[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
CARE COORDINATION: ASSESSING VETERANS
NEEDS AND IMPROVING OUTCOMES
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HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
TUESDAY, JUNE 13, 2023
__________
Serial No. 118-19
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via http://govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
52-878 WASHINGTON : 2024
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COMMITTEE ON VETERANS' AFFAIRS
MIKE BOST, Illinois, Chairman
AUMUA AMATA COLEMAN RADEWAGEN, MARK TAKANO, California, Ranking
American Samoa, Vice-Chairwoman Member
JACK BERGMAN, Michigan JULIA BROWNLEY, California
NANCY MACE, South Carolina MIKE LEVIN, California
MATTHEW M. ROSENDALE, SR., Montana CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa FRANK J. MRVAN, Indiana
GREGORY F. MURPHY, North Carolina SHEILA CHERFILUS-MCCORMICK,
C. SCOTT FRANKLIN, Florida Florida
DERRICK VAN ORDEN, Wisconsin CHRISTOPHER R. DELUZIO,
MORGAN LUTTRELL, Texas Pennsylvania
JUAN CISCOMANI, Arizona MORGAN MCGARVEY, Kentucky
ELIJAH CRANE, Arizona DELIA C. RAMIREZ, Illinois
KEITH SELF, Texas GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia NIKKI BUDZINSKI, Illinois
Jon Clark, Staff Director
Matt Reel, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman
AUMUA AMATA COLEMAN RADEWAGEN, JULIA BROWNLEY, California,
American Samoa Ranking Member
JACK BERGMAN, Michigan MIKE LEVIN, California
GREGORY F. MURPHY, North Carolina CHRISTOPHER R. DELUZIO,
DERRICK VAN ORDEN, Wisconsin Pennsylvania
MORGAN LUTTRELL, Texas GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia NIKKI BUDZINSKI, Illinois
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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TUESDAY, JUNE 13, 2023
Page
OPENING STATEMENTS
The Honorable Mariannette Miller-Meeks, Chairwoman............... 1
The Honorable Christopher R. Deluzio, Acting Ranking Member...... 2
WITNESSES
Panel 1
Dr. M. Christopher Saslo, Ph.D, Assistant Under Secretary for
Health/Chief Nursing Officer, Office of Patient Care Services,
Veterans Health Administration, U.S. Department of Veterans
Affairs........................................................ 3
Accompanied by:
Dr. Sachin Yende, MD, Chief Medical Officer, Office of
Integrated Veteran Care, Veterans Health Administration,
U.S. Department of Veterans Affairs
Dr. Jennifer Strawn, Ph.D, Deputy Chief Nursing Officer/
Executive Director, Office of Nursing Service, Veterans
Health Administration, U.S. Department of Veterans
Affairs
Ms. Jill Debord, Executive Director, Office of Care
Management and Social Work Services, Veterans Health
Administration, U.S. Department of Veterans Affairs
Dr. Julie Kroviak, MD, Principal Deputy Assistant Inspector
General, Healthcare Inspections, Office of the Inspector
General, U.S. Department of Veterans Affairs................... 5
Panel 2
Ms. Andrea Sawyer, Advocacy Director, Quality of Life Foundation. 16
Mr. Matt Brady, Director, Complex Case Coordinator Program,
Wounded Warrior Project........................................ 18
Mr. Roscoe Butler, Senior Health Policy Advisor, Paralyzed
Veterans of America............................................ 20
APPENDIX
Prepared Statements Of Witnesses
Dr. M. Christopher Saslo, Ph.D Prepared Statement................ 33
Dr. Julie Kroviak, MD Prepared Statement......................... 38
Ms. Andrea Sawyer Prepared Statement............................. 46
Mr. Matt Brady Prepared Statement................................ 50
Mr. Roscoe Butler Prepared Statement............................. 57
CARE COORDINATION: ASSESSING VETERANS
NEEDS AND IMPROVING OUTCOMES
----------
TUESDAY, JUNE 13, 2023
U.S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, D.C.
The subcommittee met, pursuant to notice, at 1 p.m., in
room 360, Cannon House Office Building, Hon. Mariannette
Miller-Meeks [chairwoman of the subcommittee] presiding.
Present: Representatives Miller-Meeks, Radewagen, Van
Orden, Luttrell, Kiggans, Brownley, Deluzio, Landsman, and
Budzinski.
OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN
Ms. Miller-Meeks. Come to order.
As a 24-year veteran and a physician who has worked with
the VA, I have seen first-hand how important coordination is to
providing timely, quality care, especially for veterans with
complex health needs. It is one of my top priorities in
Congress to ensure veterans have access to care where they need
it and when they need it.
VA's care coordination programs should help veterans
navigate the complex world of healthcare both within the VA and
with VA's community partners. VA's Patient Aligned Care Team,
or PACT, model provides, or should provide, personalized,
patient driven care and positively can impact a veterans
experience in the primary care setting. However, high need,
high risk veterans often lack support for their complex
clinical and psychosocial needs beyond that setting. This is
not due to a lack of compassionate coordinators and social
workers within the VAs, but rather due to poorly defined roles
and jurisdictions for these advocates. Veterans who receive
care across multiple locations are at the greatest risk for
lapses in care, especially when their medical records are
either not returned to the VA or the VA does not correctly
input vital medical information. Communication between the VA
and its provider partners could be greatly enhanced with
coordinators who are empowered to work across clinical and
arbitrary bureaucratic lines.
As we will hear from the Veteran's Affairs Office of
Inspector General (VA OIG) and from our second panel of veteran
advocates, veterans with complex cases who do not receive
proper care coordination more often than not experience
detrimental health outcomes. Some of their stories are
heartbreaking. The Quality of Life Foundation, Wounded Warrior
Project, and Paralyzed Veterans of America have managed to
establish programs that cross multiple disciplines to
effectively manage the care for some of our most complex,
injured, and ill veterans. VA can and must do better.
I look forward to hearing how we can better coordinate the
coordinators and ensure that no veteran falls through the
cracks.
With that, I yield to the ranking member and her
substitute.
OPENING STATEMENT OF CHRISTOPHER R. DELUZIO, ACTING RANKING
MEMBER
Mr. Deluzio. Thank you, Madam Chairwoman. Of course, I am
sitting in for Ms. Brownley today, who is still in
Transportation and Infrastucture (T&I) markup, I am sure, will
join us when she can.
As the largest integrated healthcare system in this
country, the Veterans Health Administration is perhaps one of
the most well positioned to effectively coordinate patients
care. Given the patient population it serves, my fellow
veterans care coordination is critical. As compared to their
non-veteran peers, veterans have a greater number of medical
comorbidities, and psychosocial needs that need to be
considered and well-coordinated when delivering healthcare.
However, as we will hear from some of our witnesses today,
there are many ways in which the Veterans Health
Administration, VHA, needs to improve its coordination of
veterans care to ensure veterans receive the soonest and best
care possible, whether directly from the VA or from fee for
service or community care providers.
As defined by the Federal Agency for Healthcare Research
and Quality, care coordination entails deliberately organizing
patient care activities and sharing information among all of
the participants concerned with the patient's care to achieve
safer and more effective care. Despite the existence of
numerous care coordination and case management programs across
VHA, the committee regularly hears about instances where
veterans with complex care needs have not received the help,
they need to navigate VHA's direct care system or fee for
service or community care, experiencing delays or serious gaps
in care. There are too many instances where veterans fall
through the cracks and do not receive the care they need, when
and where they need it. In the most serious cases, like those
we will hear about from our Office of Inspector General
witness, lapses in care coordination can lead to poor patient
outcomes and patient harm.
I hope today's hearing will help us examine ways VHA can
address some of the root causes of care coordination
breakdowns. At the outset, I see at least three areas to be
addressed.
First, care coordination programs within VHA tend to be
fragmented or siloed within certain program offices or clinical
service lines. They generally target specific categories of
patients diagnoses or clinical specialties, leading veterans to
be passed off from one care coordinator to another. This
heightens the risk of care coordination breakdowns as veterans
transition from one coordinator or one setting of care to
another accomplishing the exact opposite of the goals these
programs are intended to meet.
Second, information technology limitations also present
barriers to care coordination. We are still years away from
having integrated electronic health record at VA and Department
of Defense (DoD). Meanwhile, VA's legacy system makes it such
that veterans traveling to or relocating from one VA facility
to another have to be registered at their new facility before
providers at that facility can access their VA electronic
medical record. VA's ability to electronically access and
receive medical records from non-VA community providers is
still very limited. This means that VA staff often have to
request paper copies of medical records from non-VA providers,
leading to delays and gaps information from fee for service or
community care encounters.
Third, and last, a lack of strong oversight across VA
medical facilities and gaps in existing policies lead to
inconsistent patient care experiences for veterans. Some care
coordination programs are only available at VA medical
facilities that have chosen to offer them, and even in care
coordination programs that all facilities are required to
offer, caseloads and patients experiences can vary
considerably.
Certainly, much for us to examine today and many
opportunities for VHA to improve. I would add that with the
ongoing implementation of the The Sergeant First Class Heath
Robinson Honoring our Promise to Address Comprehensive Toxics
(PACT) Act, thousands of veterans with complex cancers and
respiratory illnesses will be entering the VA healthcare system
in the coming years. It is therefore an opportune time for this
committee and VHA to consider ways to strengthen care
coordination frameworks and ensure VHA will be prepared to
serve this cohort of veterans and their caregivers.
Madam Chair, thank you again for organizing this hearing. I
look forward to it and I yield back.
Ms. Miller-Meeks. Thank you, Mr. Deluzio.
I just wanted to have a point of information, and that is
most of you know that votes will be coming up shortly, so we
will take a recess for votes. At this time, I would like to
introduce the witnesses today and I would like to thank you for
joining us.
Joining us from the Department of Veterans Affairs is Mr.
Christopher Saslo, who is the assistant undersecretary for
Patient Care Services and the chief nursing officer.
Accompanying Dr. Saslo today is Dr. Sachin Yende, the chief
medical officer in the Office of Integrated Care. If I
mispronounce anybody's name, I do apologize. Ms. Jennifer
Strawn, the executive director, Office of Nursing Services and
deputy chief nursing officer, and Ms. Jill Debord, executive
director of Care Management and Social Work Services. We also
have Dr. Julie Kroviak, the principal deputy assistant
inspector general of healthcare inspections in the office of
the Inspector General.
Dr. Saslo, you are now recognized for 5 minutes to deliver
your opening statement.
STATEMENT OF M. CHRISTOPHER SASLO
Mr. Saslo. Thank you. Good afternoon, Chairwoman Miller-
Meeks and ranking members and distinguished members of the
subcommittee.
Thank you for the opportunity today to discuss VHA's
various care coordination programs within VA, community
providers and emergency services. Accompanying me today, as
mentioned, is Dr. Sachin Yende, chief medical officer for the
Office of Integrated Veterans Care, Dr. Jennifer Strawn,
executive director for the Office of Nursing Service and our
deputy chief nursing officer, and Ms. Jill Debord, executive
director for Care Management and Social Work services.
Care Coordination and Integrated Case Management (CCICM) is
a practical approach rather than a program with a framework
that promotes care coordination stratification across the
entire care continuum. It focuses on the complex and high to
moderate veterans who have complex care coordination needs.
Preliminary data illustrates that our CCICM model provides
positive impacts to care outcomes and increasing veteran trust
scores.
To illustrate this, I would like to share one of our many
care coordination integrated care management success stories. A
veteran with multiple complex comorbidities has been utilizing
community emergency rooms to address all of their medical
needs. The veteran has found to have 16 ER visits in a 2 month
period of time. The lead coordinator assigned to this veteran
was able to build a rapport and gain the veteran's trust while
assessing for global needs. The urgent consults were scheduled,
and follow up was obtained while connecting the veteran three
to five times a week via phone. The coordinator assisted the
veteran with support using therapeutic listening and
motivational interviewing to empower the veteran to feel
confident about their healthcare decisions. The coordinator
also assisted with obtaining an emotional support animal for
the veteran, which made a positive impact in their mental
health and coping abilities.
As a result, since being assigned a lead coordinator, the
veteran has had zero visits to any urgent care or emergency
department. The veteran expressed confidence in the care team
and in control of their health and wellness. The veteran is now
able to proactively manage care and enlist the lead coordinator
with urgent requests on an as needed basis.
While this story highlights positive outcomes, we also know
that there are opportunities to enhance and improve that care
coordination within our system. With the number of veterans
using VA care as it grows and the veteran patient population
typically having more complex medical and social needs than any
other population, that care coordination is critical. To meet
these needs, VA provides a broad array of services.
VHA is developing a long-term strategy to ensure all
veterans across their continuum of care receive the soonest and
best care possible, both within the VA and in the community. It
is imperative that VHA optimizes and integrates its care
coordination and services and its resources. VHA's strategy
must address the current navigational and access to care
challenges. Without intervention to better coordinate the care,
veterans will continue to have higher rates of emergency
department visits, hospital admissions, and substantial
increases in healthcare costs. When fully implemented, the new
coordinating care will benefit thousands of veterans and their
qualified family members, increasing their access to care and
improving health outcomes.
Last year, VHA leadership assembled an interdisciplinary
integrated project team, or IPT, bringing together the offices
in patient care services, such as nursing service and care
management and social work services, and our integrated
veterans care team to address these challenges and serve as the
team's resource and planning framework. This initiative aims to
decrease navigational and fragmented care challenges through
proactive identification of veterans with complex care
coordination needs. The objective is to enhance and align
resources to organizational needs to support stabilization of
our workforce and drive innovation.
Finally, under the framework for CCICM, veterans will have
high quality, coordinated care that is delivered in a
consistent manner across all care settings. We are serving
record numbers of veterans both in the VA and in the community,
with significant progress toward our timeliness goals. I will--
was going to say Chairwoman Miller-Meeks, but you have
changed----
Mr. Van Orden. [Presiding] I appreciate that.
Mr. Saslo [continuing]. and ranking member, we appreciate
your continued support and look forward to answering your
questions.
[The Prepared Statement Of M. Christopher Saslo Appears In
The Appendix]
Mr. Van Orden. Thank you, Dr. Saslo.
The chair now recognizes Dr. Kroviak for 5 minutes.
STATEMENT OF JULIE KROVIAK
Dr. Kroviak. Thank you. I appreciate the opportunity to
discuss the OIG's oversight of VHA care coordination.
The OIG's Office of Healthcare Inspections reviews the
quality and safety of healthcare provided across VHA, and our
reviews frequently highlight challenges associated with
coordinating veteran care across multiple service lines and a
wide variety of healthcare settings.
My written testimony highlights some of the many issues and
breakdowns that providers and patients have faced in navigating
the complexities of care coordination, from enrolling in VA to
receiving care at the VA and then receiving care in the
community. Gaps in any of these steps of care transition
compromise patient safety and fracture confidence in the
system. Unfortunately, it is during these transitions of care
that the most vulnerable patients face the greatest risks.
Transitioning from DoD to VA can introduce new stressors to
service members and their families, and the reintegration
challenges can be magnified for a veteran with traumatic brain
injury, Post Traumatic Stress Disorder (PTSD), or substance use
disorder. Gaps in care coordination for those members diagnosed
with high-risk mental health or substance use issues can be
fatal during this period.
The OIG is finalizing a national review evaluating the
risks for service members with documented opioid use disorder,
or OUD, as they transition their care from DoD to VHA. We found
that VHA providers are not consistently placing critical
information regarding the OUD diagnosis in the veterans VA
medical record. Failure to identify and document a patient's
known OUD history may decrease the likelihood of a patient
receiving timely VA care and support.
