STATEMENT OF THE HONORABLE EVERETT ALVAREZ, JR.
CARES COMMISSION CHAIRMAN
FOR PRESENTATION BEFORE THE SENATE COMMITTEE ON VETERANS' AFFAIRS
March 2, 2004
Mr. Chairman and members of the Committee, good afternoon. I am pleased to be here today on behalf of the entire Commission, to present the Capital Asset Realignment for Enhanced Services (CARES) Commission’s Report. With me today are Vice-Chairman John Vogel, and Commissioners Mr. Charles Battaglia and Dr. Richard McCormick.
The Commission’s journey began in February, 2003, when The Honorable Anthony J. Principi, Secretary of Veterans Affairs, asked the Commission to provide specific impartial and equitable recommendations for realignment and allocation of capital assets to meet the demand for veterans health care services over the next 20 years. As you know, Sir, the goal of CARES is to enhance services, not to save money – but to spend appropriated funds wisely. In fulfilling our obligation to Secretary Principi, to veterans and their families, to stakeholders and partners, and to the dedicated VA staff, Commissioners:
At the public hearings, the Commission had the opportunity to hear from approximately 770 invited local speakers, including VISN leadership, veterans, veterans service organizations, state directors of veterans affairs, local labor organizations, medical and nursing school and other allied health professional affiliates, organizations with collaborative relationships, and local elected officials. Seven governors and 135 Members of Congress participated or provided statements for Commission hearings.
The CARES Commission Report is the compilation of information gathered at these site visits, public hearings, and meetings as well as information obtained from the public comments and VA. It represents the best collective judgment of the Commissioners, who applied their diverse expertise in making decisions related to the future of VA’s infrastructure. I would like to emphasize, Mr. Chairman, that the focal point of the Commission’s effort and report is enhancing access to health care for
Mr. Chairman, to assess the reasonableness of each proposal in the Draft National CARES Plan, the Commission developed and applied the following factors:
In applying these factors, the Commission evaluated each proposal using available data and written analysis submitted by each VISN and by VA’s Under Secretary for Health, Dr. Robert Roswell. The Commission’s recommendations are based on this evaluation and the knowledge gained through the Commission’s study of VA’s infrastructure and health care system.
Through the public meetings, site visits, hearings and informal meetings with individual veterans and stakeholders, the Commission developed a deeper appreciation for the complexity of the system-wide issues confronting VA and the significance of the changes proposed in the Draft National CARES Plan. The Commission identified a variety of issues that are critical to VA’s success as it continues to realign and transform its health care system. The Commission believes that resolution of these national crosscutting issues is essential to achieve the changes the Secretary desires and to accomplish CARES goals for enhanced services to veterans.
The Commission identified six national crosscutting issues. These are:
The Commission determined that for VA to reach a successful outcome from the CARES process, it was essential that recommendations be developed for these crosscutting issues. These issues and related recommendations, while appearing at times to be discrete from one another, are in fact interdependent, and require careful integration. For example, facility mission changes and managing excess property concentrate on the realignment of capital assets. The prioritization and placement of community-based outpatient clinics and contracting for care in local communities focus on developing equitable access to quality health care. Similarly, the issues of mental health services and long-term care deal with providing access to quality services.
Recommendations on the national crosscutting issues served to guide the Commission’s decision-making as it reviewed the VISN-specific proposals in the Draft National CARES Plan. The Commission believes that these crosscutting recommendations should be the basis for developing national policy guidance.
Mr. Chairman, I would now like to discuss each of the six national crosscutting issues.
The intent of the CARES process is to realign resources in order to enhance access to health care services for our nation’s veterans. To accomplish this goal, it is critical to eliminate duplicate clinical and administrative services at VA facilities, increase efficiencies, and allow reinvestment of financial savings.
The Draft National CARES Plan proposed consolidation of services at 40 facilities – 18 with small workload volumes (“small facilities”) and 22 within close geographic proximity of other facilities (“proximity”) or with multiple campuses (“campus realignment”). Of the 18 small facilities, the Draft National Cares Plan identified seven facilities that would convert to a new type of facility modeled after the Centers for Medicare and Medicaid Services designation of a critical access hospital. The Commission used the term “facility mission changes” to describe all recommended changes to facilities.
As mentioned earlier, the Commission applied specific factors in its evaluation of each mission change proposal to assess the proposal’s reasonableness. In applying these factors, the Commission relied on the broad expertise and experience of the Commission members. Further, due to a lack of supporting data for the Draft National CARES Plan’s proposals on facilities with a potential mission change, the Commission evaluated each facility using its own factors, taking into consideration the unique issues in the various VISNs and issues associated with urban and rural areas, and utilized data in a number of areas such as past, present and projected VA workload; whether there were alternative community resources, costs; quality of care; and financial analyses. I should emphasize, Mr. Chairman, that the Commission considered access and quality of care to be the primary drivers in meeting the health care needs of veterans.
