THE HONORABLE ROBERT H. ROSWELL, M.D.
UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS AFFAIRS
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
July 24, 2002
Mr. Chairman and Members of the Committee:
The Department of Veterans Affairs ( VA) provides mental health services for veterans across a continuum of care, from intensive inpatient mental health units for acutely ill persons to residential care settings, outpatient clinics, day hospital and day treatment programs, community-based outpatient clinics ( CBOCs), and intensive community case management programs. VA views mental health as an essential component of overall health and offers comprehensive mental health services, including programs for substance abuse, as part of its basic benefits package.
In FY 2001, VHA saw 4,153,719 patients for all health care services; 886,019 (21.3 percent) of these received mental health care. Of those who received mental health care, 712,045 veterans were treated in specialized mental health programs. The remaining 173,974 received mental health care in general medical care settings. Of the overall total number of patients receiving mental health care, 285,161 met criteria for inclusion in the Capacity Report, i.e., an inpatient admission or six or more outpatient visits.
The 712,045 unique veterans treated in specialized mental health programs represent a 4.9 percent increase from the previous year, over four times the increase for the period from FY 1999 to FY 2000. Only 10.1 percent of these patients required an inpatient stay, demonstrating VA's emphasis on providing care in the least restrictive, most accessible way that meets patients' needs, which includes enhancing our capability to provide mental health services in CBOCs. Over 85 percent of veterans who use VA mental health services are in Priority Groups 1-6, our "core mission" patients. The clinical care costs for specialized mental health services in FY 2001 were approximately $2,400,000,000. For FY 2002, it is estimated that VA will provide care in mental health programs to 729,400 unique patients at a cost of more than $2,484,000,000.
The clinical care costs mentioned above cover major expenses such as staffing, but do not include the costs of psychotropic medications. Pharmacy costs for psychotropic medications in FY 2001 were $375,117,569, an increase from $304,696,503 in FY 2000. The figure for FY 2001 includes prescriptions for both patients who were treated in specialty mental health services and patients who received care from non-specialty providers such as primary care clinicians.
This statement describes VA's mental health clinical services, education and research initiatives, program monitoring efforts, and special programs for homeless veterans.
Treatment for mental illnesses in VA rests essentially on two main approaches, pharmacotherapy and psychosocial rehabilitation (including psychotherapy). It is our practice to provide the latest medications for mental disorders to veterans who need these drugs and to prescribe them in accordance with the best medical evidence. VA's formulary for psychotropic medications is one of the most open in organized health care. It includes virtually all of the newer atypical antipsychotic and anti-depressant drugs.
In most cases, medications alone are not enough to bring patients with serious mental illnesses to their optimal level of functioning and well-being. The application of psychosocial rehabilitation techniques, designed to optimize patients' strengths and promote recovery, is essential. These interventions include patient and family education, cognitive behavioral therapy, working and living skills training, and intensive case management. Treatment is provided in both inpatient and outpatient settings and can include supervised living arrangements in the community.
Assisting veterans to engage in meaningful and productive work activities is an important part of their therapeutic rehabilitation. VHA accomplishes this primarily through the Compensated Work Therapy ( CWT) program and Compensated Work Therapy/Transitional Residence ( CWT/TR) program.
In FY 2001, 22,053 veterans had contact with the CWT program and 13,700 worked through the program. There currently are more than 105 individual CWT operations connected to VA medical centers nationwide. Through CWT programs with companies and government agencies, veterans earned $33.4 million.
The CWT/TR program includes 34 sites at 26 currently operational programs with 55 residences and 433 operational beds in FY 2001. Nine program sites with 17 residences are designated to exclusively serve homeless veterans. The average length of stay is approximately six months. Increased competitive therapeutic work opportunities are occurring each year. At discharge from the CWT/TR program, 41 percent of the veterans were placed in competitive employment and four percent were in training programs.