These care coordination challenges continue for VHA
patients, with many of our reports finding failures involving
VHA clinical and administrative leadership, and frontline
staff. Our reports have substantiated unreasonable delays in
responding to critically ill veterans needing emergent care,
dangerous errors in discharge planning for high-risk veterans,
and failures in coordinating end-of-life care for a terminally
ill veteran transferring between levels of care within VA. We
have also seen failed coordination between the Veterans Crisis
Line, local suicide prevention teams, and emergency department
staff, as well as failures with vet center staff coordinating
with local VA medical centers to ensure that clients deemed
high risk for suicide receive appropriate clinical support.
The expansion of VHA's partnership with community providers
has further challenged care coordination. Once a veteran and
their VHA provider agree on a need for a community care
referral, a variety of VHA clinical and administrative staff
enter into a complex process to complete a simple goal
scheduling an appointment for a veteran. We reviewed VA's
implementation of the Referral Coordination Initiative, which
is designed to improve timeliness of scheduling community care
appointments. Despite a goal of complete implementation 2 years
ago, full implementation has yet to be achieved.
The challenges of community care coordination continue
beyond timely scheduling. Our reports have highlighted
deficiencies for veterans receiving care in the community,
including delays in diagnosis and treatment, lack of or
miscommunication between providers, and quality of care
concerns. We are in the final stages of developing a community
care cyclical review, and the initial phases of data analysis
support many of the issues identified in our publications. We
are hopeful that these reviews will support VHA leaders efforts
to introduce efficiencies and reduce the risks associated with
community care. From a quality of care standpoint, until timely
clinical information sharing between the community and VHA is
ensured with each care encounter, VHA has no reasonable
assurance that veterans are getting the care they need. Reviews
from our Office of Healthcare Inspections as well as from our
Office of Audits and Evaluations confirm current processes put
veterans at risk.
We do appreciate VHA staff's exhaustive efforts to
coordinate safe care across multiple venues for millions of
veterans. The complexity and scale of that work will only
increase as more veterans engage with the community and VA
healthcare services expand in response to the PACT Act. The OIG
will continue to enhance and adapt our work to support VA
leaders and frontline staff with meaningful and impactful
oversight, with a shared goal of increasing efficiencies and
processes and assuring high quality care delivery.
This concludes my statement. I would be happy to answer any
questions.
[The Prepared Statement Of Julie Kroviak Appears In The
Appendix]
Mr. Van Orden. Thank you, Dr. Kroviak. I appreciate that.
I now recognize myself for 5 minutes.
Dr. Kroviak, I got to tell you, I read all your testimony,
I reread the testimony from last time you were here, and I
appreciate it greatly. I found this particular set, or this
testimony fascinating. It was terrifying. It was fascinating
because it was like watching a slow moving train wreck and it
was terrifying because I find it interesting that someone as
brilliant as you are, and you are, could not identify the root
problem that you alluded to. It is so obvious. It is the fact
that there is no accountability. There is no accountability
across any of these levels.
I had my staff, which are awesome, they did the word
search. A lot of people say accountable--accountable,
accountability, right. There are zero instances in anybody's
testimony from this panel or the next of the word fired,
censured, referred for discipline, nothing.
You have a veteran in southwestern Nevada who committed
suicide because they were essentially blown off. They had all
these problems, everybody knew about it, and they were not
treated appropriately, and they committed suicide.
I come from a naval background, as does my friend Morgan,
as does my colleague, Mr. Deluzio. When a ship's captain is
asleep in their cabin at night and the ship runs aground, the
captain is held ruthlessly accountable. They are fired
immediately even though they are asleep. I did not find any
testimony of a single instance of anyone being fired, referred
for discipline, or censured, and we have dead veterans.
I would like to make a suggestion for you. When these
instances happen, I think every single person that is involved
in that chain of custody, for lack of a better term for these
veterans, should write a personal letter to the widow or the
widower or the mother or the father and the children of these
dead veterans and apologize to them for their lack of care. I
think every single person from the Veterans Administration in
that chain of custody for a veteran that is responsible for
these suicides needs to go to all of these funerals. I would be
more than happy to submit an amendment. I am sure everybody
would sign on it. We will pay for that. We will pay for your
travel costs. As soon as your folks at the Department of
Veterans Affairs start going to some of these funerals, like we
have gone to God, I do not know how many of my friends, you
will change. Until that happens, nothing will. If you have no
accountability, do not have an organization, you have a paid
mob.
Can you, with a piece of paper and a pencil, could you
possibly draw me a line and block chart of all of these various
coordinators that currently exist and are being paid for by the
American taxpayers that have been failing our veterans for
decades?
Dr. Kroviak. Sir, I can certainly appreciate-the disdain
you feel--our reports hold VHA accountable to their policies
and practices, and we assign recommendations to whom is
ultimately responsible for correcting those actions. We have no
authority to manage or punish VHA staff in our oversight
position.
Mr. Van Orden. Does anybody?
Dr. Kroviak. That would be from VA.
Mr. Van Orden. Okay, so check me out. I represent Tomah. It
is where the whole candy doctor guy opioid thing blew up. Had a
veteran commit suicide from that. We had 900 veterans being
seen by a single lady that did not appropriately rate them, 600
of the 900, 2/3s have been determined that she did that
incorrectly. She got fired. I was there with Denis, the
Secretary of Veterans Affairs--fired. I want you to tell me how
we can make sure that your reports--because they do not hold
anybody accountable, they do not. It is a harshly worded,
email--I want you to tell us how we can help you to empower you
to make sure that these people are actually held accountable.
By that, I mean the door hitting them in the behind as they are
leaving the institution permanently.
Can you help me with that?
Dr. Kroviak. I believe I can definitely help with that.
Mr. Van Orden. Thank you.
Dr. Kroviak. We are always thrilled to provide briefs of
our reports to congressional staff, and we take their
interest--the local interest, and the authority they have to
hold local leaders accountable for their recommendations and
action plans that are put into place.
Mr. Van Orden. Thank you, ma'am. My time has expired.
I am frustrated, but my brothers and sisters are dead.
With that, I yield back.
I recognize Mr. Deluzio for 5 minutes.
Mr. Deluzio. Thank you, Mr. Van Orden. I will echo your
very good and correct point that the consequence here is
people's lives. I think it is a good reminder of what is at
stake when there are mistakes in the lack of coordination.
Those are the stakes. They are serious ones.
I guess my question -I will start with Dr. Saslo and then
Dr. Kroviak, love to hear from you as well, from the OIG
perspective.
I am thinking about, first, coordination of care or the
lack thereof, that happens on the community care fee for
service side. My understanding is many providers--well, there
is not a requirement to submit records to VA in an electronic
form, for instance, and some do not do it in a timely manner or
at all. I am wondering what the ways in which those lapses in
coordination are impacting veterans who are serving in the VA?
Mr. Saslo. Thank you for the question.
One of the things I think is important to acknowledge is
that we recognize that the challenges in getting the medical
records back in a timely manner and being able to integrate
them into the veterans record is extremely important for that
continuity of care. One of the reasons for the Care
Coordination Integrated Case Management Project itself is
because of the gaps that we have identified both within VA and
within the community care itself. Our goal is to actually be
able to identify for those complex needs, or moderate to
complex needs, that we have one individual who is that lead
coordinator who will not only be able to work with the veteran,
but also working with the different care teams across the
continuum so that the information that we receive is not only
provided in a timely manner, but also handed off to the correct
individual that will then continue that care within the VA if
it is necessary, or managing the care within the community.
Mr. Deluzio. Dr. Saslo.
Mr. Saslo. Yes, sir.
Mr. Deluzio. I am sorry to interrupt, but just for the sake
of time, I am curious, if a provider does not provide any
records at all, or they do it in a very untimely fashion, what
is the consequence for them?
Mr. Saslo. Dr. Yende.
Dr. Yende. I can take that question, Congressman.
Previously we used to link claims reimbursement for
community care providers with receipt of medical records. That
means we need to confirm that they have sent the medical
records. As you rightly pointed out, the fax system is very
challenging to work with. We had instances where the provider
said that they had sent the records, we could not verify on the
VA side, and we had delays with claims processing. I believe we
had several congressional inquiries asking why those claims
processing were delayed. In order to make sure that our
veterans were getting timely access, we decided to waive it.
You ask a very important point, and we realize that there
are challenges getting medical records back. I totally
understand that care coordination cannot be done without it. We
have two or three approaches we are pursuing.
Number one, VA is one of the five Federal agencies that
participates in health information exchanges. That is a
mechanism where we can get those records electronically. Those
Health Information Exchanges (HIEs) account for about 70 plus
percent of HIEs locally. Through those we get those records,
but they are not complete in most instances.
Number two, we have worked out processes with our Third
Party Administration (TPA) partners where if we feel that a
provider is not providing records consistently, which is what
you alluded to, we will work with their TPA partners to make
sure that they send those records to us.
Finally, as you said, really, technology is a solution out
here. Trying to work through faxes, trying to make sure those
faxes get into our medical records, is a very laborious
process. We are really exploring some technology solutions out
here, and we hope to brief you in the near future.
Mr. Deluzio. Thank you.
Dr. Kroviak, I am going to give you the remainder of my
time. My question is the same. One, how bad is this problem
where providers outside the VA are not turning in records at
all or in a timely fashion, and is there any real consequence,
and is the lack thereof hurting care for veterans?
Dr. Kroviak. It is absolutely impacting care for veterans.
It is not getting better from our work. I do believe technology
is the solution, but I do not believe we are anywhere near
making that solution a reality.
Mr. Deluzio. Thank you.
Mr. Van Orden, I yield back.
Mr. Van Orden. Thank you, Mr. Deluzio.
The chair now recognizes Mr. Luttrell for 5 minutes.
Mr. Luttrell. Thank you, Mr. Chairman.
Good morning, Ms. Kroviak. Your one year anniversary in
this position, correct? Last year?
Dr. Kroviak. In this position, it might be August, but I
was the deputy prior to that, so it is been several years.
Mr. Luttrell. How many Inspector General (IG) reports have
you presented on these topics?
Dr. Kroviak. On community care?
Mr. Luttrell. Mm-hmm.
Dr. Kroviak. I cannot count, but I suspect almost every
report we published in the Office of Healthcare Inspections
touches on aspects of care coordination.
Mr. Luttrell. Is there a repetitive nature to these
reports?
Dr. Kroviak. Yes.
Mr. Luttrell. Very similar to the ones that you just read
for us today?
Dr. Kroviak. Yes.
Mr. Luttrell. Is there anyone sitting on this panel with
you today responsible for any of the issues that you listed
directly?
Dr. Kroviak. Directly? I would have to assume not. I think
we are talking with leaders at the table. In terms of
individuals at facility levels...
Mr. Luttrell. Is there anybody that directly reports to
anybody sitting on this panel?
Dr. Kroviak. From any of our reports? I could not say, but
I am not 100 percent sure, but I would not--they would probably
be----
Mr. Luttrell. If you are following my line of questioning
here, and you can see how this panel is unified on these
issues--we are done. I want names. I do not want any more IG
reports that get lost in the sauce and hung on the shelf or the
Department does not take it seriously. You have repeatedly done
your job. Well done. It has obviously fallen through the cracks
because these issues are the same issues that we keep hearing
over and over again.
Mr. Saslo, do you have any response at all to the IG report
and how we can course correct this ship that is continually
sinking?
Mr. Saslo. Yes. I believe, as I started earlier, the entire
integrated project team that we have put together really has
looked at a number of those failures that does not ensure that
the veterans timely access to care or their care coordination
is being addressed.
I will ask Dr. Strawn or Ms. Debord to address it a little
bit further, but from an awareness standpoint, we have two
different professions that really help to coordinate the care
within VHA, our nursing partners as well as our social work
partners. Coming together and working with our integrated
veterans care team, we have actually identified several
different mechanisms that are going to help to minimize any of
the fragmentation in care and hopefully over the course of the
roll out to make sure that we do not have those veterans
falling through the cracks, making sure that we----
Mr. Luttrell. How long have you been in this position?
Mr. Saslo. I have been in my position as an assistant
undersecretary since October. I have been with the VA for 27
years.
Mr. Luttrell. Twenty seven years--so you are familiar with
these issues?
Mr. Saslo. Yes, sir, I am.
Mr. Luttrell. What are we doing wrong?
Mr. Saslo. We are----
Mr. Luttrell. That is rhetorical. How do we fix the
problem?
Mr. Saslo. We are looking at being able to do----
Mr. Luttrell. No more looking. We are done looking.
Mr. Saslo. I apologize for the verb. We are in the process
of addressing that through the CC&ICM framework, which will
allow us to help make sure that that complex care that our
veterans are sometimes losing is going to be addressed by lead
coordinators, by making sure that the teams are actually
effectively engaged, so that it is not just you are going to go
to the mental health clinic or you are going to go for your
orthopedic clinic, how do we have that continuity of care to
make sure that one person helps to mitigate many of those
issues.
I will ask Dr. Strawn or Ms. Debord to go ahead and add to
that.
Dr. Strawn. What Dr. Saslo has described is what we are
calling--it is a framework. It is a care coordination and
integrated case management framework.
Within VA, there are multiple programs, and there are care
coordinators within each program. A veteran who may suffer from
medical chronic conditions, may have mental health issues, may
have social determinants of health issues, those patients or
veterans may have multiple case managers. What we have found is
that there is siloing and fragmentation. With the new CCICM
framework, a veteran who needs moderate or complex care
coordination will have an assigned lead coordinator, and that
coordinator will assist them, internal and external to VA to
navigate the healthcare system.
Mr. Luttrell. Ms. Strawn, real quick, I am running out of
time here, how long have you been with the VA?
Dr. Strawn. I have almost been with the VA 30 years.
Mr. Luttrell. Thirty, years twenty six years. Mr. Yende?
Dr. Yende. About a decade.
Mr. Luttrell. Ten years. Ms. Debord.
Ms. Debord. Thirty years.
Mr. Luttrell. Thirty years. How many of those reports have
you read from the IG? Every one of them? Collectively, you are
over 100 and some odd years of experience in the VA, and the
report has not changed in decades.
I think we need to take a hard look in the mirror. I hate
to be brash, but as a veteran, I am being brutally honest.
Understand.
Ms. Kroviak, will you get me those names? I want everybody
that is responsible for this IG, the reporting officer, whether
it is the secretary or whomever. Enough is enough. Deal.
Thank you.
Mr. Chairman, I yield.
Mr. Van Orden. Thank you, Mr. Luttrell.
I just like to sum something up. You guys, the four of you
have over 100 years of experience in the Veterans
Administration, and nothing is going to change until one of you
get fired.
I now yield to Ms. Budzinski for 5 minutes.
Ms. Budzinski. Thank you, Mr. Chairman. Thank you to the
witnesses.
In Dr. Kroviak's testimony, she mentioned the VA OIG
encouraged VHA leaders to broadly disseminate findings from the
OIG's oversight publications to all facilities to alert them of
the potential risks and to promote processes that would prevent
or correct similar deficiencies at other facilities.
My question is really for any of the witnesses right now,
to what extent is the VHA doing this now? There are many
lessons to be learned just from the reports of the OIG findings
reported. I am just curious, any reaction to that?
Ms. Debord. Are you asking, representative, how often we
disseminate the information across the workforce?
