Fiscal Year 2004 Performance and Accountability Report Published November 15, 2004
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VA's inherent responsibility is to serve America's veterans and their families with dignity and compassion and to be their principal advocate for medical care, benefits, social support, and lasting memorials. VA promotes the health, welfare, and dignity of all veterans in recognition of their service to the Nation. VA positively impacts the lives of veterans and their families, as well as the Nation as a whole. As stewards for the government, VA strives to improve the efficiency, effectiveness, and management of all VA programs. The following illustrations are a few examples of VA innovation and our desire to improve.
Medical Care
The Veterans Health Administration (VHA) has four distinct missions: provide health care; provide health professional training; conduct medical research; and serve as backup to the Department of Defense (DoD) and National Disaster Medical System. These missions not only serve veterans but provide benefits to the general public as well. The primary mission of VHA is to provide health care to veterans. VA health care facilities are involved in advancing the prevention, diagnosis, and treatment of disease conditions prevalent in the VA as well as the non-VA population. VHA has consistently improved the quality of care provided to veterans over the past several years. According to two organizations that monitor quality of care across the country, the National Committee for Quality Assurance and the Behavioral Risk Factor Surveillance System, in FY 2003 VA outperformed both the Medicare fee-for-service system and non-government medical systems in 18 of 18 comparable clinical indicators. In September 2004, the Congress on Improving Chronic Care recognized VA for pioneering work and contributions in the care of the chronically ill. VA was recognized for its performance measurement procedures and electronic health record system; officials credited VA for influencing the national discussion of improving health care quality by leading through example. VA has become the benchmark in a number of areas of quality of care, which benefits the Nation as a whole.
VHA is the vanguard for national standards for electronic medical records. VHA is participating with the Department of Health and Human Services (HHS) in an initiative to adopt uniform national standards throughout the Federal government for electronic health records. To date, 24 health care related standards have been approved for adoption. The VA electronic health record system is fully electronic, portable, and readily accessible. It was developed by VA employees working closely over time with clinicians and other end users. VHA developed the electronic record system to provide a single place for health care providers to review and update a patient's health record and order medications, special procedures, X-rays, diets, laboratory tests, and nursing orders. In VHA's system, all aspects of a patient's record are integrated including active problems, allergies, current medications, laboratory results, vital signs, hospitalizations, and outpatient clinic history. These records are all password-protected to guarantee patient privacy. President George W. Bush chose the VHA medical center in Baltimore to announce his commitment to ensuring that all U.S. citizens have an electronic health record in the next 10 years. The setting selected by the President exemplifies the positive impacts on quality of care and patient safety obtained through VHA's use of electronic health records for all veterans.
VHA is collaborating with the Centers for Medicare and Medicaid Services, an agency of HHS, to transfer VHA's electronic health record technology to the private physician office setting. This software, VistA Office EHR (Electronic Health Record), will include existing VistA functions of order entry, documentation, results reporting, etc. VistA Office EHR will be enhanced in the area of physician office patient registration and will interface to existing billing systems and provide for reporting of quality measures. Distribution of the software is expected to begin in July 2005. VistA is currently being used by the Department of Health for the District of Columbia and health care systems in Finland, Germany, Egypt, and Nigeria.
VA conducts an education and training program for health professions students and residents that enhances the quality of care provided to veteran patients within the VHA health care system. VA's graduate medical education is conducted through affiliations with university schools of medicine. Each year some 28,000 medical residents and 16,000 medical students receive part of their clinical training in VHA facilities through affiliations with 107 of the Nation's 126 medical schools and over 1,200 educational institutions. VA supports 8,800 physician resident positions in almost 2,000 university programs accredited by the Accreditation Council on Graduate Medical Education. VA is a leader in the training of associated health professionals. Through affiliations with over 1,200 individual health professions schools and colleges, some 32,000 associated health students receive training in VA facilities each year. Clinical traineeships and fellowships are provided to students in more than 40 professions, including nurses, pharmacists, dentists, audiologists, dietitians, social workers, psychologists, physical therapists, optometrists, nuclear medicine technologists, physician assistants, respiratory therapists, and nurse practitioners. VA is the largest provider of health care training in the United States.