Additionally, VHA offers a vocationally oriented program, the Incentive Therapy (IT) program. Veterans working in IT provide direct services to VA Medical Centers, for which they receive remuneration. Such work is done usually in preparation for transfer to CWT, or direct job placement. In FY 2001, 8,806 veterans were served by IT. Some stations sponsor Incentive Therapy On the Job Training programs (IT/OJT) in which veterans learn vocational skills while providing services to the host Medical Center. The IT program operates at over 80 Medical Centers.
VA's clinical services are increasingly being structured to accommodate mental health participation in medical and geriatric primary care teams and medical capabilities in mental health primary care teams. Best practice models have been identified in the field based on criteria that included patient clinical improvement, prevention, screening activities, and patient satisfaction. We have data showing that when medical primary care services are integrated with mental health care, clinical outcomes, as measured by standard VA indicators (e.g., Preventive Disease and Chronic Disease Indices), are improved, as is patient satisfaction.
Section 8(a) of Public Law 107-95 requires that each VA primary care health care facility develop and carry out a plan to provide mental health services, either through referral or direct provision of services. Section 8(c) also requires that each VA medical center develop and carry out a plan to provide treatment for substance use disorders, either through referral or direct provision of services. Treatment for substance abuse disorders is to include opioid substitution therapy, where appropriate. In the first two quarters of FY 2002, all VISNs prepared plans to implement this section of the law. VHA HQ has approved all plans and is monitoring their implementation quarterly.
Innovative uses of technology such as tele-mental health are also being implemented to enhance mental health services to distant sites (e.g., CBOCs) and provide psychiatry support to Veterans Outreach Centers. In addition there are 10 tele-mental health demonstration projects either operational or in development. By disseminating information about best practices across the system, program development is encouraged, and higher quality, more cost-efficient care will be delivered to VA patients.
VA has identified several particular target populations and has developed special emphasis programs designed to serve those populations. They include veterans with serious mental illness (e.g., those suffering from schizophrenia and other psychoses); homeless veterans with mental illness; veterans suffering from Post-traumatic Stress Disorder ( PTSD); and those with substance abuse disorders. A significant percentage of all veterans receiving mental health services are seen in the following special emphasis programs.
Serious Mental Illness
Since 1996, the number of veterans seen with serious mental illness has increased by six percent while the cost has increased by four percent, reflecting decreased hospital days of care counterbalanced by increased spending on outpatient care. The average length of stay for general inpatient psychiatry decreased from 29.9 to 17.0 days nationally, and the average number of days of hospitalization within six months after discharge (reflecting readmissions) dropped from 12.4 to 6.7. The percent of discharged general psychiatry patients receiving outpatient care within 30 days of their discharge has increased from 50 percent in FY 1996 to 59 percent in FY 2001. These indicators suggest more effective hospital treatment and aftercare, including intensive case management services. A 17 percent decrease in the number of general psychiatric patients hospitalized in FY 2001 compared to FY 1996 was accompanied by a 29 percent increase in general psychiatric patients receiving specialized mental health outpatient care, resulting in a net 28 percent increase in individual veterans treated in specialty mental health. These data suggest an effective move from inpatient to community-based mental health treatment nationwide.
VA has committed itself to expanding state-of-the-art treatments of serious mental illness, using the Assertive Community Treatment (ACT) model. VA now operates one of the largest networks of such programs in the country, the Mental Health Intensive Case Management (MHICM) program. As of April 2002, VA had 65 active MHICM programs with another 10-12 in various stages of development, a 33 percent increase in this fiscal year alone. VISN plans for expansion of MHICM teams are reviewed quarterly.
Another aspect of VA's care for veterans with seriously mental illness is our commitment to using state-of-the-art medications, which result in improved clinical outcomes, decreased incidence of side effects, and increased compliance with prescribed medications. Patient functioning and patient satisfaction are increased. In FY 2001, of the 78,210 veterans with a diagnosis of schizophrenia who received antipsychotic medications, 72 percent received the new generation of atypical antipsychotic medications, such as olanzapine, clozapine, risperidone, quetiapine, or ziprasidone.
VA operates the largest national network of homeless outreach programs. VA expects to spend $144 million on specialized programs for homeless veterans this year. In FY 2001, VA initiated outreach contact with 44,845 veterans. VA's Health Care for Homeless Veterans (HCHV) program incorporates:
These activities serve not only to help homeless veterans; they play a role in de-stigmatizing mental illness in the homeless population.