Ms. Budzinski. Yes.
Ms. Debord. When it has to do with something that is in my
area, care management and social work and the programs that I
have oversight for, we review the OIG reports, we work with
those facilities that are managing those, those chiefs and
execs, because we take this incredibly seriously. In my 30
years, I have done care coordination across the spectrum. We
can do this better, and we really believe we can.
The integrated case management program, the Care
Coordination and Integrated case management program, which we
are just starting to work on as a framework with Integrated
Veteran Care (IVC), we really do believe that we have some
immature data that suggests that this will have an impact on
veterans' trust, on some of the things that impact their
health. It is new. We began this process in December. We are
going to be deploying this to 12 sites across the country no
later than September. They have been selected. We really
believe that we can start to see the needle move.
We take our own responsibility incredibly seriously.
Ms. Budzinski. Could I just follow up with Dr. Kroviak? Do
you have--would you want to add anything in addition?
Dr. Kroviak. It is challenging, and I appreciate the
frustration that hundreds of reports are published. The reality
is when we go into sites, though we find dedicated skilled
staff, we do have repeat findings onsite specific to individual
facilities. Certainly, we can go onsite to one facility and
find similar findings at others. I do not have as much
confidence that these reports are being disseminated or studied
as a true risk assessment tool that we would hope for.
Ms. Budzinski. Mm-hmm. Okay. Okay.
I have a question for Dr. Saslo. The OIG also shared their
assessment of VA Video Connect, VVC. VVC is a crucial tool for
older veterans, those with mobility issues, and vets living in
rural areas like the district I represent. The OIG found that
VHA would not--was not able to support the increased demand for
VVC despite having created emergency preparation plans for
disaster scenarios prior, plans created prior to the pandemic.
Dr. Saslo, I think we can all agree no one--no one
anticipated obviously a pandemic like the one that we just
experienced, and VHA was doing their best to care for our
veterans. Now that the pandemic is over, what improvements has
VHA made to the VVC program and is there a plan in place for
future emergencies?
Mr. Saslo. Thank you for the question.
One of the things that I think is really relevant is the
fact that VVC, as it rolled out, was something that we did as a
reflex to the pandemic whereby it was already established
earlier on, just not to the degree. What we learned as a result
of the project itself, or the program, is that we have a lot of
opportunity to improve and also increase the way that we expand
it.
We partner with our Office of Rural Health, which is
looking at different modalities in which we can expand that
connection piece to our most vulnerable patients. Within VHA
itself, we have multiple program offices that are working in
tandem with the Office of Connected Care in order to make sure
that VVC is actually more robust than it ever has been before.
We are also using our opportunities with Integrated
Veterans Care so that those veterans that need the care
consistently and are at risk for not being able to do it in
person have a consistent process that we use in order to engage
them.
I do not know if you want to add anything else to that.
Ms. Budzinski. Yes, and I think just a follow-up question.
In rural communities in particular, when you are looking at
coordination and unique challenges that they face, could you
speak a little bit more to, like, what those are and how you
are working through those challenges?
Mr. Saslo. One of the things that is probably the most
challenging at times is bandwidth, in making sure that our
veterans, who may have the opportunity to have a connected
device, which we have the opportunity to provide for, does not
always necessarily have the necessary bandwidth in their area
in order to make those connection pieces the most stable or
consistent. Our Office of Connected Care is working with a lot
of the different community providers, Verizon, T Mobile, et
cetera, to try to find ways that we can enhance and expand that
bandwidth itself. That is definitely one of the biggest
challenges I think we have seen in our successful expansion of
the VVC program.
Ms. Budzinski. Okay, thank you.
I think I am out of time.
I will yield back, chairwoman.
Ms. Miller-Meeks. Thank you, Ms. Budzinski.
The chair now recognizes Representative Radewagen.
Ms. Radewagen. Thank you, Chairwoman Miller-Meeks and
Ranking Member Brownley, for holding this hearing today. Thank
you to the witnesses as well for your testimony.
Dr. Saslo, in your testimony you discuss VA's efforts to
simplify veteran referrals to community care via the Referral
Coordination Initiative, or RCI. This initiative has been in
the work since before the pandemic, yet VA OIG states in their
testimony that no VA facility has fully implemented RCI. They
also state that there are no clear staffing models or
mechanisms in place to evaluate whether staff are meeting
goals.
Community care is VA care. What is VA doing to ensure that
veterans do have the access and care coordination they deserve?
I think this is kind of following a little bit along Eli
Crane's questioning.
Mr. Saslo. Thank you for the question.
I am going to defer to Dr. Yende because I think the
Integrated Veterans Care Program really can touch on some of
the opportunities that we are addressing.
Dr. Yende. Thank you for that question, Congresswoman. A
couple of questions there. I will try to answer all of them.
Number one, you are right, RCI was an initiative started to
help veterans understand their options for direct care and
community care. At sites where it has been implemented, we have
seen reduction in access times. You are absolutely right, we
need to do a better job in terms of implementing RCI across the
enterprise and making sure that we give some guidance in terms
of staffing.
Number two, you asked a question about how we are trying to
improve care coordination for community care. We started a
community care program--Patient Community Care (PC3) and Choice
were present prior to it, but we really started a community
care program in 2018 through community care networks. Since
then, we have seen a huge increase in utilization of community
care.
When we implemented policies, we have very clear guidance
to the field that there would be care coordinators in our
community care offices. These care coordinators look at the
request for community care, they do a risk stratification,
which is standard care coordination process. Consider a veteran
who needs to go and see an orthopedic surgeon. Let us say the
veteran does not have transportation. It is the role of the
community care Registered Nurse (RN) care coordinator to help
the veteran make sure that there is transportation in place so
that they can get to the appointment. That is an expectation
from that office.
As OIG and several of you have pointed out, our care
coordinators are currently siloed. We have care coordinators on
the direct care side as well as we have care coordinators on
the community care side. What we are trying to do with the
CCICM framework, and as part of this IPT, we started last fall,
is really trying to bring all the care coordinators together,
identify who would be the lead and help the veteran. Now, in a
given scenario where the veteran is going out to the community,
let us say they are trying to get orthopedic care, the best
person to coordinate that care could be the community care,
care coordinator, but in some cases, it might be the PAC clinic
care coordinator. We are trying to work out those processes as
to who could serve as the care coordinator for those complex
veterans and can help with that care coordination process.
Ms. Radewagen. Thank you.
Dr. Saslo, in your testimony you note the importance of a
strong care coordination between VA and community providers.
However, we often hear from veterans that are either wrongfully
denied community care or their community care referral is
delayed. In your opinion, what can be done to streamline
community care referrals? How do care coordinators fit into
this process anyway?
Ms. Radewagen. Thank you for the question.
I think it is important to recognize that the framework
that we are talking about is not building a whole new set of
case management or care coordination. What it is doing is
trying to identify how best to serve that veteran's needs and
if those needs happen to be for community care referral,
identifying, as Dr. Yende said, the individual who has the most
effective ability to ensure the veteran's care would be the
person that is identified as that lead coordinator.
In turn, that lead coordinator then works with either the
community partners directly or with the hospital, if the
patient is going into the hospital for the orthopedic surgery,
coming back, what those needs might be for the patient in order
to be able to go home safely and effectively in order to get
the kind of care that they need. That lead coordinator is
really going to be the piece that we are hoping will help to
reduce the silos that we have had in place related to the
different areas where care coordination and case management
already occur. Having a lead coordinator will help us to be
sure that we have got one person who is identified and within
the patient's record who is easily recognized for helping to
coordinate that care.
Ms. Radewagen. Thank you, Chairwoman Miller-Meeks.
I yield back.
Ms. Miller-Meeks. Thank you, Representative Radewagen.
It sounds as if we have too many care coordinators and not
enough care coordination.
I am just going to ask that question of both Dr. Yende and
Mr. Saslo. Does the VA have too many siloed care coordinators?
Maybe that is the appropriate question.
Mr. Saslo. I think the fair answer to that is we do not
have enough individuals working for care coordination or case
management. What we have is a lack of someone being identified
to be able to coordinate the multiple layers that oftentimes go
with a veteran's complex care. Many of our veterans, as you are
aware, have multitudes or have numerous care issues, whether it
be behavioral health, medical, psychosocial, and so having one
person identified as that lead will help to break down those
silos working with those care coordinators or those case
managers within the other arena so that the care is now
identified as a responsible process and that we can have
communication that is going to be a lot more effective.
Dr. Yende.
Ms. Miller-Meeks. Dr. Yende.
Dr. Yende. Yes, and if I may give an example. You rightly
pointed out we have silos, but let us take a veteran--I think
one of the panelists are going to describe a veteran who had
PTSD, who had issues with cancer care, which was going out into
the community, and had other issues that they had to address.
Care coordination is a fairly sort of sophisticated function.
People need to have an understanding in terms of care
coordination in that particular area. Imagine that veteran who
needs care coordination for their mental health and needs care
coordination when they go out in the community. Both these
skills will not be available in that same one individual. We
need to have care coordinators in these individual areas within
VHA. What you have rightly pointed out is assuming that these
care coordinators are providing the support to the veteran, how
does all this get coordinated? That is exactly what we are
trying to do with CCICM.
Also, please understand that care coordination is not a
static function. A veteran on a given day might need help with
oncology care, and the oncology navigator or care coordinator
may have to step in and guide the veteran. Three months from
now, the mental health issues may become more predominant, at
which point the mental health coordinator who has the necessary
expertise in that area needs to step in. We really are trying
to design a system that can accommodate the veterans dynamic
needs, rather than saying there is one person who is always
going to coordinate all of your care throughout your lifetime.
That is really what we are trying to achieve here.
Ms. Miller-Meeks. Our witnesses on the second panel
recommend that the VA establish essentially a coordinator for
the coordination, either at the facility or the Veterans
Integrated Services Network (VISN) level. Maybe what is
required is that there is one coordinator assigned to the
veteran instead of a facility coordinator who then coordinates
only a specific medical entity or a specific problem.
One of today's witnesses referenced the Federal Recovery
Care, FRC, Coordinator program and its utility during the surge
of complex injuries post 9/11. Why did the VA move away from
this program, and how is your latest care coordination IPT
using any lessons learned from this joint DoD VA program?
Mr. Saslo.
Mr. Saslo. I am going to ask Ms. Debord to go ahead and
take that.
Ms. Debord. Yes, ma'am.
What I would say, representative, is that as far as the
FRCs, they were really very critical right in the wake of the
Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/
Operation New Dawn (OND) conflict. We were really intensively
elevating everything that was happening on for care
coordination very high and just hitting it hot. I would say
today what we are doing with CCICM, which I am talking with our
Quality of Life Foundation and Wounded Warrior Project
colleagues, is that we have an opportunity to take CCICM, this
lead coordinator, and elevate that person's authority, their
knowledge base of all systems, so that that person really can
do a similar job as what they did in the FRC.
I think what we are hoping to do, and again, it is new, we
recognize that we are in the infancy, but as we continue to
roll this out, that the training allows these people an
elevated status, that they know multiple systems, they speak
multiple different languages, DoD, community care, VA, and are
able to help the veterans navigate those systems and feel the
authority to elevate things when things are not getting through
that need to happen.
Ms. Miller-Meeks. [Audio malfunction] program that was
working. It is not the status that is required, it is that the
coordination is given.
With that, I am going to thank our witnesses on the behalf
of the subcommittee for their testimony for presenting to us
today. You are now excused.
We will resume with the second panel after we go vote. We
will resume after votes.
[Recess]
Ms. Miller-Meeks. Welcome everyone and thank you for your
participation today.
On our second panel, we have Ms. Andrea Sawyer, advocacy
director with the Quality of Life Foundation, Mr. Matt Brady,
director of Complex Case Coordination Program with the Wounded
Warrior Project, and Mr. Roscoe Butler, senior health policy
advisor with Paralyzed Veterans of America (PVA).
Ms. Sawyer, you are now recognized for 5 minutes to deliver
your opening statement.
STATEMENT OF ANDREA SAWYER
Ms. Sawyer. Good afternoon, Madam Chairwoman, and members
of the subcommittee. My name is Andrea Sawyer, and I am the
advocacy director for the Quality of Life Foundation, a
national nonprofit organization founded to address the unmet
needs of caregivers and the Nation's most seriously wounded,
ill, and injured veterans.
We have evolved directly to work with veterans and
caregivers as they attempt to apply for and navigate the
Program of Comprehensive Assistance for Family Caregivers and
other clinical support programs within the Department of
Veterans Affairs. Serving all generations and focusing the
majority of our time on those with significant wounds,
illnesses or injuries, we often assist those with complex
clinical needs.
Additionally, I am the wife of a seriously injured
medically, retired and medically complex combat injured
veteran, and I have been managing his care since his return in
2007.
As one of the few organizations working exclusively with
the Veterans Health Administration, Quality of Life Foundation
has had a front row seat to witness and help others utilize
many of the programs and services available within the VA.
While we do not provide clinical recommendations of any kind,
our role is to ensure that veterans and caregivers are prepared
for the Program of Comprehensive Assistance for Family
Caregivers (PCAFC) process, assist in the drafting of clinical
appeals to ensure the VA is following its own regulations and
directives, and we assist veterans and caregivers in navigating
other programs and supports available to them within and
outside of the VA, specifically the Veterans Health
Administration.
Through our work directly with veterans and their
caregivers, done so, by reviewing the medical record, we help
advocate for the population we serve within all VHA programs.
Many of the cases that come to us have a lack of whole health
coordination and management. Many have some basic care
coordination, better known as a primary care treatment plan,
some have care managers who resolve simple issues or referrals
through low level intervention. However, many of our veterans
have multiple complex care needs and no one to create a case
coordination and case management plan. VA is severely lacking
in case management services. Case management is a time
intensive level of care management that looks at a veteran
holistically to document and manage all the veteran's
conditions and any social/environmental issues that develop as
a result of the care needs of the veteran.
As such, Quality of Life Foundation makes the following
recommendations: number one, create a cadre of specially
trained case managers similar to the Federal Recovery Care
Coordination Program as envisioned by the Dole-Shalala
Commission, who can manage the most complex cases by developing
comprehensive treatment plans for each need that a veteran has.
These case managers should have a VISN level lead. Second, ease
the process of obtaining a case manager. Per our written
testimony, it is hard to ask for what one does not know about.
Third, review the current community care network and outside
provider records' integration process. Fourth, review the
actual caseloads of different care and case management and
social work teams across the VA and ensure that different roles
are being filled as individual jobs and not as collateral
duties. Fifth, establish a ``pathway to advocacy'' for outside
organizations to officially assist veterans and caregivers
within VHA so that all veteran service organizations and non-
profit organizations are able to effectively advocate within
VHA.
In conclusion, Quality of Life Foundation believes VA needs
to simply realign their resources and bring back older, more
robust models of case management for those most severely
impacted veterans. These program models have existed in the
past, but then case management was siloed, and veterans
suffered. The original veteran driven case management plans,
not current vet centric plans, should allow the veterans
treatment goals to be the focus of the plan. Allowing Veterans
Service Organizations (VSOs) and nonprofit organizations to
advocate for care that exists within the system would also help
veterans and facilities focus on the needs of veterans.
Veterans would get more timely appropriate care with the help
of a holistic full-time case manager with authority to cut
through VA red tape. Veterans with lesser care needs would then
have access to lower-level care managers available to them.
Overall, VA would save money if veterans are able to get
timely appropriate care that is managed across the spectrum of
the medical community, and veterans would have better health
outcomes and quality of life.