Homelessness is a problem throughout the country, and approximately one-third of the adult homeless population is thought to be veterans. On any given day, as many as 250,000 male and female veterans may be living on the streets or in shelters. During the past year, more than 74,000 homeless and at-risk veterans received medical or mental health care from VA, and more than 20,000 veterans received transitional and supported housing, directly or in partnerships with grant and per diem or contract residential care providers. Additionally, VA is participating in a collaborative initiative with the Departments of Housing and Urban Development and HHS to provide permanent housing, health care, and other supportive services to those experiencing chronic or long-term homelessness. The total cost of this pilot program is $35 million with VA contributing $5 million. VHA, through its Homeless Providers Grant and Per Diem Program, awarded funding through four separate initiatives during the past year: Per Diem Only Awards, Special Need Grant, Life Safety Code Grant, and a Technical Assistance Grant.
VHA provided Per Diem Only awards to 80 projects in 30 states that will create 1,583 new beds and 2 service centers. With the addition of these awards to other Grant and Per Diem Program actions, VHA now supports nearly 7,000 beds that are available to homeless veterans. Special Need Grants totaling approximately $15.7 million have been awarded to 29 current Grant/Per Diem providers to enhance the delivery of services to the homeless veteran population of women, including women who have care of minor dependents; frail elderly; terminally ill; and the chronically mentally ill. This funding is for 3 years to provide for operational costs that would not otherwise be incurred but for the fact that the recipient is providing services to this population. Most organizations chose to collaborate their delivery of service with their local VA medical center (VAMC) that will receive approximately $4.3 million annually in internal funding. Approximately $900,000 was awarded under the Life Safety Code Grant to 8 existing Grant/Per Diem providers to renovate facilities to comply with the Life Safety Code of the National Fire Protection Association. Also, VHA awarded $1.5 million to 2 organizations under the Technical Assistance Grant component. These organizations have expertise in preparing grant applications relating to the provision of assistance for homeless veterans and will use this expertise to assist nonprofit community-based groups so that they may successfully locate and apply for grants. All of these activities benefit not only homeless veterans, but the entire homeless population.
VHA has continued efforts to increase scientific career opportunities for under-represented minorities. These efforts include supporting institutional collaborations between VA and minority-serving institutions, involving students and faculty from these institutions partnered with VA mentors; providing applied training in research on VA-funded projects to participants ranging from high school students and college undergraduates to graduates and pre-doctoral students; and offering a supportive career path for mentored research within VA for people who have completed their clinical fellowships or doctoral training within the last 2 years. The program provides a full salary to awardees for 3 years. This program, modeled after successful programs offered by the National Institutes of Health and the Robert Wood Johnson Foundation, strengthens VHA's partnerships with historically black colleges and universities, Hispanic-serving institutions, tribal colleges and universities, and other institutions with sizeable concentrations of Asian Americans, Pacific Islanders, native Hawaiians and Alaska natives.
Rural American Indian veterans and Alaska Native veterans have benefited from a formal agreement between VHA and HHS that augments historical local collaboration between VHA and the Indian Health Service. This agreement advances efforts to share information and technology; develop health promotion programs; and allow joint appointments, financial reimbursements, and provider certification. Formal collaboration, including co-sponsoring of continuing medical training for health care staff, combines the strengths and expertise of both VHA and IHS to increase access and enhance services.
The Richmond VAMC established a Parkinson's Disease Research Education and Clinical Center. The Center has an interdisciplinary team operating a core Parkinson's clinic that provides neurology exams and nursing interviews as well as physical exams, psychological assessments, neuropsychological screenings, telemedicine clinics, and caregiver support groups. As knowledge is gained from this clinic, recommendations for improving the efficiency and effectiveness of health care services to this target population will be shared inside and outside VA.
VHA made effective use of the Internet to educate veterans and the public on health and other issues. A comprehensive Web site on hepatitis C was launched through a collaborative effort between VHA and the University of California at San Francisco's Center for HIV Information. The new Web site is accessible to veterans and health care providers as well as the general public. It includes general information and links to other Web sites. The site also offers information for health care providers that is searchable by topic and includes best practices, guidelines, and slides.
VA also developed a Web site entitled VA Kids designed to help young people understand what it means to be a veteran. The VA Kids Web page supports President George W. Bush's initiatives on education and volunteerism by providing an entertaining and informative way for young people to learn why veterans are special. The Web page contains information targeted for students in kindergarten through grade 12 and for teachers. VA Kids also has information about VA, Veterans Day, scholarships, student volunteer opportunities, rehabilitative and special events for disabled veterans, and links to veteran-related sites. For younger students, VA Kids has interactive activities such as puzzles, coloring pages, matching contests, and age-appropriate language to describe a number of patriotic topics. For older students, there is information on volunteer programs, scholarships, and more sophisticated educational resources, games, and reference links. The teachers' section contains additional information, links, and suggested classroom activities.