Secretary Principi recently convened the first meeting of VA's Advisory Council on Homelessness Among Veterans. The Council's mission is to provide advice and make recommendations on the nature and scope of programs and services within VA. This Council will greatly assist VA in improving the effectiveness of our programs and will allow a strong voice to be heard within the Department from those who work closely with us in providing service to these veterans.
Post-Traumatic Stress Disorder
VA operates an internationally recognized network of 147 specialized programs for the treatment of PTSD through its medical centers and clinics. This figure includes new specialized programs funded by the Veterans Millennium Health Care and Benefits Act that are operational and seeing new patients. In FY 2001, VA Specialized Outpatient PTSD Programs (SOPPs) saw 57,783 veterans, an increase of 8.6 percent over the previous year. Of these, the number of new veterans seen was 23,082. For SOPPs, continuity of care, measured as number of visits across 2-month intervals (a marker for quality of care), was maintained between FY 2000 and 2001.
Specialized Inpatient and Residential PTSD Programs had 5,012 admissions in FY 2001. Overall inpatient PTSD care is declining while the alternative, residential care, is increasing. Outcomes for outpatient PTSD treatment (e.g., continuity of care) and for Specialized Inpatient PTSD Programs (e.g., PTSD symptoms at four months post discharge) were maintained or improved in FY 2001 over FY 2000.
These specialized Mental Health PTSD programs act in collaboration with VA's 206 Vets Centers, which are community-based operations staffed by a corps of mental health professionals, most of whom have seen active military service, including combat.
In FY 2001, 429,032 VA patients had a substance use disorder diagnosis. Of these, 125,660 were seen in specialized substance abuse treatment programs. Most of the rest of these veterans were seen in non-substance abuse mental health care settings or received non-mental health services. The number of veterans receiving inpatient care for substance use disorders is decreasing, as part of the shift to outpatient care. Studies show that for many patients residential and outpatient substance abuse treatment can be as effective as inpatient services. To accommodate this shift, services are increasingly being developed on a residential and outpatient basis. From FY 2000 to 2001, VA saw a 9.5 percent decrease in the number of veterans treated in its in-house specialized substance abuse programs. At the same time, a number of networks instituted contracts for residential substance abuse treatment services. Consequently, VA has begun a process to determine where these veterans are now being treated and the adequacy of that treatment. As of January 2002, in the 31 new Substance Abuse programs established to implement the requirements of § 116 of Public Law 106-117, 1500 additional patients had been seen. VHA is also reviewing its capacity to provide opiate substitution services and the need to expand these services.
Under 38 U.S.C. § 1706(b), VA is required to maintain its capacity to meet the specialized treatment and rehabilitative needs of certain disabled veterans whose needs can be uniquely met by VA. Mental health encompasses four of the designated populations, veterans with severe, chronic mental illness, veterans suffering from post-traumatic stress disorder ( PTSD), homeless veterans with mental illness, and veterans with substance abuse disorders.
From FY 1996 to FY 2001, VA has maintained or increased capacity to treat veterans in both the SMI and PTSD categories in terms of patients served. Although overall capacity has increased, there has been a decrease in the number of veterans with substance abuse who meet SMI criteria and were served in specialized programs by the system as a whole, from 105,898 in FY 1996 to 89,963 in FY 2001. The Networks completed an initial review of variation in April 2002, the results of which are being analyzed. Based on this ongoing analysis, VHA will identify areas for improvement. Several performance monitors are in place to ensure our ability to maintain capacity to treat specialized mental health disorders.