Mr. Chairman, if I may, I would like to address the Commission’s recommendations on those facilities with a potential mission change where the Commission did not concur in whole or in part with the Draft National Cares Plan.
Before I do, Sir, I will say that the Commission did not concur with the Draft National CARES Plan’s proposal designating seven medical facilities as critical access hospitals primarily because VA had not established a clear definition or clear policy on the critical access hospital designation prior to making decisions on the use of this designation. We understand, however, that the Under Secretary for Health has assembled a team of experts and a draft definition has been developed. The Commission has not evaluated this newly developed definition.
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VISN 6 – Beckley, West Virginia: The Commission did not concur with the proposal to convert the Beckley VA Medical Center into a critical access hospital and recommended closing the acute inpatient hospital beds and contracting for acute inpatient care in the community as soon as reasonable. The Commission also recommended that the Beckley VA Medical Center retain its multi-specialty outpatient services and the nursing home.
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VISN 17 – Waco, Texas: The Commission concurred with the proposal to transfer services from the Waco campus to appropriate locations within the VISN as follows: 1) a portion of acute care inpatient psychiatry to Austin; 2) the balance of acute care and all the long-term inpatient psychiatry to the Temple VA Medical Center; and 3) post-traumatic stress disorder residential rehabilitation services to the Temple VA Medical Center, with no decrease in capacity. The Commission concurred with the proposal to transfer the
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2. Community-Based Outpatient Clinics
Following the VISN’s submissions outlining the needs for additional CBOCs, the Under Secretary for Health developed criteria to organize proposed CBOCs into three priority groups. The Under Secretary indicated to the Commission that priority groups were established in order to constrain demand on the system. The Commission believed the Under Secretary’s approach to determine priority groups has the effect of limiting access to outpatient care, which is contrary to the goal of CARES. It also had unintended consequences in that it inadvertently disadvantaged veterans in rural communities by generally placing CBOCs for rural areas in the second priority group because of the relatively small veteran populations in these markets. Further, the same population data used to propose a CBOC could be clustered in different ways yielding various results in the prioritization of CBOCs.
VISNs also proposed new CBOCs to address overall workload issues and space capacity issues at parent facilities and existing CBOCs. The Commission learned that several facilities are currently operating at and over capacity for outpatient care. Proposed CBOCs that address space issues associated with increased workload are in the third priority group. Without timely development of new sites of care, whether designated as CBOCs or otherwise, there will be greater demand on existing clinic space and examination rooms, leading to inefficient workflow and a reduction in the total number of patients that can be seen in a given day. This in turn could lead to increased wait times.
Some parent facilities also have projected growth in inpatient workload, requiring conversion of outpatient space back to its original inpatient purpose. Without the timely establishment of new CBOCs, many facilities will require construction to accommodate workload increases, a more costly solution with longer-term ramifications.
The Commission recommended that the Secretary and the Under Secretary for Health use their authority to establish new CBOCs with the VHA medical appropriations without regard to the three priority groups. Also, the Commission recommended that VISNs set priorities for new CBOCs based on VISN needs to improve access and to respond to increases in workload. Additionally, the Commission recommended that VISNs be able to establish new sites of care to reclaim space at the parent facility to meet increasing demand for inpatient care. Further, the Commission endorses the legislative requirement and VA policy to include basic mental health services in CBOCs, whenever feasible. Finally, the Commission recommended that VISNs collaborate with academic affiliates to develop learning opportunities using CBOCs as teaching sites to enhance quality of care in community-based service settings.
The National CARES Program Office recognized early in the methodology used to project mental health services did not accurately account for services provided by VA. As a result, the model projected decreasing requirements for outpatient mental health services while national projections included significant increases in outpatient primary and specialty care needs.
The Commission is pleased to learn that the National CARES Program Office has recently completed reworking enrollment forecasts for mental health services. Changes to the model included ensuring that VA actual workload and projected workload data a re comparable and account for the needed mental health services for Vietnam Era veterans and those who follow, such as those serving in
4. Long-Term Care
The Commission learned that long-term care, including nursing home, domiciliary and non-acute inpatient and residential mental health services, was not included in the current CARES projections due to the absence of an adequate model to project future need for these services. Nevertheless, the Draft National CARES Plan includes a number of initiatives that directly impact nursing home care, domiciliary care, and residential and long-term mental health care.