VA also provides backup medical services to DoD in time of war and to the National Disaster Medical System in times of national emergencies or natural disasters. For example, VA provided emergency assistance to the States of Florida, Mississippi, and Alabama in the aftermath of hurricanes Charley, Frances, Ivan, and Jeanne. VA augmented local hospitals with more than 300 VA health care workers to help care for the injured. Employees at VA facilities volunteered their time to help victims of the hurricanes by collecting donations such as non-perishable food, personal hygiene items, and gift certificates to local businesses for disaster-area residents.
Medical Research
VA conducts medical research in a wide array of areas that address veterans' illnesses and disabilities and benefit the United States population as a whole. Some of the exciting advances in the past year included:
- New center for limb loss care: VA awarded $4.7 million over 5 years to researchers at its medical center in Providence, Rhode Island, to develop state-of-the-art care for veteran amputees, in collaboration with Brown Medical School and the Massachusetts Institute of Technology. The new "Center for Rebuilding, Regenerating and Restoring Function After Limb Loss" will provide patient care and conduct research in tissue engineering, neurotechnology, materials science, robotics, and advanced surgical techniques. VA expects the center to significantly improve outcomes for recent combat-injured veterans and other VA patients who have suffered amputation.
- Study questions benefits of costly schizophrenia drug: A VA study comparing an older, pennies-a-day schizophrenia drug with a newer, far more expensive one found little advantage to the higher priced drug. The researchers compared haloperidol, given with a drug to minimize its side effects, to olanzapine, the most expensive among the newer antipsychotic drugs. The study showed little difference in the overall effectiveness of the drugs, despite the huge price difference: Olanzapine costs VA more than $8 per day per patient, compared to about 10 cents per day for the haloperidol combination.
- Harmless virus helps slow HIV progression by boosting immune proteins: A study at the Iowa City VA Medical Center and University of Iowa shed light on the workings of a harmless virus, GBV-C, that has been shown to slow the progression of HIV and prolong survival for many patients. Scientists infected white blood cells with GBV-C and HIV, or with HIV alone. The cells with GBV-C showed an increase in immune-system proteins that bind to the same white-blood-cell receptors, or molecular "docking sites," used by HIV. When the receptors are not available, HIV is unable to infect the cells and spread through the body.
- Study explains role of brain chemicals in sleep: Researchers at the Greater Los Angeles Healthcare System and UCLA showed for the first time how three brain chemicals-serotonin, norepinephrine and histamine-play distinct roles in regulating sleep. According to the study, serotonin and norepinephrine affect muscle tone, keeping the body still at night, while histamine controls wakefulness. The researchers discovered this by studying dogs with narcolepsy, a sleep disorder. Narcolepsy is marked by cataplexy, a state in which the body goes limp, as if asleep, but the brain stays fully alert. Using electrodes to monitor the dogs' brain activity, the researchers noted that during cataplexy, neurons with histamine remained active, while those containing serotonin and norepinephrine fell silent.
- Researchers link two molecules to multiple sclerosis nerve damage: Scientists with VA, Yale and University College London identified two molecules that may underlie nerve-fiber degeneration in secondary progressive multiple sclerosis (MS). MS is a disease of the central nervous system that attacks myelin, the protective coating around nerve fibers. The new finding is the first observation in humans of specific molecules that contribute to the degeneration of nerve fibers.
- Brain scans show how a placebo eases pain: A VA researcher and colleagues produced the strongest evidence yet that a placebo-the mere expectation of relief, with no real treatment-causes physical changes in how the brain responds to pain. In related studies at the Ann Arbor VAMC and two universities, scientists used functional magnetic resonance imaging to map changes in blood flow in the brains of volunteers. The volunteers were subjected to harmless but occasionally painful electric shocks or heat. When they believed an anti-pain cream had been applied to their arm, they rated the pain as less intense-and the pain circuits in their brain showed less activity.