To track its progress and enhance its performance in mental health services, VA has one of the most sophisticated mental health performance monitoring systems in the nation. To monitor the care provided in mental health programs to over 700,000 veterans per year, VA uses measures of performance, quality, satisfaction, cost, and outcomes (e.g. PTSD symptoms; homeless veterans who are domiciled). The results published annually in VA's National Mental Health Performance Monitoring System report indicate that quality of care, as indicated by performance monitors associated with quality and patient satisfaction, is essentially being maintained or is improving. Lengths of inpatient stay (LOS) have increased slightly from 16.6 days in FY 2000 to 17.0 in 2001, but there has been an overall 39 percent decrease in LOS since FY 1995. Readmission rates and days hospitalized after discharge decreased slightly from FY 2000 to FY 2001. There have been slight decreases in measures of outpatient care in the past year, mostly by less than four percent. However, the number of outpatient visits is down by 8.5 percent, from 17.2 to 15.7 average visits per year for general psychiatry patients.
The Seriously Mentally Ill Treatment Research and Evaluation Center (SMITREC) created a Psychosis Registry, a listing of all veterans hospitalized for a psychotic disorder since 1988. This registry tracks the health care utilization of these veterans over time. Over 70 percent of these veterans are still in VA care. The percentage of patients with long inpatient stays (over 100 days) is decreasing while the number of patients receiving atypical antipsychotic medications has increased. SMITREC is studying aspects of patients' adherence to treatment regimens, a key element in maintaining patients in the community with optimal good health.
To support its mental health programs and to ensure acquisition of the most current knowledge and dissemination of best practices, VA has undertaken a number of activities. These include development of practice guidelines, educational programs, and partnering with other organizations involved in mental health services.
VHA has also published up-to-date, evidence-based practice guidelines for major depressive disorders, psychoses, PTSD, and substance use disorders. The International Society for Traumatic Stress Studies used VA's initial PTSD guidelines as a start for their guideline development. Earlier this month, work started on a new stand-alone VA/ DoD PTSD Clinical Practice Guideline. The Major Depression guidelines, revised in collaboration with the Department of Defense ( DoD), were published in FY 2001. A new "stand-alone" Substance Abuse guideline created with DoD has been published, and the revised Psychoses Guidelines are currently in review. Automated clinical reminders are in development to assist clinicians in following the practice guidelines and document and track compliance.
Last year, MHSHG inaugurated a new quality improvement program - the National Mental Health Improvement Program (NMHIP). NMHIP uses validated data collection, expert analysis, and active intervention by an oversight team to continuously improve the access, outcomes, and function of patients in need of our mental health programs. The program draws upon existing MHSHG resources such as the Northeast Program Evaluation Center (NEPEC), and the Mental Illness Research, Education and Clinical Centers ( MIRECCs), as well as resources in VHA's Health Services Research and Development Service, including existing initiatives in the Quality Enhancement Research Initiative ( QUERI), and the Office of Quality and Performance. Currently NMHIP is reviewing general assessment measures for patients with mental disorders, focusing on the Global Assessment of Functioning Scale (GAF) and the SF-36 functional status survey instrument. NMHIP is also beginning to look at diagnosis-specific assessment tools starting with those for schizophrenia.
VA has been a leader in the training of health care professionals since the end of World War II. More than 1,300 trainees in psychiatry, psychology, social work, and nursing receive all or part of their clinical education in VA mental health programs each year. Recently, VA has developed an innovative Psychiatry Resident Primary Care Education program with involvement of over thirty facilities and their affiliates, representing approximately 11 percent of VA's more than 700 psychiatry residents who receive training in VA facilities each year. In addition, 100 psychology and psychiatry trainees are involved in the highly successful Primary Care Education (PRIME) initiative, which provides mental health training within a primary care setting. This type of activity is changing how VA is training mental health providers and preparing them to meet the primary care needs of mentally ill patients. It serves and improves the mental health of veterans seen in medical and geriatric primary care in both VA and the nation.
In addition, VHA's Office of Academic Affiliations, in collaboration with the Mental Health Strategic Health Care Group and the Committee on Care of Seriously, Chronically Mentally Ill Veterans, has recently introduced a new interdisciplinary fellowship program in Psychosocial Rehabilitation. This program will train fellows from Psychiatry, Psychology, Social Work, Mental Health Nursing, and Rehabilitation in the latest state of the art approaches to treating and reintegrating those with serious mental illnesses into the community.