Thank you for your time, and I look forward to answering
any questions you may have, especially about the Federal
Recovery Care Coordination Program. Thank you.
[The Prepared Statement Of Andrea Sawyer Appears In The
Appendix]
Ms. Miller-Meeks. Thank you, Ms. Sawyer.
Mr. Brady, you are now recognized for 5 minutes to deliver
your opening statement.
STATEMENT OF MATT BRADY
Mr. Brady. Thank you, Chairwoman Miller-Meeks, ranking
member, and distinguished members of the Health Subcommittee
for this opportunity to speak about care coordination at the
VA.
As you know, effective care coordination not only produces
better outcomes, but gives the veteran confidence in their
system of health. To frame the issue of today's hearing from
Wounded Warrior Project's perspective, our goal is to help
warriors receive the appropriate care in a timely manner in the
setting they want. We provide care coordination as part of
three programs.
The first is our Complex Case Coordination Program, which
helps veterans with complex cases that are multifaceted and
need urgent action to address mental and physical healthcare
needs utilizing high quality VA or community-based services.
The second is our Independence Program, which helps
veterans with moderate to severe brain injury, paralysis, and
neurological conditions live more independently with a better
quality of life.
The final is Warrior Care Network, which aims to reduce
gaps and inefficiencies in mental healthcare delivery through
innovation and collaboration.
Based on these programs, we have a number of
recommendations for Congress to consider, all of which are
outlined in our written statement. Today, I want to point out
three specific bills and discuss some targeted ideas that may
inspire future bills for the subcommittee.
The first bill is H.R. 3520, the Veteran Care Improvement
Act, specifically section 2, which would codify an access to
care standard for the VA's mental health Residential
Rehabilitation Treatment Programs (RRTPs). If somebody today
decides to turn their life around, ask for help with substance
or mental healthcare, why would we allow them to wait 30 days
to get that care? If this was your family member, you would not
find this acceptable. We can do better. I know we can do better
also. Additionally, we can do a better job communicating of
records between the VA and the community residential care
facilities, address follow on care, and medication needs.
The second bill that I will highlight is H.R. 452,
Elizabeth Dole Home Care Act. A key provision would instruct
the VA to provide informal geriatric and extended care program
assessment tools to give options to the eligible veteran and
caregiver, letting them decide which programs are appropriate
for them. If a caregiver is denied or discharged from the
caregiver program, the VA needs to help find and enroll them in
other VA provided home based care and support.
Last, I will note our support for S. 1792, the Care Act.
Section 3 has the potential to transform how organizations like
ours advocate for veterans and their family members in
navigating VHA programs and services.
Our organization has been delivering this kind of help for
thousands of veterans, and we know the life changing impact
that an advocate can have when people need help.
To that end, I would like to close by speaking to our
interest in seeing the VA create a system that helps centralize
care coordination and patient advocacy, particularly for those
with complex needs. There are several pilot programs across VHA
that are currently exploring how we can improve integrated case
management, but the fact is, veterans need consistent,
coordinated care no. We understand the VA, like many
organizations, continue to experience staff shortages in
critical areas. We appreciate everyone who chooses to work to
make veterans lives better.
Our recommendation can be instituted rather quickly.
Designate a lead social worker, your best social worker--you
know who they are--at each VA medical center. Have them serve
as the lead for advocates to address critical coordination
issues, serve as the organization's subject matter expert, and
most importantly, having the authority to cross service lines
and facilitate immediate assistance.
Care coordination is only part of the solution. We must
also empower veterans and advocates with the knowledge about
the access to care standards and their options in care, help
them actively participate in their care pipe, providing them
with information, resources, and education, allowing the
veteran to make informed decisions, effectively communicate
their needs, and take ownership of their health.
Thank you again for the opportunity to testify. I look
forward to your questions.
[The Prepared Statement Of Matt Brady Appears In The
Appendix]
Ms. Miller-Meeks. Thank you, Mr. Brady.
Mr. Butler, you are now recognized for 5 minutes to deliver
your opening statement.
STATEMENT OF ROSCOE BUTLER
Mr. Butler. Chairwoman Miller-Meeks, Ranking Member
Brownley, and members of the subcommittee, Paralyzed Veterans
of America (PVA) would like to thank you for the opportunity to
submit our views on VA's efforts to coordinate veterans care.
Veterans with complex healthcare conditions, like spinal
cord injuries or disorders, receive care from various
healthcare professionals to include primary care physicians, a
wide range of specialists, visiting nurses, and caregivers,
many of whom are family members. This care is provided through
a number of service points. It may be provided at one of VA's
25 Spinal Cord Injury and Disease (SCID) centers, through VA's
6 long-term care centers, or at other VA facilities. Care may
also be provided through community care providers, in state
veterans or community nursing homes, or in veterans residents.
This often poses a difficult challenge to the many dedicated
professionals who are working tirelessly to ensure that the
delivery of high quality acute and long-term care is
administered by the right providers in order to achieve optimum
care outcomes for veterans.
However, when coordinating care outside of the Department,
VA's ability to coordinate care drops dramatically because most
civilian facilities and agencies are not knowledgeable or
equipped or properly staffed to handle SCID patients' acute and
long-term care needs. PVA is concerned about VA's current lack
of long-term care beds, which is severely impairing its ability
to coordinate care for veterans with SCIDs. More than half of
the veterans on VA's SCID registry are over the age of 65, and
the number of veterans needing this level of care is increasing
rapidly. Nationwide, there are very few long-term care
facilities capable of approximately serving veterans with SCID,
and only one of VA's six specialized long-term care facilities
lies west of the Mississippi River.
Today, VA care coordinators spend a tremendous amount of
their time attempting to locate providers, facilities, or
agencies in the private sector to meet SCID veterans' long-term
care needs. To be clear, these were scarce prior to COVID, and
VA SCID care coordinators tell us they are getting scarcer.
Nursing home and home health agencies often pursue contacts
with VA, but do not maintain them long enough once they find
they lack the necessary training to perform the critical tasks,
like bowel and bladder care, that some veterans with SCID need.
Facilities lacking proper staffing are often unwilling to
procure additional personnel for SCID veterans whose greater
care needs consume a larger than anticipated share of their
existing workforce time. Even if they are willing to hire
additional personnel, nationwide provider and nursing shortages
will often preclude them from finding the personnel that they
need. These starts and stops are frustrating to veterans and
those who coordinate their care.
The 65 percent statutory cap on what VA can pay for home
care can almost impact care coordination because it limits care
options which may contribute to unfortunate results.
In light of the limited access to VA facility, long-term
care, and the desire of many veterans with SCID to receive
noninstitutional long-term care, VA must expand access to home
and community based services to meet the growing demand for
long-term care services and supports. Facility based long-term
care services are expensive, with institutional cares exceeding
costs of Home and Community Based Services (HCBS). Studies have
shown that expanding HCBS entails a short-term increase in
spending followed by a slower rate of institutional spending
and overall long-term care cost containment. Reduction in costs
can be achieved by transitioning and diverting veterans from
nursing home care to HCBS if they prefer it and the care
provided meets their needs. Passage of H.R. 542, the Elizabeth
Dole Home and Community Based Services for Veterans and
Caregiver Act, would address many of these barriers to care. I
cannot stress enough how important it is for Congress to pass
this important legislation sooner rather than later.
PVA appreciates the subcommittee's interest in this
critical area, and I would be happy to answer any questions you
may have.
[The Prepared Statement Of Roscoe Butler Appears In The
Appendix]
Ms. Miller-Meeks. Thank you, Mr. Butler.
I will defer my questions until the end so that other
members can address the panel. I now recognize Ranking Member
Brownley for any questions she may have.
Ms. Brownley. Thank you, Madam Chair. I am sorry that I was
not able to be here for the panel one discussion, but I did
read the testimony.
This question really is for any of you. We heard today from
the VA and their testimony about they are rolling out a new
care coordination framework and management system to have one
point of contact within a patient's primary care team to help
ensure veterans needs are met. Based on what you heard today,
and this is are you confused as I am? `Cause and I am curious
to know if you have heard of this program before today because
for me, it was the first time I had ever--I mean, I read the
testimony, but it was the first time I became aware that this
was -this was underway. Do any of you think that this is going
to solve the problem?
Ms. Sawyer. I am going to put on two hats here. I am the
advocacy director at Quality of Life Foundation, but I am also
a caregiver for a warrior who returned in 2007 and was severely
injured with multiple conditions that we had to manage.
I would tell you that CC&ICM with lead coordinator has
existed probably since the dawn of time. What we used to call
it was you needed a case manager for your case managers. For
those of us who had warriors coming back at the beginning of
the war, 2006, 2007, I had a bazillion case managers on the DoD
side and transitioning over to VA, I just add more to the
layers. Everybody was talking past each other. Originally the
person managing those was me until we met up with the person,
who at that time, was head of the newly stood up Federal
Recovery Care Coordination Program. I managed to get a case
manager for my case managers. That person had Federal level
authority across DoD, VA, Medicare, and could work in Social
Security programs.
For my warrior, and for many others that had that same
level of case management need, that program was there. If we
were only within the VA, the person that would have handled
care would have been OIF/OEF, which is now the Post 9/11
military2VA (M2VA) Office or potentially a polytrauma case
manager.
Those models have changed through the years. Basically, the
FRC program rolled down into kind of a consultant basis, but
then a consultant on just the VA employee/facility side. A VA
facility consults the FRC program, you no longer have
interaction with the warrior. As organizations we can refer
people to the program. They look through the record, and then
they can contact the facility which, if they have a difficult
case, can engage the program. Basically, if you do not know
they exist--and there are, I believe, only ten, I think, within
the VA now, where there used to be, I think, a robust program
of 75 or more across the country. That number may be a little
elevated. They just do not exist like they did anymore. There
is certainly not that level of case management at any facility.
Do I know that CC&ICM is rolling out again? Yes. Do I think
it is something we had before? Yes. Was it adequate? No. That
is why Dole-Shalala stood up the FRC program.
When I was listening to the VA testify and they said that
we came in hot and heavy and we kind of triaged folks and took
care of them. What I would like to say to the VA as the
caregiver of one of those warriors is just because you changed
your model of case management did not mean that my veteran did
not have the same needs. Basically, they took away our--not in
our case, because I fought like the devil to keep our FRC--but
in a lot of cases, they just took away these case managers and
left caregivers to navigate the system on our own. As a
caregiver, while I am good at that, that is not my intended
role. It is to provide that daily support and supervision; it
is not to medically case manage them.
I had to go to Veteran's Affairs Central Office (VACO) and
fight very hard to get a coordinated treatment care plan that
still exists today for my warrior and in a lot of cases, for
advocacy. I am so sorry. That is what I advocate for some of
our most seriously injured or impacted cases and what their
caregivers do for their warriors also. We talk about how we get
it done, how to get it done.
Ms. Brownley. Well, thank you for that. Your warrior was
very lucky to have you.
I yield back.
Ms. Miller-Meeks. Thank you, Ranking Member Brownley.
I now recognize Representative Van Orden for any questions
he may have.
Mr. Van Orden. Thank you, Madam Chairwoman.
Ms. Sawyer, I read your testimony. It was gut wrenching. I
want to know, is that veteran in Arkansas?
Ms. Sawyer. Yes, sir?
Mr. Van Orden. Who is their congressperson?
Ms. Sawyer. I cannot tell you who their congressperson is
on the House side. I am so sorry.
Mr. Van Orden. Will you do me a favor?
Ms. Sawyer. I will find that. We work with Senator Boozman
a lot.
Mr. Van Orden. Okay. Please do. I would like to speak to
him or her personally about this.
Ms. Sawyer. Yes.
Mr. Van Orden. I want to make sure that this issue is
resolved. In that spirit, I would like the name of every single
person that that veteran has come in contact with, because I
will be holding them directly accountable.
Ms. Sawyer. Well, I appreciate that.
Mr. Van Orden. Okay.
Ms. Sawyer. I will say your staff has been involved in that
case with me since 2016, and the staff on this committee has
been wonderful to work with.
Mr. Van Orden. They are awesome.
Ms. Sawyer. Yes, they are.
Mr. Van Orden. Okay.
In the break, I did not just vote, I had my crack graphics
team develop something to help the Veterans Administration
figure some stuff out. That is a wheel. It has been invented
long time ago. I will give this to you if you would like. You
can take it home, put it on your desk. You are reinventing the
wheel, and the ranking member, boom, spot on. You have got
institutional knowledge of the Veterans' Affairs Committee. If
she does not know that it is going on and our chairwoman,
nobody does.
Command Sergeant Major, you put in here that a lot of
veterans in this population remain confused by the number and
types of VA services, employees roles, their delivery and
eligibility criteria. Okay. You wrote that. I got, I do not
know, 300, 400 Facebook messages and emails and phone calls. I
know that Congresswoman Kiggans did also because the Veterans
Administration was capable of pumping out some ludicrously
political garbage on their website, terrifying our veterans.
Everybody knew about that. It was a lie. The Veterans
Administration lied for political purposes to our veterans,
terrified them, and that went out like on a coconut wire, dude.
Our veterans do not know the services that are available to
them, and that is shameful. We are waiting for a public apology
from the Department of Veterans Affairs and waiting for them to
use their public affairs officers to get out the word, the
truth, to tell people the services that are available, because
they are available. The Veterans Administration, they work so
hard. I am incredibly proud of our VA. I get all of my
healthcare through the VA. I am 100 percent service-connected,
disabled veteran, and I go to Tomah, and I am proud of them. I
was just there last week. I told them I am proud of them.
Ms. Sawyer, I am going to have to disagree with part of
your testimony here.
Ms. Sawyer. Okay.
Mr. Van Orden. This is why--you are good. The establishment
of a cadre of specially trained case managers. No. The
Veterans' Affairs Committee has not done what the command
sergeant major would call troop to task. They got plenty of
people sitting around, and they are working, and they are
qualified, and they are dedicated, but they need to do troop to
task, command sergeant major. They need to be able to draw a
line and block chart where I can put my finger on it and say,
this person is directly responsible for this veteran's care. If
that veteran winds up committing suicide, that person, not a
system----
Ms. Sawyer. Right.
Mr. Van Orden.--of a series of things. The system is not
responsible, an individual is responsible. That is what you
guys need to do. I will be frank with you, the only thing
missing from the word salad testimony that you guys gave today
was a bucket of ranch dressing. It is unacceptable. Use 50,000
words to say nothing. We are not taking this anymore. I will
not allow our veterans to be disabused or ignored or commit
suicide because a bunch of bureaucrats cannot get their act
together.
Mrs Sawyer, you are doing God's work, Command Sergeant
Major, you are too, Mr. Butler, you have my undying support.
Thank you very much for what you are doing.
With that, I yield back.
Ms. Miller-Meeks. Thank you, Representative Van Orden.
I now recognize Representative Kiggans for any questions
she may have for 5 minutes.
Ms. Kiggans. Thank you very much, Madam Chair.
I do not necessarily have any questions, just a couple of
comments to piggyback off of Mr. Van Orden's remarks.
I was geriatric primary care nurse practitioner. For me and
having to coordinate care with the Veteran Administration on a
civilian side, I know we are doing some good work with
community care and really trying to incorporate them. Half the
battle, maybe it is in charting. I know we are working through
some of the charting systems with the VA. I hope that is a step
in the right direction. Having patients that receive just VA
healthcare, I would almost throw up my hands. Getting the
charts, the diagnosis, the med list from VA was next to
impossible. We would just kind of write it off if he got care
at the VA, and the caregiver would then--it would be their
responsibility to try to communicate with the civilian provider
what happened to the VA and vice versa. We can do so much
better.