VA’s nursing home care units vary in mission and case mix. Some operate as short-term medical rehabilitation units and some operate as traditional long-term care units. Some provide care for seriously mentally ill patients who also have care needs related to medical illnesses and dementia. The Commission noted that these patients are extremely difficult to place in community nursing homes, as most do not admit patients with severe psychiatric illness.
The Commission heard conflicting rationale for moving current long-term care beds. On the one hand, the Under Secretary for Health and certain VISN officials contended that long-term care beds should be located on the same campus as a tertiary care center to enhance overall medical care. Some proposals in the Draft National CARES Plan are consistent with that view. On the other hand, several proposals call for moving long-term care beds to campuses without medical beds, or for contracting with community nursing homes not connected to a hospital. The Commission noted that the norm for community nursing homes is that the nursing home facility is located away from facilities with medical services and, VA currently has nursing homes that are not located on the same campus as the medical center.
In addition, inconsistent views have been expressed by VISNs concerning the extent to which community nursing homes can adequately provide care for veterans with serious psychiatric needs. Some VISNs expressed a willingness to contract for all nursing home beds, while others argued strongly that a sizable portion of VA nursing home patients could not be adequately cared for in community nursing homes.
Due to the lack of an adequate model to project future need for long-term care services and because of the conflicting rationale for addressing long-term care needs in the VISNs, the Commission recommended that VA develop a strategic plan for long-term care services, including the long-term care for the seriously mentally ill. Additionally, the Commission recommended that long-term care facilities located away from the medical center campus should be accepted as a care model. Further, the Commission recommended that in developing a strategic plan, VA should consider broader collaboration with states to leverage VA and other public funding through the State Veterans Home programs.
It should be noted that although there is a need for VA to complete a strategic plan for long-term care services, the Commission observed existing long-term care facilities, primarily nursing home units, that have poor facility conditions or require infrastructure improvements resolve privacy and safety issues. Recognizing this, the Commission did not want to disadvantage current patients in VA’s long-term care facilities and recommended that renovations to existing long-term care and chronic psychiatric care units be accomplished.
Much of VA’s vacant space is not contiguous, but consists of pockets of space scattered throughout the campuses, making it useless for other purposes. The Commission also recognized that additional vacant space would be created through mission changes and consolidations. Further, there is an unspecified amount of acreage that is not currently in use and numerous properties in VA’s inventory are historically important or have historic designations.
The Draft National CARES Plan outlines demolition and divestiture, particularly in the early years of the CARES implementation phase, as the primary methods to reduce current vacant space as well as vacant space that will be created through mission changes and consolidations. The Commission recommended that VA consider all options for divesture, including outright sale and transfer to another public entity.
The Draft National CARES Plan also places significant reliance on the enhanced use lease process to address excess space or property. The Commission, however, has determined that the enhanced use lease process as currently structured is not effective.
Across the country, Commissioners consistently heard testimony on the structural problems with the enhanced use lease process. In the field, there often is insufficient expertise or resources to attract potential investors or to navigate local zoning and land use requirements. Within VA, the review and approval process is arduous and time-consuming. The Commission, therefore, recommended that the enhanced use lease process be reformed to ensure timely action on proposals and that VA develop a more efficient process, perhaps creating a separate organization to pursue disposal of excess VA property and land.
As previously stated, there are numerous historic properties in VA’s inventory, many of which can no longer be used for medical care services. As with other types of excess property, VA must use medical care appropriations that could otherwise be used to provide direct medical care to pay for the upkeep and maintenance of property that no longer has a medical purpose. Rather than rely on medical care appropriations, the Commission recommended that VA seek a separate appropriation for historic preservation funds to stabilize and maintain historic property.
6. Contracting for Care
VA uses contracting as one vehicle for improving access to care and has significantly expanded access to care with CBOCs. The benefits of contracting for care in the community are it can add capacity and improve access faster than can be accomplished through a capital investment; it provides flexibility to add and discontinue services as needed; and it allows VA to provide services in areas where the small workload may not support a VA infrastructure, such as in highly rural areas.
The Commission concurs with the Draft National CARES Plan’s proposal to utilize contracts for care in the community to enhance access to health care services. However, before taking action to alter existing VA services, VA must ensure that there are viable alternatives in the community. Additionally, the Commission recommends that the Secretary ensure that VA has quality criteria and procedures for contracting, and monitoring service delivery, as well as the availability of trained staff to negotiate cost-effective contracts.
Mr. Chairman, there are six additional issues that are distinguished from these national crosscutting issues in that they are relevant in selected VISNs, rather than in most or all of the VISNs. These issues are no less significant to any other issues we reviewed and I would like to briefly address the recommendations for each of them.
