specialties.

Total inpatient hospital bed days of care (BDOC) have declined by over 20% per year (FY99 - 91,514; FY00 - 70,692; FY01 - 51,117 estimated). Conversely, Nursing Home Care beds days of care have been increasing from 34,436 in FY99; to 39,961 in FY00; to an estimated 45,000 this FY.
The average length of stay (ALOS) in acute medicine has been reduced from 6.31 days in FY98 to 5.14 days in July 2001. Adjusted for age and diagnosis, our ALOS is comparable to that in the private sector.
The total number of outpatients treated per year continues to increase at about 20% each year, from 15,014 in FY99 to 18,086 in FY00 with an estimated 23,000 this fiscal year.
Due to the increasing number of veterans being seen and the costs of current medications, our pharmacy expenditures have increased from $7.5 million in FY00 to $12.1 million in FY01 and we expect this to increase to $18 million in FY02.
Over 7,000 veterans are currently receiving their outpatient primary medical care at our CBOCs in South Bend and Muncie.
Currently over 90% of our surgeries are performed in an ambulatory/outpatient setting.
Program changes and workload shifts from inpatient to outpatient care, have allowed us to increase our direct care positions at NIHICS by 25.8, while actually reducing non-patient care staff by 8.1 positions during FY01.
Our inpatient Substance Abuse Treatment Program (SATP) was 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.
Our inpatient program for patients diagnosed with Post Traumatic Stress Disorder (PTSD) was converted to an outpatient program for those patients not otherwise requiring hospital care.
A Mental Health Intensive Case Management (MHICM) program was started in FY 1999 in an effort to return and maintain patients to a community setting. VISN 11 provided a grant in FY01 to implement a psycho-social rehabilitation model that will improve community rehabilitation efforts and train our providers in community placement programs. 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.
NIHICS received two, two-year grants from VACO in FY01 to establish outpatient Substance Abuse and Post Traumatic Stress Disorder treatment programs at the Fort Wayne campus to better serve the large veteran population of northeast Indiana, particularly those veterans residing in Fort Wayne and Allen County.
NIHICS reviewed the steam distribution needs at the Fort Wayne campus and developed a project to change our boiler plant from high pressure steam to low pressure steam distribution. This project was completed in the fall of 2000 and will result in ongoing savings that have a payback of 3 to 4 years.
NIHICS is working closely with the Indiana Department of Natural Resources to develop a plan to demolish unoccupied and unused buildings on the National Historic Register at the Marion campus. Most of these buildings are nearing or over 100 years old and are very inefficient to operate and maintain. The demolition of these buildings will provide for better utilization of the land and increased potentials for enhanced use partnering with private and commercial sources.

We are continuing to work together with our labor partners to provide a workplace that is employee friendly. Regular, recurring meetings are being held between top management and the leaders of both AFGE locals to ensure communications are open and substantive.

NIHICS 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 clinical 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 NIHICS 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.