I know Mr. Van Orden hit on the fact that when we had that
little political stunt about Republicans taking away veteran
benefits, which again fabricated lie, but I too received
multiple hundreds, like you said, of comments and emails
saying, why are you taking away my healthcare. The VA has the
capability to get that word out to veterans. Use it in a
constructive, good manner, not for political games, which we
hate. That is I know why I ran for office, to not do those
things and to advocate for our veterans, for our military men
and women.
We need to prioritize. I know that so many of us on this
committee today are willing to work to do that, especially
those of us who are veterans, who are healthcare providers. I
think we understand that language. We are going to work
together to make sure the word gets to our veterans.
I am having to hold an event in my district to inform
veterans what resources are out there. I am having to put that
event together. The VA should be doing these types of things
and educating. I know as a primary care provider, it was so
hard for me to understand what resources were available to
veterans, to caregivers, and their families. It should not be
that hard. I do not know, the VA should be educating providers,
primary care providers especially. We can do so much better. We
are going to work together and get that job done for you all.
Thank you for your advocacy and work as well.
I yield back.
Mr. Van Orden. We will do a second round of questioning and
I would like to recognize our ranking member for 5 minutes.
Ms. Brownley. Thank you, Mr. Chair. I appreciate it very
much.
Ms. Sawyer, going back to your conversation on my first
question.
Ms. Sawyer. Sure.
Ms. Brownley. You are recommending, you know, a case
management social work lead operation. Sounds more like going
back to the good old days where it was working better, correct?
Ms. Sawyer. Yes, ma'am.
Ms. Brownley. More or less. You are suggesting that the
point that this should happen at the VISN level. Let me just
say, I think for some of us who have served on this committee
for a while, and I am one of those, we get really nervous when
the VISN has control of something that we believe is very
important and critical to the health outcomes for our veterans.
Because the VISN has medical centers, VISNs, they have their
autonomy and kind of - kind of do things the way they want to
do things.
Ms. Sawyer. Right.
Ms. Brownley. I get very frustrated because we have got -
we have got a gazillion people with coordinator titles out
there, but some of them have, you know, a tenth of an Full-time
Equivalency (FTE) or, you know, whatever.
Ms. Sawyer. Right.
Ms. Brownley. Tell me why that is where you want to start.
Ms. Sawyer. I actually want to start in the facility
levels. Okay. That is a little bit of a--I think in the oral
statements it gets a little lost. I want to start at the local
facility levels. It is not that I think there are tons of care
coordinators out there and care managers, which are--care
managers are really defined by single disease or injury or
condition. I want at the local level some of those folks,
instead of being siloed in their care management roles, to be
trained for full holistic case management of the veteran. Right
now, at the VISN level, there is no person for a case manager
to go to. I would like that there is like the VACO level should
exist at the facility level but does not and there is no layer
in between. There is no authority of that case manager to do
anything. That would be the reason to add a level at an
intermediate level at the VISN to give that case manager some
authority.
Also going back to another part of that plan, when we
talked about those Federal individual recovery plans, that is
what an FRC put together, it was a veteran led plan where the
veteran said what he wanted his care management goals to be.
Currently, VA leads a vet centric model where the veteran is at
the center and the VA tells the veteran what they are going to
give them. We want it to be the other way around.
Really, the third thing we would like to do is for VA to
have some more centralized authority as far as case management
is concerned. Right now, what we see is standardized authority
throughout the VA, which allows every single medical facility
and every single VISN, as you said, to kind of look at what the
standard is and then apply it as they see fit. There is no, as
we said, again and again, accountability because everybody can
say, oh, well, it was standardized, it is not centralized
authority, it is just standardized. It is a suggestion that I
just have to fulfill. We want it to be a more centralized
authority so that there is someone to hold accountable. Here is
your model, here is what you are required to do, and should you
fail to do that and should there be a medical consequence for
this patient, there is someone to hold accountable when, God
forbid, somebody winds up in the hospital because their care
was not coordinated, and then they have an infection that is
bad enough that they lose their leg, which is what is looking
like it is going to happen in our case in Ohio.
Ms. Brownley. Thank you for that.
Mr. Brady and Mr. Butler both, thank you for mentioning the
Elizabeth Dole bill. I appreciate that very much.
I wanted to ask you, Mr. Brady, you talked about the -you
talked about I guess it is a nomenclature problem that you
talked about in terms of younger veterans and the way we
recognize some of the long-term care services, geriatrics, and
so forth, that can be pretty confusing and may stigmatize, et
cetera. Do you have some suggestions around destigmatizing and
improving outreach efforts for younger veterans who may need
the long-term care services?
Mr. Brady. Rank member, thank you.
Yes, absolutely. The first easiest thing to do is to not
have every picture of geriatric care being somebody over the
age of 70. That is the first easiest thing. We had a meeting
with Health and Human Services to talk about where there was
potentially some overlap in services that they could be giving.
The conversation centered around everybody in the room looking
at every picture, every website, and there is no way that
warriors see, veterans see themselves as that. I still feel I
am 34. My wife tells me, no, you are not. When I look at those
pictures, I do not see myself in there.
Ms. Brownley. Yes.
Mr. Brady. We need to get veterans that are closer to that
age, right and then discuss geriatric in a different light with
them, right. Advanced care, advanced age, advanced veteran, and
stay away from geriatric.
Ms. Brady. That would be my suggestion.
Ms. Brownley. Very good. Yes, very good. Thank you very
much.
I yield back, Madam Chair.
Ms. Miller-Meeks. Thank you.
Mr. Butler, thank you very much for your testimony. In my
younger years as a nurse in the Army, I was on the neurosurgery
floor on Walter Reed on Ward 10 and turned a number of striker
frames and worked with spinal cord injured veterans quite a
bit, as did my husband, who is a nurse.
In your testimony you mentioned the importance of
coordinated care in this population, the SCID community, and
what strengths in the hub and spoke model of care could work in
other areas of VA care, and should the VA focus more on complex
populations like your membership, rather than investing in
numerous coordinators who try to manage a more basic general
population?
Mr. Butler. Thank you, Chairwoman Miller-Meeks, for that
question.
VA has an excellent model, VA's spinal cord injury system
of care. One thing that they could do is examine that model and
why is that model so superior to the coordination of care
throughout the SCID program in comparison to care outside of
that system? They may find that there is some uniqueness in the
way the SCID care is delivered throughout that system that they
can use throughout the entire VA healthcare system to gain some
leverage in the coordination of care outside the SCID system of
care.
Ms. Miller-Meeks. As a template, then?
Mr. Butler. Yes.
Ms. Miller-Meeks. Ms. Sawyer, in your testimony--you and
Mr. Brady both mentioned the Federal Recovery Coordinator
program. As you heard me in the last panel--and I thank the
previous panel for still being here--you heard me say the old
adage, if it ain't broke, don't fix it. It sounds like we
developed an FRC program in order to fix the deficits after 9/
11 in coordination of care, and it seemed to be working.
What were the strengths in that program that should be
continued and what were the barriers that proved to limit
continued implementation today?
Mr. Brady. Sure, I will go. Chairwoman, great question.
When it was in full implementation, the FRC had great
latitude in which to really execute, right, the plan for the
warrior to execute where it was going to go, not just in the
DoD, but the VA, the benefits, the Social Security
Administration. This incredible amount of latitude in which to
work really centered on the injured veteran. I think the
problem with that is we got away from that and now we are at a
level where there is not the direct interaction, there is not
the direct care with developing the care plan with the veteran.
There is a level of ownership I think when you are an
advocate, when you are somebody in a Federal Recovery
Coordinator, there is some ownership in the people you deal
with and how you treat them and where you see them going. I
think that we have gotten to a point where there is much fewer,
they are farther in between. This may have been the consequence
of obviously a drop in the amount of wounded veterans coming
back.
That is what I would say.
Ms. Miller-Meeks. It sounds like what you are saying is
that we are going from a program that worked but had less
wounded veterans coming back from war to now a bureaucracy
centered coordinator rather than a veteran centered coordinator
or case manager.
Ms. Sawyer, you talk about seeing veterans with case care
managers who typically manage one clinic or one specific
disease program, which is what I mentioned earlier. That seems
to align with what the committee sees as multiple layers of
coordinators, advocates, and champions that have little overlap
in function and limited ability to extend past their respective
silos. I know I am running out of time, but what does the VA
need to do to truly provide care coordination with veterans
with complex needs? Then in writing, if the three of you could
submit to the committee, are there any organizations outside of
the VA--outside of the VA, any health systems that you think do
case management and care coordination especially well? If you
could refer that to us.
Ms. Sawyer. I will be glad to do that. There are several of
that are out there.
One of the things I wanted to respond to with that and with
your question, we do see these very siloed case managers. One
of the reasons I said a specially trained cadre is not because
I think VA needs to add more employees. I do not. I think we
need to realign the employees we have. I do agree with the VA
when they stated that care managers are very single, focused,
and siloed, but what you need is a person who is trained to be
able to look at all of those clinical needs together, and it is
simply just a--so when I said a specially trained cadre, I
simply mean that you take some of those people who are
individually siloed and train them to be an across the board
case manager, to look at all of these individual care plans
that each specialist puts in place, see where they overlap, see
where they are contra indicated, and be able to weave those
things out, give your family a single point of contact, and be
accountable to see that each one of these plans and needs that
the warrior has can do that--or they can be accountable for
that and for helping manage that.
I also think it is important that that person be
responsible for portraying to the VA what the veteran wants. I
feel like in this system a lot of times as a caregiver with a
veteran and with the cases that I work also, is that I have the
VA telling me a lot of the times what we are going to do, and
it does not fit in with what we want to do. That is not
something in the civilian medical model that we deal with.
Sorry.
Ms. Miller-Meeks. Thank you.
I know all of you would want to answer that question. I
have already gone over my time.
Ranking Member Brownley, would you like to make any closing
remarks?
Ms. Brownley. Thank you, Madam Chair.
I will just say that I think this is a really, really
important discussion, and we have not even touched upon some
other care coordinators in the VA. For example, for women
veterans, all of their, if they become pregnant, all of their
healthcare needs are outside of the VA. There is a coordinator
for that to make sure, but you know, they do not even have the
chance, really, except for their primary caregiver, not even
have a chance within the VA that somebody might pick them up
and advocate for them in terms of services they need. They
are--they are lost on the outside.
I have spent some time going to other medical centers
across the country. We made a lot of trips, I think, 2 years
ago, but spent a lot of time in Texas and Oklahoma. I mean,
every medical center that we went to, the maternity coordinator
was well way overworked, way, way, way overworked. No way that
she or he could possibly manage the caseload that they had.
I think this is an important conversation to have. I think
we have to even dig deeper, and I think we need to watch
carefully what the VA is doing in terms of a solution and say
our piece.
With that, I will yield back.
Ms. Miller-Meeks. Thank you, Ranking Member Brownley.
I would like to thank everyone for their participation in
today's hearing and for the productive conversation. It is one
of my priorities, and I know the same goes for my colleagues on
both sides of the aisle, to take care of all veterans and to
ensure that care is being properly coordinated to meet both the
patient's needs, the family's needs, and improve health
outcomes. No veteran should be left in the dark about their
ongoing medical care or the coordination of that care.
I look forward to working on these issues and many more
with the Department, the stakeholders, and my colleagues on
this subcommittee.
The complete written statements of today's witnesses will
be entered into the hearing record.
I ask unanimous consent that all members have 5 legislative
days to revise and extend their remarks and include extraneous
material.
Again, I would ask our panelists to provide for us any
medical care healthcare systems that you think does an
exemplary job of case management care coordination hearing.
Hearing no objections, so ordered.
I thank the members and the witnesses for their attendance
and participation today. This hearing is now adjourned.
[Whereupon, at 3:17 p.m., the subcommittee was adjourned.]
?
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A P P E N D I X
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Prepared Statement of Witnesses
----------
Prepared Statement of M. Christopher Saslo
Good morning, Chairman Miller-Meeks, Ranking Member Brownley and
distinguished Members of the Subcommittee. Thank you for the
opportunity today to discuss VHA's various care coordination programs
within VA, community providers and emergency services. Accompanying me
today is Dr. Sachin Yende, Chief Medical Officer, Office of Integrated
Veteran Care (IVC), Dr. Jennifer A. Strawn, DNP, RN, NEA-BC, Executive
Director, Office of Nursing Services/Deputy Chief Nursing Officer, and
Ms. Jill DeBord, LCSW, Executive Director Care Management & Social Work
Services.
Overview
The number of Veterans using VA care over the past 5 years has
grown 6 percent and, generally, the Veteran patient population who
utilizes VA has more complex medical and social needs than the general
population. VA provides a broad array of services that must be
coordinated across the VA network to meet the unique needs of the
Veterans we serve. Care coordination is a system-wide approach to the
deliberate organization of all Veteran care activities to facilitate
the appropriate delivery of health care services across all settings.
Care coordination exists within the individual programs, including
primary, specialty, mental health, and emergency care as well as long-
term, and social work services and what we have learned is Veterans
move across these different programs. In addition, as use of community
care increases, care coordination of services within VHA and the
community is increasingly more complex and common.
VHA is deploying an overarching framework called Care Coordination
and Integrated Case Management (CCICM), which coordinates the work
between various programs within the enterprise, so Veterans have one
point of contact to assist with their care needs. In December 2022, VHA
established an integrated project team (IPT) between CCICM and the
Office of Integrated Veteran Care (IVC). The IPT aimed to enhance
operations between CCICM and IVC to increase VHA's ability to offer
collaborative, coordinated and seamless care experience(s) for
Veterans. The goal is to expand and leverage pre-existing CCICM
processes, procedures, and reporting throughout the health care
continuum to include Referral Coordination (RCI) and IVC initiatives to
further enhance VHA's ability to offer collaborative and coordinated
care for Veterans. VHA will start implementing recommended IPT
enhancements this fiscal year across the enterprise for the most
vulnerable Veterans who require moderate to complex care coordination.
A Patient Aligned Care Team (PACT) involves a team of health care
professionals working together with each individual veteran, to plan
for life-long health and wellness that addresses the whole person. A
PACT achieves coordinated care through deliberate collaboration. Team
members meet often to talk with Veterans and each other, discussing the
patient's health care goals and the progress toward achieving them.
They coordinate all aspects of the Veteran's health care within the
PACT and with other care teams outside the primary care system, as
needed.
PACT members coordinate the Veteran's care from the primary care
team to specialists and other health care professionals who are part of
the Veteran's health care plan. If needed, the care team coordinates
the transition during emergency room services, inpatient stays, or dual
care with non-VA clinicians. In addition, they work with the Veteran on
private sector referrals and arrange for community resources when
needed. The focus is on building trusted, personal relationships that
promote open communication and sharing of information. The goals
include improved quality of care and patient safety.
Enhancing Collaboration Between VA and Community Providers
Strong care coordination between VA and community providers ensures
Veterans receive timely and high-quality care regardless of where that
care is provided. VA's care coordination model is a Veteran-centered,
team-based approach, which involves receiving the request for community
care, assessing the Veteran's needs, developing and implementing a care
coordination plan, and ensuring appropriate follow-up.