1. Infrastructure and Safety
VA has identified 63 medical centers requiring seismic correction. Many of these medical centers are large facilities located in high population density areas. Of this total, the Draft National CARES Plan has prioritized 14 sites that require immediate seismic strengthening for a total funding requiring of $560.8 million. The Commission recommended that Secretary Principi seek necessary funding to correct documented seismic/life safety deficiencies as soon as possible.
2. Education and Training
Although VA has transformed from a primarily inpatient delivery model to a community-based outpatient delivery system, generally speaking, medical schools and other clinical affiliates have not made the transition from the traditional inpatient teaching modalities to incorporate community-based outpatient primary and specialty care delivery into their educational programs. The Commission, therefore, recommended that VA and its academic affiliates develop a plan to add a community-based outpatient component to existing and new education and training sites.
Additionally, in light of VA’s significant involvement in nursing education and the dramatic impact the nursing shortage has on VA’s ability to provide access to quality care for veterans, the Commission believes there is strategic value to formalizing the relationships between VA and schools of nursing. The Commission recommended that VA establish national policy guidance for schools of nursing comparable to the medical school model and actively promote nursing school affiliations, as well as affiliations with other health profession educational institutions.
3. Special Disability Programs
The Commission found that VA uses a hub and spoke model to care for spinal cord injury and disorder patients. Patients travel to the “hub” tertiary hospital for inpatient care or complex services. For more routine services, patients receive care at regional “spoke” VA medical centers. Similarly, VA’s Blind Rehabilitation Centers are structured to serve blind veterans in an inpatient environment.
The addition of two blind rehabilitation centers in VISNs 16 and 22 will assist blind veterans throughout the country. The Commission believes inpatient settings are not the only solution, particularly because many blind veterans do not require a residential program. Rather, a more appropriate response to serving many blind veterans is to provide rehabilitation and retraining in community or home settings. As such, the Commission recommended that VA develop new opportunities to provide blind rehabilitation in outpatient settings close to veterans’ homes.
For Spinal Cord Injury Centers, there is no strategic approach to balancing the mix of acute and LTC beds. The Commission believes the proposed addition of four spinal cord injury centers and additional beds in four other locations will benefit many veterans. The Commission, however, recommended that VA assess their acute and long-term spinal cord injury bed needs to provide the proper balance of these beds.
The Commission also recommended that VA coordinate among VISNs the placement of special disability centers to optimize access to care for veterans.
4. VA/Department of Defense (DoD) Collaboration
The Commission reviewed a wide range of VA/DoD sharing initiatives across the country and found varying degrees of support and momentum for their completion. At those sites with successful initiatives, the Commission noted a clear, mutual commitment to the value of the collaboration, dedication from the top local leadership to the making the collaboration work, and a sustained effort to monitor and manage the day-to-day activities. From its review, the Commission recommended that to ensure a successful collaborative relationship between DoD and VA, there must be clear commitment from their top leadership, both to the initial establishment of collaboration and to its ongoing maintenance, especially when there is a change in the local leadership
5. Research Space
The Draft National CARES Plan includes more than 20 research leases, new construction and enhanced use lease. The Commission notes that VA has excelled in this core mission and, therefore, concurred with the proposals for enhancing research space.
VA has undertaken a number of changes in care delivery designed to enhance access to services. Primary among them are CBOCs. However, the use of advanced practice nurses and telemedicine are two other illustrations of new approaches to delivering care.
Veterans reported a high satisfaction with the care provided by advanced practice nurses and access was clearly enhanced when wait times were reduced, services were brought closer to where veterans live, and continuity of care was enhanced.
The Commission also observed telemedicine to be an effective tool to enhance access to care and leverage clinician productivity especially for veterans living primarily in rural areas and in locations where specialty medical are not readily available.
The Commission recommended that VA use advanced practice nurses and telemedicine to enhance access and quality of care, and urges wider application of these resources throughout the system. Furthermore, the Commission believes that this does not have to be limited to only advanced practice nurses but should include other critical health care professionals such as pharmacists, physician assistants, and other health care team members.
Mr. Chairman, I have highlighted significant recommendations from the Commission’s Report. I would like to conclude my testimony today by saying that there were cases where the Commission came to a different conclusion than the Draft National CARES Plan. However, the driving force for the VISNs and the Commission was enhancing medical services to veterans. The Commission strongly believes that it is good public policy that VA continue to integrate the CARES process into its planning, budget, and legislative cycles.
Mr. Chairman and members of the Committee, I would like to thank you for the opportunity to address you. That concludes my formal remarks. My fellow Commissioners and I would be pleased to answer any questions.