Benefits
VA's compensation program is critical to improving the quality of veterans' lives and that of their families. In FY 2004, over 2.5 million veterans received compensation benefits for disabilities incurred in or aggravated during military service. VA recognizes that certain veteran populations have unique needs or disabilities based on the circumstances of their service, and the compensation program specifically addresses these populations. Regulations that provide for presumptive service connection ease the veterans' burden of showing that certain medical conditions are related to service; these veterans include prisoners of war, those exposed to radiation in service or exposed to herbicides in Vietnam, and Gulf War veterans. Through new legislation, the list of presumptive conditions continues to expand. The list of presumptive conditions for veterans who were exposed to herbicides in Vietnam now includes diabetes; unexplained chronic multisymptom illnesses were added to the list of presumptive conditions for veterans who served in the Southwest Asia Theater of Operations during the Gulf War.
In FY 2004, Secretary Principi sent a letter to each veteran returning from Southwest Asia and Afghanistan and having separated from military service. The letter was to thank those veterans for their service and to inform them of VA benefits and services available to them. Approximately 200,000 letters were mailed for this initiative. VA continues to expand its outreach efforts to those who served in Operation Iraqi Freedom and Operation Enduring Freedom to ensure the successful dissemination of valuable information.
In addition, the compensation program provides additional allowances for a veteran's dependents if the veteran is at least 30 percent disabled from a service-connected condition. It also provides for veterans' survivors in the Dependency and Indemnity Compensation (DIC) program, making benefit payments to the eligible parents, unremarried surviving spouses, and children under 18 years of age of veterans who either died of a serviceconnected disability, or died from a disease or injury incurred or aggravated while on active duty for training, or died from an injury incurred while on inactive training. In certain circumstances, DIC payments may also be authorized for survivors of veterans who were totally disabled from a service-connected disability when they died, even though this disability did not cause their deaths. Surviving spouses and parents receiving DIC may be granted a special allowance to pay for aid and attendance by another person if they are patients in a nursing home or require the regular assistance of another person. Surviving spouses receiving DIC may be granted a special allowance if they are permanently housebound. Each year over 300,000 dependents receive benefits from this program.
VA's benefits programs also address other quality-of-life issues for service-disabled veterans by providing for specially adapted home grants to eligible veterans. This includes remodeling a home to accommodate special needs arising as a result of certain service-connected disabilities, such as loss of use of lower extremities, or blindness. Grants for adaptive equipment for an automobile are available to qualified veterans, as well as clothing allowances for qualified veterans who use prosthetic or orthopedic appliances as a result of a service-connected disability.
A pension benefit is of critical importance to many low-income veterans. It is available to veterans with qualifying wartime service who are permanently and totally disabled, and to their survivors. Veterans of a period of war who are age 65 or older and meet service and income requirements are also eligible to receive pension, regardless of their current physical condition. Death pension is provided for surviving spouses and children of wartime veterans who died of nonservice-connected causes, subject to specific income limitations. Each year, over 500,000 veterans and their surviving family members receive benefits from these programs. The average age of veterans in this program is 68 years old. In FY 2004, more than 342,000 veterans and more than 220,000 of their survivors received this benefit.
VA's education programs assist veterans in readjusting to civilian life by helping them obtain affordable higher education. These programs enhance the Nation's competitiveness through the development of a more highly educated and productive workforce. About 321,800 veterans received Montgomery GI Bill program benefits in FY 2004. An independent evaluation of VA's education programs demonstrated a positive return on investment of 2 to 1 in the form of increased income taxes for every program dollar spent.
Each year, VA supports more than 200,000 veterans in their applications for home loans. The main purpose of the VA home loan program is to help veterans finance the purchase of homes with favorable loan terms and at a rate of interest that is competitive with the rate charged on other types of mortgage loans. While clearly of direct benefit to our veterans, this activity also impacts on local economies across the country.
VA also plays a critical role in helping veterans maintain home ownership in certain trying situations. Alternatives to foreclosure can help veterans either retain their homes or avoid damage to their credit ratings, while reducing government costs.
VA's Vocational Rehabilitation and Employment (VR&E) program provides services to more than 55,000 disabled veterans annually. Eligible service-disabled veterans are given the assistance necessary to enable them to become employable and to obtain and maintain suitable employment to the maximum extent possible. VR&E also offers independent living services for severely disabled veterans who do not have employment potential.
In FY 2004, approximately 11,000 disabled veterans were successfully rehabilitated. This represents a 15 percent increase over the number rehabilitated during FY 2003.