With the Community Embedded Staff Program, one or more VA staff
members are physically or virtually stationed at community facilities
within their respective markets. Within this program, an embedded nurse
or community liaison collaborates with community hospitals to improve
care coordination and Veterans' experiences. This team of nurses,
social workers, care coordinators, or a combination thereof, works to
coordinate care for Veterans who present to a community hospital,
including working closely with those providers to create an integrated
care plan for the Veteran, attempting transfer to the appropriate level
of care (nursing home, VA hospital, rehabilitation clinic), or
connecting with a VA PACT provider.
Another such example is the VA Liaison Program which has integrated
VA Liaisons for Healthcare, who are VA social workers and nurses, with
public-private partnership (P3) sites to coordinate an individualized
transition into VA health care for Veterans who receive specialized
treatment at a P3 site. VA Liaisons for Healthcare are assigned to each
site in Wounded Warrior Project's Warrior Care Network, which consists
of four academic medical centers that specialize in posttraumatic
stress disorder, and six Avalon Action Alliance sites that offer an
intensive outpatient program to treat brain injuries.
Referral Coordination Initiative
VA is continuing our efforts to simplify a provider's referral of a
Veteran to another provider. The Referral Coordination Initiative (RCI)
aims to ensure Veterans have comprehensive information about their care
options at the time of scheduling. Referral coordination teams include
local staff with administrative and clinical expertise who talk with
Veterans about their available care options with a VA provider, in-
person or virtually, or when eligible, through the Veterans Community
Care Program.
In August 2022, we released a systemwide update that allows
clinicians to capture the clinically appropriate care options for these
referrals. Additionally, the staff scheduling the requested care can
document discussions with Veterans regarding the full range of care
options and the outcome of that conversation. As of December 2022, we
have seen a 24 percent improvement in scheduling internal consults for
key RCI specialties across VHA, with average times decreasing from 10.4
days to 7.9 days. We continue to improve and standardize documentation
and discussion notes, as well as roles and responsibilities for the
referral coordination teams. Additional guidance will be included in
the new Consult Management policy expected later this year.
Ensuring Coordination for Mental Health and Emergency Services
Section 201 of the Veterans COMPACT Act of 2020 (Public Law 116-
214) expanded eligibility for emergent suicide care for Veterans (as
defined in 38 U.S.C.Sec. 101) and former Service members described in
38 U.S.C. Sec. 1720I(b), in acute suicidal crisis. Care can be
provided in VA and non-VA facilities for medical and mental health
needs associated with the acute suicidal crisis for a period of up to
30 days for inpatient or crisis residential care and up to 90 days for
outpatient care.
To optimize acute suicidal crisis care while ensuring Veterans'
care is optimally delivered, VA is piloting a program to establish a
network of dedicated Care Coordinators at VA medical centers.
Leveraging the CCICM team structure, the pilot will fund five VHA
facilities with acute psychiatric admissions and five VHA facilities
with no acute psychiatric unit. This effort will ensure optimal
coordination across potential medical and mental health services,
ensure efficient navigation through both the VA and non-VA systems,
provide Veterans or other individuals with a single resource to ensure
optimal resolution of the suicidal crisis event, and provide VA with
invaluable information on best practice models for expansion.
Care Coordination for Specific Veteran Populations
Rural and Elderly Veterans
VA employs close to 19,000 clinical social workers. These dedicated
employees provide clinical assessment and interventions that include
care coordination and case management across all areas of programming,
including for Veterans residing in rural and highly rural areas, and
elderly Veterans.
In FY 2019, Veteran Health Administration (VHA) enrollees ages 65
and older accounted for 48 percent of all VHA enrollees, 57 percent of
all VHA rural health enrollees, 64 percent of all VHA acute care
hospital admissions, and 59 percent of all VHA expenditures. VHA
enrollee projects between FY 2019 and FY 2039 include projected 38
percent increase in the number of VHA enrollees ages 85 and older and
278 percent increase in women VHA enrollees ages 85 and older.
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VA social workers provide clinical interventions for Veterans in
rural and highly rural areas through primary care. The Social Work in
Patient Aligned Care Team (PACT) Staffing Program increases access to
clinical social work services for this population. Over 142 social
workers have been initially funded by the Office of Rural Health (ORH)
to provide high quality social work interventions across 41 rural
sites. This approach has led to positive outcomes in health and
wellness for Veterans through proactive outreach and intervention.
Since 2016, VA PACT social workers in funded or sustainment phases of
the program, have served over 100,000 unique Veterans (64.27 percent
rural).
The Intensive Community Mental Health Recovery program serving
rural Veterans with serious mental illnesses is called Rural Access
Network for Growth Enhancement (RANGE). An adaptation of this program -
Enhanced RANGE (E-RANGE) - more specifically addresses the needs of
homeless Veterans with serious mental illness diagnoses who live in
rural areas. RANGE and E-RANGE teams across VHA have been initially
funded by ORH and provide mental health treatment and care coordination
for this special population of Veterans with more than 90 teams
covering more than 130 rural locations across the Nation.
VA Social Workers also provide clinical assessment and inventions,
including care coordination and case management, for elderly Veterans.
Social workers are embedded within Geriatric and Extended Care programs
focused on supporting elderly Veterans and routinely assist with
coordinating care both internal and external to VA. Programs include
Medical Foster Home, Home Based Primary Care, Community Living Center,
Adult Day Health Care, Home Maker & Home Health Aide, Community Nursing
Home, Veteran-Directed Care, Hospice & Palliative Care. These programs
touch Veterans across the system, including those in rural and highly
rural areas. ORH partners with Care Management and Social Work Services
to integrate rural social workers into the Patient Aligned Care Team
model to improve care coordination for rural Veterans and their
interdisciplinary care teams.
Women Veterans
The number of women Veterans using VHA services has nearly tripled
since 2001, growing from 159,810 to over 600,000 today. Women Veteran
care coordination and management creates, enhances, and expands care
coordination in areas of maternity care, mammography, cervical cancer
screening, breast cancer care, and infertility treatment. ORH and
Women's Health collaborate to expand access to these services to rural
areas.
Maternity Care Coordination
VA has a robust Maternity Care Coordination (MCC) Program to
support pregnant Veterans through every stage of pregnancy and after
delivery. As of May 2023, over 150 Maternity Care Coordinators,
including at least one at every VA medical center, communicate and
connect with Veterans, collaborate with VA and community clinicians,
monitor the delivery of care, and track outcomes. MCCs contact,
educate, and support Veterans at regular intervals throughout pregnancy
and postpartum. MCCs connect pregnant and postpartum Veterans to
appropriate resources and needed services both within VA and within the
local community. MCCs also ensure Veterans are scheduled for an
appointment with their PACT within 12 weeks after the pregnancy ends.
Fertility/In Vitro Fertilization Services
VA continues to develop care coordination for Veterans and VA
beneficiaries eligible for fertility care, those who are enrolled in
the medical benefits package and recognizes the importance of
coordinating that care. Most highly specialized infertility care is
authorized by VA for provision in the community by reproductive
endocrinologists. Care coordination is essential to the provision of
high-quality, time-sensitive fertility services for Veterans and VA
beneficiaries. Between fiscal years (FY) 2017 and 2021, over 26,000
Veterans and or their beneficiaries received fertility counseling and
treatment through a VA facility.
In September 2016, Congress passed the Continuing Appropriations
and Military Construction, Veterans Affairs and Related Agencies
Appropriations Act, 2017 and Zika Response and Preparedness Act (PL
114-223, Div. A, Sec. 260) which authorized VA to provide Assisted
Reproductive Technologies (ART), including In-Vitro Fertilization
(IVF), to certain eligible Veterans and their spouses. Pursuant to 38
CFR Sec. Sec. 17.380 and 17.412, VA has furnished care for over 300
Veterans and their spouses with a service-connected disability
resulting in infertility between FY 2017 and FY 2021.
In 2019, VA established Fertility/In Vitro Fertilization
Interdisciplinary Teams (IVF-IDT) in each Veterans Integrated Service
Network to coordinate care for fertility services. The Fertility/IVF-
IDT meets regularly to discuss and review Veterans' requests for
fertility care and services, ensuring Veterans and VA beneficiaries
meet eligibility requirements set forth in law and outlined in VHA
Directive 1332, Fertility Evaluation and Treatment, and VHA Directive
1334, In Vitro Fertilization Counseling and Services Available to
Certain Eligible Veterans and Their Spouses.
A key role of members of the Fertility/IVF-IDTs is to ensure
Veterans have access to information about available fertility and
family building services through VA. Members ensure information on
fertility benefits are readily available to Veterans and VA facility
staff. The IDT ensures the existence of a transparent process that is
efficient and effective in the timely management of fertility consults.
In addition, Fertility/IVF-IDT members ensure Veterans and VA
beneficiaries are receiving appropriate fertility care. They monitor
authorized fertility care and cryopreservation through record review to
track fertility treatments and ensure fertility services do not exceed
authorized limits.
Interdisciplinary members communicate with Veterans and VA
beneficiaries about fertility eligibility and services while providing
resources and support. If it is determined a Veteran is ineligible for
VA fertility services, the Fertility IVF-IDT provides written
notification of ineligibility with an explanation where eligibility
criteria were not met for fertility services authorized by VA and
notice of how to appeal this decision.
Cervical Cancer and Breast Cancer Screening
Screening for cervical cancer through Pap tests and/or Human
Papilloma virus screening and screening for breast cancer with
mammograms is critical to identifying cancerous or precancerous
conditions. These screening tests require precise tracking of
timelines, results, and referral orders to ensure that all eligible
Veterans are followed. Often, a return visit or advanced evaluation is
recommended. Women's health care coordinators ensure timely scheduling
of initial screening, follow up, and community provider scheduling, and
they then finalize all required documentation. Care coordinators have
proved to be critical in executing accurate and reliable screening
across the system.
In 2022, 90 percent of VA sites had full-or part-time breast cancer
screening coordinators, and 78 percent had full-or part-time cervical
cancer screening coordinators. State-of-the-art information technology
assistance is available through national electronic health record
clinical reminders, the System for Mammography Results Tracking, and
the Breast Care Registry. To enhance the availability of Women's Health
Coordinators at all sites, VA has funded over 170 Women's Health Care
Coordinators through the Women's Health Innovations and Staffing
Enhancements (WHISE) program. Through ORH's Rural Health Initiative, 40
VA medical facilities received funding to recruit and hire 53 care
coordination personnel in the areas of mammography and cervical cancer
screening, maternity care, and breast cancer care. This allowed
facilities that serve mainly rural women Veterans to create, enhance,
and expand women's health care coordination and management for rural
women Veterans.
VA follows the United States Preventive Services Task Force
Recommendations for Cervical Cancer Screening and the American Cancer
Society Guidelines for Breast Cancer Screening in average risk women.
In response to the Dr. Kate Hendricks Thomas SERVICE Act (SERVICE Act;
Public Law 117-133), VA has expanded access to ensure that eligible
Veterans who were deployed in support of a contingency operation in
certain locations and during certain time periods can receive a breast
cancer risk assessment and clinically appropriate mammography
screening. Beginning in March 2023, providers began offering breast
cancer and toxic exposure screenings to Veterans identified through the
SERVICE Act. In addition to ensuring timely scheduling of initial
screening, follow up, and community provider scheduling, breast and
cervical cancer care coordinators would generally transition care
coordination over to Oncology or necessary specialty care after a
diagnosis.
Conclusion
Veterans have more options than ever before to receive timely and
coordinated care. We are serving record numbers of Veterans both in VA
facilities and through community care with significant progress toward
our timeliness goals. Within VA, the goal of care coordination is to
improve patient experience and health outcomes through effectively
organized health care and sharing of information with Veterans, their
care teams, and caregivers.
Chairman Miller-Meeks and Ranking Member Brownley, we appreciate
your continued support and look forward to answering your questions.
______
Prepared Statement of Julie Kroviak
Chairwoman Miller-Meeks, Ranking Member Brownley, and Subcommittee
Members, thank you for the opportunity to discuss the Office of
Inspector General's (OIG) oversight of how the Veterans Health
Administration (VHA) coordinates the delivery of veterans' health care.
The OIG's Office of Healthcare Inspections routinely reviews and
publicly reports on the quality of health care provided across VHA and
on risks to patient safety.
Coordination of health care defines a series of activities that
must occur for a patient to achieve the most desirable outcomes of
their treatment. There is nothing passive about these activities; the
choreography of delivering care is often a complex interchange of
clinical and administrative activities that must always be precise.
From aligning appropriate specialty teams to ensuring essential
medications and equipment are in place, providers must also work to
anticipate the patient's future needs as well as potential
complications. This complex coordination often occurs, as many of the
OIG reports discussed below show, for patients facing serious
illnesses. These patients rely on a comprehensive assessment of not
only their specific condition but the supports in place to ensure their
recovery, such as the safety and appropriateness of a patient's
discharge environment, clear education and instructions to the patient
and their caregivers, and reliable processes that ensure all
participants have all relevant information. When there are breakdowns
at any point in coordination, the safety of the patient is compromised
and the trust placed in the system responsible for providing that care
is lost.
This testimony highlights some of the many issues that care
providers and patients have faced in navigating the complexities of
care coordination. These reports recognize that VHA personnel often
have to overcome inefficient and ineffective processes or system
limitations to ensure safe transitions and quality care both within VHA
and with outside care providers. The discussion that follows focuses on
(1) the transition from the Department of Defense (DoD) to VA care, (2)
barriers to care coordination within VA, and (3) breakdowns that can
occur when engaging community care providers. Ultimately, effective
care coordination is dependent on dedicated and skilled staff
consistently adhering to sound clinical and administrative policies and
practices that result in desired outcomes for patients and their
caregivers and families.
Although the specific OIG reports highlighted below detail
deficiencies at various points of coordination or at a particular
facility, the findings and recommendations should be considered by VHA
leaders and staff participating in patient care across the Nation.
CARE COORDINATION CHALLENGES DURING THE TRANSITION FROM THE DEPARTMENT
OF DEFENSE TO VA
Many challenges can occur within the first 12 months of discharge
from DoD associated with leaving active duty and transitioning to
civilian life, such as homelessness, family reintegration, employment,
posttraumatic stress disorder, and substance misuse, which can increase
the risk for suicide.\1\ While improvements have been made in the
interoperability of VA and DoD electronic health record (EHR) systems,
significant risks remain when VA providers find DoD records are not
complete or accessible, or when VA providers have not thoroughly
reviewed and evaluated those records during former service member's
earliest encounters in VA.
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\1\ VA, Executive Order 13822 Fact Sheet, accessed June 1, 2023.
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The OIG is finalizing a national review in which a team evaluated
the transition of clinical care for service members with opioid use
disorder (OUD) from DoD to VHA.\2\ Failure to identify and document a
patient's known OUD history and related treatment during this critical
transition period may decrease the likelihood of a patient receiving
timely VA care and support. Of particular concern, veterans have been
found to be ``twice as likely to die from accidental overdose compared
to non-veterans.'' \3\
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\2\ VA/DoD Clinical Practice Guideline for the Management of
Substance Use Disorders, Version 4.0, 2021. Care transition refers to
the transition of healthcare from DoD to VHA for a service member upon
separation from the military; Diagnostic and Statistical Manual of
Mental Disorders Fifth Edition, Text Revision (DSM-5-TR), ``Substance
Related and Addictive Disorders,'' accessed December 15, 2022. OUD is
defined as a ``problematic pattern of opioid use leading to clinically
significant impairment or distress'' as manifested by at least two
symptoms from a list of psychological, physical, occupational,
interpersonal, or recreational consequences, within a 12-month period.