VA's educational efforts involve both traditional programs and innovative distance learning techniques. Face-to-face workshops serve a useful purpose for certain kinds of demonstrations (e.g., Prevention and Management of Disturbed Behavior Training) and for networking. Distance learning such as satellite broadcasts, Internet training, and teleconferencing, offers accessible, cost-effective training.
VA's National Center for PTSD, established in 1989, is a leader in research on PTSD. Its work spans the neurobiological, psychological and physiological aspects of this disorder. Women's sexual trauma and mental health aspects of disaster management are also addressed by the National Center, which has become an international resource on psychological trauma issues.
VA's Mental Illness Research, Education and Clinical Centers ( MIRECCs), which began in October 1997, bring together research, education, and clinical care to provide advanced scientific knowledge on evaluation and treatment of mental illness. The MIRECCs demonstrate that the coordination of research with training health care professionals in an environment that provides care and values results in improved models of clinical services for individuals suffering from mental illness. Furthermore, they generate new knowledge about the causes and treatments of mental disorders. All of the MIRECCs have active projects that are of direct benefit to veterans. In order to help create a new generation of mental health scientists, the MIRECCs, with the support of the Office of Academic Affiliations, have established Special Mental Health Fellowships to train young psychiatrists and psychologists for research careers. Their videoconference curriculum is accessible by non-MIRECC VA trainees as well. VA currently has eight MIRECCs located across the country, from New England to Southern California.
Mental health currently has two projects in the VHA Quality Enhancement Research Institutions ( QUERI) program. These include the Substance Abuse QUERI project, associated with the Program Evaluation Resource Center (PERC), and the Mental Health QUERI project. The Mental Health QUERI actually has two sets of activities: the Major Depression QUERI associated with the VISN 16 MIRECC, and the Schizophrenia QUERI associated with the VISN 22 MIRECC. The goal of QUERI is to promote the translation of research findings into practice and observe their impact on quality of care.
VHA has established an interagency Memorandum of Agreement ( MOA) with the Substance Abuse and Mental Health Services Administration (SAMHSA) and Bureau of Primary Health Care (BPHC) of the Health Resources and Services Administration (HRSA). This MOA will support a cross-cutting initiative to determine if there are statistically significant differences over a full range of access, clinical, functional, and cost variables between primary care clinics that refer elderly patients to specialty mental health or substance abuse services (MH/SA) outside the primary care setting and those that provide such services in a integrated fashion within the primary care setting. It will also address improving the knowledge base of primary health care providers to recognize MH/SA problems in older adults.
VA is also a partner with the National Institutes of Mental Health and the DoD in the National Collaborative Study of Early Psychosis and Suicide (NCSEPs). This ongoing project is designed to better understand the clinical and administrative issues of service members who suffer from psychotic disorders during military service, their course of care, and the transition from DoD to VA care in such a manner that continuity of care is maintained.
In FY 2001, VA Research Service funded 379 mental health projects at a cost of $53,756,149. VA investigators also were awarded $131,600,314 from other sources that funded an additional 1,189 mental health projects.
VA Mental Health programs provide a comprehensive array of clinical, educational and research activities to serve America's veterans. Our clinical programs are designed to provide the highest quality, most cost-efficient care, across a continuum of care designed to meet the complex and changing needs of our patients. Our educational programs train a significant proportion of our nation's future mental health care providers and ensure that our employees remain on the cutting edge of knowledge about the best clinical practices using traditional as well as innovative educational approaches. Our mental health research programs encompass both basic science as well as the essential translation of scientific findings into clinical practice. The Mental Illness Research Education and Clinical Centers ( MIRECCs) are excellent examples of the creative fusion of all three of these tasks.
Mr. Chairman, our mental health care system is strong and effective, but no system is perfect. Quality improvement activities such as NMHIP and QUERI symbolize VA's ongoing commitment to continuing improvement in the delivery of comprehensive, high quality clinical services to those veterans who need our care. It is imperative that high quality mental health services be available across the VA health care system. We are continuing our efforts to assure availability of appropriate services and the implementation of evidence-based practices in real world clinical settings.
Mr. Chairman, I will now be happy to answer any questions that you or other members of the committee may have.