The Philadelphia VA Insurance Center was chosen from among 22 organizations as the recipient of the 2004 Government Customer Support Excellence Award in the category of Overall Excellence for the performance of a nationwide toll-free call center. Sponsored by the Government Customer Support Association, the award recognizes customer support excellence by call centers and help desks. The Insurance Center was also named the recipient of the 2004 Leo C. Wurschmidt, Jr. Customer Service Team Award, VBA's highest award for customer service. The award was based on a program of special outreach created to ensure that recently separated, disabled veterans were taking advantage of VA life insurance benefits.
The special outreach program was developed in response to findings that severely disabled veterans underutilize insurance benefits. The program includes creating a database of matches to identify non-takers of the insurance, personally calling and sending letters to each veteran, and expediting the application process. To date, over $90 million in insurance benefits have been extended to disabled veterans as a result of this special outreach. For recently separated servicemembers, the Insurance Center worked in coordination with the Servicemembers' Group Life Insurance's marketing department to develop informational brochures to be distributed through VA's Transition Assistance Program. The brochures provide information on all open insurance programs and are designed to assist veterans in making an educated choice regarding their life insurance needs. VA hopes that these efforts will ensure the retention of a valuable benefit for those most in need and will also raise all veterans' awareness of their earned insurance benefits.
Burial
Primarily through NCA, VA honors veterans with a final resting place and lasting memorials that commemorate their service to the Nation.
VA provides interment of veterans and eligible family members. In FY 2004, more than 93,000 decedents were interred in 120 VA national cemeteries.
VA provides headstones and markers for the graves of eligible persons in national, state, other public, and private cemeteries. Presidential Memorial Certificates, bearing the President's signature, are issued to recognize the contributions and service of honorably discharged deceased veterans. In FY 2004, VA processed nearly 351,000 applications for headstones and markers and issued more than 435,000 Presidential Memorial Certificates. VA also provides an American flag to drape the casket of an eligible deceased veteran. Far more veterans receive a headstone or marker, a Presidential Memorial Certificate, and/or an American flag from VA than are buried in a national cemetery. Delivery of these benefits is not dependent on interment in a national cemetery.
In FY 2004, VA maintained more than 2.6 million graves and nearly 7,200 developed acres in a manner befitting national shrines, so that bereaved family members are comforted when they come to the cemetery for the interment, or later to visit the grave(s) of their loved one(s).
In FY 2004, VA launched a Web-based (Internet) Nationwide Gravesite Locator system. This innovation will make it easier for anyone with Internet access to search for the gravesite locations of deceased family members and friends and to conduct genealogical research. The nationwide grave locator contains more than 3 million records of veterans and dependents buried in VA's 120 cemeteries since the Civil War. It also has records of some burials in state veterans' cemeteries and burials in Arlington National Cemetery (under the jurisdiction of the Department of the Army) from 1999 to the present. Making burial locations more accessible may bring more visitors to the honored resting places that VA considers national shrines and historical treasures.
VA is partnering with the National Center for Preservation Technology and Training (NCPTT), an office of the National Park Service (NPS), to conduct research on the methods to clean historic headstones and markers. After VA, NPS has the largest number of national cemeteries, including Gettysburg National Cemetery, under its jurisdiction. Under a 2-year interagency agreement, NCPTT will identify alternatives for cleaning historic headstones and markers.
VA is partnering with Save Outdoor Sculpture! (SOS!), a non-profit organization that uses volunteers to survey public outdoor sculpture nationwide, to develop the first comprehensive inventory of memorials located in more than 100 national cemetery properties across the country. Since national cemeteries were established in 1862, they have become the sites of memorials erected to recall distinctive heroics, group burials, and related commemorations. These memorials range from modest blocks of stone, sundials, and tablets affixed to boulders to more sophisticated obelisks and single soldiers on granite pedestals. Since the project's inception in spring 2002, the number of memorials identified during the course of the inventory has risen from approximately 300 to approximately 800. More than 200 volunteers are spending an average of 8 hours researching and documenting each memorial. In addition to gathering historical information about the memorials, volunteers also document materials, dimensions, appearance, evidence of damage, and setting. The inventory will help VA prioritize conservation needs as well as develop a maintenance plan for all its memorials. When the project is complete, the inventory data will reside at VA as well as being publicly accessible online through another SOS! partner, the Smithsonian American Art Museum.
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