\3\ Elizabeth M. Oliva et al., ``Saving Lives: The Veterans Health
Administration (VHA) Rapid Naloxone Initiative,'' The Joint Commission
Journal on Quality and Patient Safety 47-8, (August 2021): 469-80.
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The OIG reviewed a sample of discharged service members with a DoD-
originated OUD diagnosis. The team then reviewed the patients' VHA
electronic health records for evidence that care providers were aware
of the OUD diagnosis and treatment. The OIG team found concerning gaps
in the records review with a significant percentage of the VHA
providers not recording the OUD diagnosis in VHA records, thus
potentially hampering future medical decisions.\4\ Additionally, the
OIG found providers perceived barriers to documenting OUD diagnoses
during the transition of clinical care, and the OIG determined that
while there was evidence of the use of risk-mitigation strategies, such
as dispensing opioid reversal agents, improvements could be made.
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\4\ Currently, this report is in draft, but, consistent with OIG
practices, has been reviewed by VA. This allows VA offices to comment
on OIG findings and recommendations, as well as to provide responsive
action plans. OIG staff is integrating that feedback into the final
report. While it is not the OIG's routine practice to testify regarding
pending reports, due to the timing of this hearing and VA having had
the chance to review the report, the findings are discussed in general
terms today.
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Veterans who are referred by VA to a DoD medical facility also may
experience coordination problems due to limitations in the
interoperability between the DoD and VA electronic healthcare records
(EHR), such as the lack of full accessibility offered by the Joint
Longitudinal Viewer (formerly known as Janus and the Joint Legacy
Viewer). The OIG has released 14 oversight reports on the deficiencies
with the new EHR system that is meant to provide a seamless health
record for veterans between DoD and VA.\5\ Despite progress, there is
still significant work to be done.
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\5\ VA OIG, Statement of Deputy Inspector General David Case--
Hearing on ``VA's Electronic Health Record Modernization: An Update on
Rollout, Cost, and Schedule'', September 21, 2022.
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Staff from several OIG divisions worked on a joint project led by
the DoD Office of Inspector General that was released in 2022.\6\ The
project assessed internal controls and compliance with legal
requirements, as well as actions by DoD, VA, and their joint Federal
Electronic Health Record Modernization (FEHRM) program office to help
ensure that healthcare providers serving veterans can access a complete
healthcare record. The joint audit found that while the agencies took
some actions to achieve the level of interoperability between DoD, VA,
and external care providers specified by Congress in the National
Defense Authorization Act (NDAA) of 2020, challenges remain. The audit
found that VA and DoD did not consistently migrate patient healthcare
information into the new EHR to create a single, complete patient
health record, because DoD and VA have separate processes for bringing
information into the new EHR. To access clinical information that
hasn't been migrated to the new system, users have been instructed to
use the Joint Longitudinal Viewer. This work-around does not meet NDAA
requirements that healthcare providers access and exchange patient
healthcare information without additional intervention. Second, the DoD
and VA did not develop interfaces from all medical devices to the new
EHR so that patient information will automatically upload to the
system. For example, some medical devices, such as some blood pressure
cuffs and IV pumps, did not have set national healthcare data standards
and still require the departments to develop effective interfaces. One
contributing factor to interoperability problems was the failure of
FEHRM program office officials to develop and implement a plan to
achieve all NDAA requirements and actively manage the program's
success, as authorized by the FEHRM's charter. Because the FEHRM
program office limited its role, DoD and VA took separate actions to
migrate patient healthcare information and develop interfaces. These
issues remain unresolved.
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\6\ DoD OIG and VA OIG, Joint Audit of the Department of Defense
and the Department of Veterans Affairs Efforts to Achieve Electronic
Health Record System Interoperability, May 5, 2022.
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As part of the OIG's oversight of VA's development and
implementation of the new EHR system, reports have been issued on care
coordination concerns affecting patients at VA facilities that have
transitioned to the new system.\7\ The OIG found several areas of
unresolved issues that create barriers to various aspects of care
delivery, such as appointment scheduling, laboratory orders, prescribed
medications, and the utility of high-risk-for-suicide and behavioral
patient record flags.
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\7\ VA OIG, Care Coordination Deficiencies after the New Electronic
Health Record Go-Live at the Mann-Grandstaff VA Medical Center in
Spokane, Washington, March 17, 2022.
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CARE COORDINATION CHALLENGES FOR VETERANS RECEIVING CARE WITHIN VHA
After veterans are enrolled and established in VHA, issues related
to care coordination can arise in both acute and long-term care
settings. For example, the OIG has repeatedly identified clinical
failures caused by unclear or inadequate processes or in the oversight
of personnel tasked with ensuring a safe transition for patients.
Facility Personnel Did Not Follow VA Processes or Failed to
Properly Coordinate Care within a Facility or Clinic
Many OIG reports focus on personnel within medical facilities
either not following policy and procedure or failing to properly
communicate to other providers and clinical staff.
For example, the OIG has reported on the death of a veteran who was
wrongly denied care at a VA emergency department. Despite being told of
the veteran's serious condition and provided with identifying
information, nurses and an administrative staffer wasted critical time
analyzing the veteran's eligibility status, later having the veteran
transported to a community hospital. In the end, it was determined the
patient in fact was a veteran and proper policies had not been
followed.\8\ Similarly, a veteran residing in a VA community living
center was found deceased after a nurse failed to initiate that
resident's transfer to an emergency department following the
recommendation of the on-call resident.\9\
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\8\ VA OIG, Delay in a Patient's Emergency Department Care at the
Malcom Randall VA Medical Center in Gainesville, Florida, June 3, 2021.
Further, the OIG has numerous reports that describe issues associated
with coordinating the after care for patients who visited emergency
departments. VA OIG, Quality of Care Concerns and Leadership Response
at the Amarillo VA Health Care System in Texas, April 14, 2022; VA OIG,
Poor Emergency Department Care of a Patient, January 25, 2023. The OIG
also reported on an emergency department physician whose delay in
recognizing the need to transfer a patient to a facility that could
provide needed life-saving treatment led to the patient's death. VA
OIG, Mismanagement of Emergency Department Care of a Patient with Acute
Coronary Syndrome at the Robert J. Dole VA Medical Center in Wichita,
Kansas, September 23, 2020.
\9\ VA OIG, Failure to Communicate and Coordinate Care for a
Community Living Center Resident at the VA Greater Los Angeles Health
Care System in California, August 17, 2022.
Failures in Coordinating Discharge from Facility Care Place
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Veterans at Risk
Careful and thorough discharge planning is critical to support safe
outcomes as patients move between providers and various care settings,
especially when transitioning back to their homes.
During an inspection at the VA Southern Nevada Healthcare System's
inpatient mental health unit, the OIG found serious gaps in discharge
planning for a patient who died by suicide the same day as being
released.\10\ The patient had been treated by various VHA facilities
for significant mental health conditions for many years before this
inpatient stay. The OIG found inadequate care by both inpatient and
outpatient staff, a failure to reconcile critical clinical treatment
and discharge plan information, delayed assignment of a required mental
health treatment coordinator, and ineffective responses to the
patient's complaints and requests. For example, staff did not request
substance use disorder assessments despite a positive drug test; failed
to understand the patient's suicide risk factors, like access to lethal
means; and did not identify coping strategies among other aspects of
unsatisfactory safety planning. These lapses placed this patient at
significant risk during their transition to home. Even after the
suicide event, the OIG found facility leaders did not properly handle
institutional disclosure processes by failing to alert the veteran's
next of kin to the deficiencies. The OIG made 10 recommendations, now
closed, for corrective action focused on improving patient care
coordination and mental healthcare delivery.
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\10\ VA OIG, Deficiencies in the Mental Health Care of a Patient
who Died by Suicide and Failure to Complete an Institutional
Disclosure, VA Southern Nevada Healthcare System in Las Vegas, July 15,
2021.
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As part of a review of allegations that an elderly patient suffered
verbal abuse and physical harm at the hands of facility staff at the VA
community living center (CLC) in Miles City, Montana, after being
discharged from an inpatient stay at the Fort Harrison VA Medical
Center, the OIG found the patient experienced deficient care
coordination and discharge planning.\11\ Because Miles City CLC did not
have a designated screening process for reviewing the appropriateness
of admissions from a VA medical center, opportunities were lost in
determining whether the CLC could support the veteran's clinical needs.
Further complicating the tragic events surrounding his abuse, care
providers in the CLC failed to ensure the patient received necessary
imaging that would have revealed a terminal diagnosis. While the
horrific events of patient abuse are inexcusable, recognizing that
failures in inpatient discharge planning contributed to this same
veteran being denied timely access to end-of-life care is devasting.
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\11\ VA OIG, Mistreatment and Care Concerns for a Patient at the
VA Montana Healthcare System in Miles City and Fort Harrison, January
26, 2023.
Failures with Coordination of Care in Non-Facility VHA Settings
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Can Result in Patient Harm
Veterans engage with VHA outside of traditional medical facility
settings, often seeking additional or complementary services,
particularly in support of mental health treatment. Similar to care
coordination provided in VHA clinic and inpatient settings, prompt and
clear communication is imperative to ensuring a patient's needs are met
when engaging with crisis hotline personnel, community-based vet
centers that provide counseling, and VA-directed home-based mental
health care.
Veterans Crisis Line
Since its establishment in 2007, the Veterans Crisis Line (VCL) has
answered millions of calls from veterans in crisis. VCL responders are
required to initiate emergency rescue services for those veterans
identified as being in immediate danger to themselves or others. In
addition, coordination activities for callers not in need of immediate
rescue are critical to ensuring appropriate care. For example, in 2021,
a VCL staff person told the veteran it was urgent that they go to a VHA
emergency department in Augusta, Georgia, after the veteran expressed
suicidal ideation.\12\ The VCL staffer notified an emergency department
nurse that the patient was directed there. The patient reported to the
emergency department as directed; however, the nurse did not document
for the emergency department physician evaluating the patient that this
was due to a VCL referral because of suicidal ideation, and there was
no evidence the physician was ever notified. On arrival, the patient
reported a chief complaint of pain and denied suicidal ideation during
a routine screening. Without knowledge of the VCL referral, the
physician did not have a complete understanding of the patient's
current condition and therefore did not ensure the patient's follow up
with mental health clinicians. Additionally, the facility's suicide
prevention staff, despite being made aware by VCL staff of the
veteran's contact with VCL, did not contact the veteran to schedule
follow-on care as required.\13\ Approximately two months later, the
veteran was found deceased from a self-inflicted gunshot wound in the
parking lot of the Aiken, South Carolina, Community Based Outpatient
Clinic. The OIG made nine recommendations to the Augusta facility in
May 2023, including several focused on managing referrals and care
coordination.
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\12\ VA OIG, Deficient Care of a Patient Who Died by Suicide and
Facility Leaders' Response at the Charlie Norwood VA Medical Center in
Augusta, Georgia, May 10, 2023.
\13\ In a different OIG healthcare inspection, emergency department
staff failed to inform suicide prevention staff of a patient in crisis,
and the patient died by suicide six days later. VA OIG, Inadequate
Emergency Department Care and Physician Misconduct at the Washington DC
VA Medical Center, July 28, 2020.
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Vet Centers
Vet centers are community-based clinics that provide a wide range
of psychosocial services to clients that include eligible veterans and
current service members. Vet center counselors communicate with local
VA medical facilities to coordinate care for shared clients, most
importantly, those who are high risk for suicide. The counselors are
required to provide timely notification to VA medical facility suicide
prevention coordinators when shared clients have a significant safety
risk. They must follow confidentiality requirements when communicating
with local VA medical facilities to coordinate care. Since 2021, the
OIG has published findings from its vet center inspection program,
which provides a focused evaluation of key aspects of the quality of
care delivered at vet centers. The OIG has consistently found in the
sites reviewed that vet center staff across the country have not
consistently complied with these requirements.\14\ For example, the OIG
found that of the 30 client records reviewed in vet centers in district
1 zone 3, 18 records had documented coordinated care with the
supporting VA medical facilities as required, and only three of the 18
followed confidentiality requirements.\15\ The OIG also found most
records did not reflect mandatory notifications to VA staff were made
for patients with significant safety risks.
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\14\ VA OIG, Vet Center Inspection of Pacific District 5 Zone 2 and
Selected Vet Centers, December 20, 2021; Vet Center Inspection of
Midwest District 3 Zone 1 and Selected Vet Centers, January 19, 2023.
\15\ Locations visited included City Center and Northeast
Philadelphia, Pennsylvania; Scranton, Pennsylvania; and Huntington,
West Virginia. VA OIG, Vet Center Inspection of North Atlantic District
1 Zone 3 and Selected Vet Centers, May 25, 2023. While a veteran using
a vet center may be referred to a VHA medical facility when in crisis,
VHA facility staff must ensure they coordinate care with vet center
staff when appropriate. For example, the OIG substantiated that a
patient died by suicide within three days of discharge from an
inpatient mental health unit in the VA OIG report, Deficiencies in
Inpatient Mental Health Care Coordination and Processes Prior to a
Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital
in Columbia, Missouri, issued on January 5, 2021. While the patient
received medication and discharge instructions that included suicide
prevention materials, the OIG identified care coordination and
discharge planning deficiencies that included the failure to coordinate
the patient's mental health treatment or include vet center staff in
the discharge planning. The vet center could have helped to facilitate
the patient's engagement with outpatient resources and timely follow-
up.
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Home-Based Mental Health Care
To coordinate the complex care of veterans with serious mental
illness and to mitigate negative outcomes, VHA utilizes Intensive
Community Mental Health Recovery programs (ICMHR). ICMHR provides case
management to veterans diagnosed with serious mental illness who are
deemed able to live in the community with the frequent support of a
multidisciplinary team coordinating the clinical and social services of
each veteran. To reduce the burden on the veteran, these visits occur
in the veteran's home and, as required during the pandemic, can be
supported when necessary via the use of telehealth.\16\ The OIG
reviewed ICMHR programs from 2019 to 2021 and found they did not meet
VHA's required visit frequency for high-intensity services. Without
meeting the evidence-based number of visits to support veterans and
ultimately reduce their risk of being in crisis, opportunities for
early and less intensive interventions are lost. Realizing that these
patients also often require long-acting injectable antipsychotic
medications, the OIG reviewed ICMHR-specific contingency plans for
emergency situations such as a pandemic, when injectable medications
may be challenging to secure. The OIG found the majority of VHA
healthcare systems did not have ICMHR-specific contingency plans for
ensuring veterans' access to needed medication.
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\16\ VA OIG, Improvements Recommended in Visit Frequency and
Contingency Planning for Emergencies in Intensive Community Mental
Health Recovery Programs, January 31, 2023.
Opportunities Exist to Support Care for Veterans Who Face
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Challenges in Accessing Care
Care coordination between care providers and their patients can be
challenging for veterans who experience obstacles in getting to any
healthcare facility. In particular, accessing in-person care can be a
formidable task for older veterans, those with mobility issues, and
individuals living in rural areas.
One way that VA has been working to reduce barriers to care is by
increasing the use of telehealth. Because providing telehealth services
is not without obstacles, the OIG recently assessed the implementation
and use of VA Video Connect (VVC) prior to and during the pandemic.\17\
VVC provides a secure environment for patients and providers to carry
out video telehealth visits, regardless of where the veteran and
provider are located. Specifically, the review team explored factors
affecting why primary and specialty care providers used telephone
communication more frequently than VVC at the onset of the pandemic and
in lieu of in-person encounters, and how VHA resolved technology
issues. The OIG also examined VHA provider experience with VVC prior to
and during the pandemic to identify the benefits of and barriers to VVC
use. When the pandemic started, VHA was not readily able to support the
increased demand of VVC use, leading providers to provide patient care
by telephone. This occurred despite VHA having developed telehealth
strategic plans, which focused on improving technology to support VVC,
increasing provider capability, and identifying emergency preparations
for disaster scenarios.
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\17\ VA OIG, Review of Access to Telehealth and Provider Experience
in VHA Prior to and During the COVID-19 Pandemic, April 26, 2023.
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Notably, the VHA Office of Connected Care's chief officer said
video visits increased from 2,000 to 40,000 per day and emphasized
that, ``the technical infrastructure was not scaled to that kind of . .
. unexpected and unplannable [sic] for growth.'' As the pandemic
continued, providers continued to use VVC, recognizing its value in
increasing access to care and enabling more comprehensive evaluations
than telephone encounters could offer. There were identifiable
barriers, however, including patient difficulties with technology, lack
of clinical and administrative support during the encounters, and
challenges with scheduling VVC appointments. VHA concurred with the
OIG's three recommendations to address those barriers that were issued
in April 2023.
OIG REPORTS HAVE FOUND CONCERNS WITH COMMUNITY CARE COORDINATION
Coordinating medical care between VHA and community providers
remains a tremendous challenge, particularly for managing patients with
complex health needs. The OIG has identified persistent administrative
and communication errors or failures among VHA, its third-party
administrators, and community care providers, as well as between the
care providers and their patients. These deficiencies, often a result
of personnel errors or policy implementation, undermine the
considerable efforts of VHA personnel to ensure a seamless experience
for veterans. VA has made considerable efforts to increase the use of
technologies that enable better information sharing with the community.
As one example, VA's participation in health information exchanges
advances the sharing of veterans' information outside VA, whether
through the community care program or not. Many OIG reports have
described the frustrations and various risks experienced by patients
referred to the community.
Administrative Failures Challenge the Coordination of
Healthcare Services
VHA has detailed numerous steps in the process to obtain healthcare
services for a veteran through its community care programs. This
process requires staff from clinical service lines and administrative
support offices in the medical facility to work with the veteran or
caregiver, the VA's third-party administrator, and the community
provider. The OIG reviewed VA's implementation of the Referral
Coordination Initiative (RCI) that sought to facilitate consult
(referral) scheduling for specialty care within VHA facilities and in
the community for eligible veterans.\18\ RCI was designed to improve
veterans' timely access to care, empower patients to make informed care
decisions, reduce providers' administrative burden and increase their
time on patient care, and enhance access to community care for veterans
eligible under the MISSION Act of 2018.\19\
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\18\ VA OIG, Additional Actions Needed to Fully Implement and
Assess Impact of the Patient Referral Coordination Initiative, October
27, 2022.
\19\ The OIG reported in 2020 on the community care consult
process, with an audit team finding patients experienced community care
appointment delays in Veterans Integrated Service Network 8 due to the
facilities' insufficient staffing and consult-processing structure at
community care departments that review, authorize, and schedule
community care. There was insufficient staffing for administrative
functions such as contacting patients and coordinating appointments.
Also, merging the consult authorization and scheduling tasks within
community care departments could allow scheduling to begin promptly.
The OIG's five recommendations focused on key process improvements. VA
OIG, Improvements Are Needed in the Community Care Consult Process at
VISN 8 Facilities, January 16, 2020.
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Under the non-RCI consult referral process, a provider first
determines whether a patient requires a specialist and then assesses
whether the patient is eligible for community care provided by a non-VA
practitioner. If the patient is eligible for care in the community, the
healthcare provider submits a referral to the facility's community care
department staff to confirm eligibility and to call the patient to
discuss appointment preferences (including provider and location).
Then, the community care staff either help schedule the appointment or
provide the patient with the information to do so.
Under the RCI process, after a facility provider (usually a primary
care physician) enters a consult for a patient requiring specialty
services, a Referral Coordination Team (RCT) determines the veteran's
eligibility for community care.\20\ A clinical RCT member, typically a
triage nurse, determines the available care options for the patient
(in-house, in another VA facility, or in the community); assigns the
consult a priority level indicating how urgently the patient needs to
be seen; determines whether any medical tests are needed; and contacts
the patient to discuss care options.
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\20\ VHA, Referral Coordination Initiative Implementation
Guidebook, December 2021. The guidebook states that the RCT is a
multidisciplinary team of clinical and administrative staff, which
includes doctors, physician assistants, licensed nurse practitioners,
registered nurses, and schedulers.
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In 2019, VHA began implementing the RCI at 139 VA medical
facilities, with expected completion across all facilities and all
specialty services by June 30, 2021. VHA staff generally agreed the RCI
had the potential to achieve its stated goals. However, facilities
struggled with implementation for several reasons, including
insufficient staffing and resources, unreliable data (such as a lack of
accurate wait times for community care), and a lack of required
training. The RCI describes two implementation models, centralized and
decentralized, but facility staff were sometimes confused about which
model to apply and noted slow responses from VHA to questions. Without
clear direction on staffing models, some facilities tested different
implementation methods. Given the staffing strain, initiative leaders
from one facility said they were planning to roll out the initiative to
only two services every month; at this time, completion may still take
several years.
The Office of Integrated Veteran Care (IVC) predecessor, the
program office responsible for overseeing the RCI, also lacked the
ability to monitor progress due to insufficient data. Because of these
deficiencies, no VA facility had fully implemented the RCI almost a
full year after VA's own June 2021 deadline, and facilities are
currently working to fully implement the process. IVC had not developed
a mechanism for facilities to evaluate whether staff were meeting the
initiative's goals. VHA did not have data to measure whether the
initiative reduced the average time to schedule appointments--one of
its key goals. Also, VHA lacked measures to evaluate whether veterans
received key information to inform care decisions, a second key goal.
The review team identified instances when facility staff did not
provide patients with key information--for example, there was a
provider who said he generally decides what is best for patients and
does not usually give them an option. Similarly, IVC had not evaluated
if the initiative reduced administrative burdens on providers, a third
key goal, and none of the four facilities the review team visited had
conducted this type of analysis.
The under secretary for health concurred with the OIG's seven
recommendations issued in October 2022 to improve RCI implementation by
better assigning responsibilities and roles, improving training,
establishing local procedures for sharing community care data to more
fully inform patients, sharing best practices among all facilities,
ensuring accurate tracking of RCI consults, and developing measures of
how well facilities meet the initiative's requirements. Five
recommendations remain open at this time.
After a veteran receives services from a community care provider,
VHA has contracted for those providers to return the treatment records
to VA. These records from non-VA care settings enable continuity of
care by VHA providers and inform treatment decisions. An OIG audit team
found in a June 2021 report that staff at six of the seven VA medical
facilities reviewed did not always index or categorize these records
accurately.\21\ Inaccurate indexing of medical records poses a risk to
veteran care and increases the burden on the VHA staff who locate and
correct the errors, reducing their time for other tasks. Errors
included using ambiguous or incorrect document titles, indexing records
for non-VA care to the wrong referral or veteran, and entering
duplicate records. These errors occurred, in part, due to inadequate
procedures, training, quality checks, and quality assurance monitoring,
as well as a lack of local facility-level policies. The OIG recommended
the under secretary for health improve non-VA medical records scanning
and indexing by ensuring VHA facilities create and fully implement
standard operating procedures. Besides clearly defining
responsibilities and procedures for accurately scanning, importing, and
indexing non-VA medical records, the OIG also made recommendations
related to training and oversight of facility community care staff
responsible for medical record management.
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\21\ VA OIG, Improvements Needed in Adding Non-VA Medical Records
to Veterans' Electronic Health Records, June 17, 2021.
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In addition to errors while indexing returned medical documents,
the OIG has also examined the impact of the backlogs at VA facilities
in scanning these documents.\22\ Beyond the continuity of care risks,
backlogs can lead to delays or denials of veterans' claims for
reimbursement of non-VA emergency care and the expiration of checks
sent to VA for payments, as the OIG reported after reviewing the
contents of unopened mail at the Atlanta VA Healthcare System.\23\ The
OIG has repeatedly found VHA staff did not enter documents into EHRs in
a timely manner, nor did they perform appropriate reviews and
monitoring to assess the overall quality and legibility of scanned
documents. The OIG also found leaders' poor communication and follow-
through, as well as staffing shortages, contributed to these backlogs.
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\22\ VA OIG, Health Information Management Medical Documentation
Backlog, August 21, 2019.
\23\ VA OIG, Atlanta VA Health Care System's Unopened Mail Backlog
with Patient Health Information and Community Care Provider Claims,
April 27, 2022.
Veterans Have Experienced Poor Outcomes When Care Was Not
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Coordinated with Community Care Providers
In a March 2021 report on the deficiencies found in the care and
administrative processes for a patient who died by suicide, the OIG
review team found that numerous administrative errors and confusion in
the Phoenix VA healthcare facility's community referral process delayed
a patient's specialized psychological testing. VA's third-party
administrator (the contractor that manages the community provider
network and appointment scheduling) incorrectly scheduled the veteran
for therapy, not testing. The patient died by suicide not having
received the appropriate testing and resulting treatment.\24\
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\24\ VA OIG, Deficiencies in Care and Administrative Processes for
a Patient Who Died by Suicide, Phoenix VA Health Care System, Arizona,
March 31, 2021.
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Another oversight report focused on a patient who ultimately died
by suicide after not receiving several authorized community care
counseling sessions. This was due to deficiencies in the coordination
of the patient's care among the Memphis VA facility's community care
staff, providers in the community, and the third-party
administrator.\25\ The patient also suffered from hyperthyroidism, a
condition that can aggravate anxiety. The patient declined a referral
to endocrinology at the facility, due to the distance from home, but
was never offered a referral to the community. In addition, a September
2022 OIG healthcare inspection examined the failure of a facility's
community care staff to adequately convey the seriousness of a
patient's cancer diagnosis to VHA and community health providers.\26\
Due to bureaucratic issues and a lack of standard guidance, the
facility incorrectly denied the patient's initial radiation therapy
request.
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\25\ VA OIG, Deficiencies in Care, Care Coordination, and Facility
Response to a Patient Who Died by Suicide, Memphis VA Medical Center in
Tennessee, September 3, 2020.
\26\ VA OIG, Community Care Coordination Delays for a Patient with
Oral Cancer at the Veterans Health Care System of the Ozarks in
Fayetteville, Arkansas, September 12, 2022.
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Managing care for veterans who have been seen in the community and
are coming back into VHA facilities for treatment presents similar
coordination risks. The OIG examined concerns related to a lack of care
coordination for patients receiving ketamine for treatment-resistant
depression (depression that has failed to respond to multiple attempts
of more conventional treatments) in the community after authorizations
for the care lapsed in September 2019 at the VA San Diego Healthcare
System in California.\27\ The OIG substantiated that the facility ended
authorizations for community care for patients receiving ketamine in
October 2019 and again in March 2020, negatively affecting 35 patients.
The OIG also identified deficiencies in facility processes. The OIG
concluded that risks for negative patient outcomes increased due to
communication and care coordination deficits, terminating community
care authorizations, accelerating timelines for care transition, and
uncertainties from suddenly changing treatment for complex patients.
Four recommendations were made to the facility director related to
community care processes for coordination of non-VA care and ensuring
coordinated, clinically informed plans for transitioning remaining
patients to care at the facility.
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\27\ VA OIG, Deficiencies in Coordination of Care for Patients with
Treatment-Resistant Depression at the VA San Diego Healthcare System in
California, August 24, 2021. In a separate report discussing the
administration of ketamine for treatment-resistant depressions, the OIG
found VHA-internal care coordination failures, including inconsistent
prescribing practices. VA OIG, Deficiencies in the Implementation and
Leadership Oversight of Ketamine at the Eastern Oklahoma VA Health Care
System in Muskogee, March 9, 2023.
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VHA MUST DO BETTER AT TRACKING AND RESOLVING HEALTHCARE COMPLAINTS
It is imperative that veterans and their caregivers have a voice in
their care and an avenue for redress when mistakes have been made. The
Patient Advocacy Program is VHA's effort to improve customer service,
support veterans' access to quality care, and provide a mechanism to
resolve healthcare delivery or coordination issues. When a veteran
submits a complaint at a VA medical facility regarding care delivered
within VHA or through a community partner, a patient advocate begins
the process of documenting the concern, communicating a resolution, and
providing follow up and feedback. Patient advocates also are expected
to identify trends to signal potential opportunities for medical
facility improvements. However, a March 2022 report found that VHA did
not effectively issue and implement adequate policy, monitor complaint
practices, and provide guidance to medical facility directors
responsible for local program management.\28\ The OIG also found that
patient advocates were not entering complaints into their tracking
system or the documentation to show how complaints were being resolved.
Further, coordinators, managers, and VHA-level Office of Patient
Advocate staff were not monitoring and reviewing patient advocate
activities. In addition to quality concerns, this leads to missed
opportunities to improve veterans' experiences because facility leaders
may not fully understand the scope of problems that veterans encounter.
The three recommendations made to VHA to update policy, implement
controls, and fulfill oversight duties of the program all remain open.
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\28\ VA OIG, Improved Governance Would Help Patient Advocates
Better Manage Veterans' Healthcare Complaints, March 24, 2022.
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CONCLUSION
High-quality care demands that patients receive the necessary care
provided by qualified clinicians in a timely manner. The reports
highlighted in this testimony call attention to the risks introduced
when care is not coordinated properly, whether due to clinical or
administrative problems. The OIG is committed to ongoing and meaningful
oversight of these issues. As VA continues to purchase an increased
amount of community care, it must redouble its efforts to make care
coordination efforts more efficient, and it must refocus attention on
patients transitioning between care providers and venues. Without an
efficient strategy to consistently monitor the access to and quality of
care provided to veterans in the community, VHA and other
stakeholders--and most importantly, veterans and their caregivers--can
have no assurance of the quality or safety of that care.
Almost every report published by the OIG's Office of Healthcare
Inspections details aspects of care coordination, whether it is a
hotline inspection detailing missteps or failures in that coordination,
or the cyclical reviews that provide VHA leaders with a risk assessment
of their medical facilities' current practices. The OIG encourages VHA
leaders to broadly distribute these healthcare oversight publications
to alert all facilities of potential risks and to promote the robust
exchange of local success stories in preventing or correcting them. The
OIG will continue to enhance our proactive tools, while revealing the
complex findings of our inspections in responding to allegations of
substandard care. Additionally, teams across the OIG will continue
their efforts to assess the various VHA program offices' operations and
monitor the issues raised in this testimony.
Chairwoman Miller-Meeks, Ranking Member Brownley, and members of
the Subcommittee, this concludes my statement. I would be happy to
answer any questions you may have.
______
Prepared Statement of Andrea Sawyer
Madame Chairwoman, Members of the Subcommittee, my name is Andrea
Sawyer, and I am the Advocacy Director for the Quality of Life
Foundation (QoLF), a national non-profit organization founded in 2008
to address the unmet needs of caregivers, children and family members
of those who have been wounded, ill, or injured serving this Nation.
Since then, we evolved and now work directly with veterans and
caregivers as they attempt to apply for and navigate the Program of
Comprehensive Assistance for Family Caregivers (PCAFC) and other
clinical support programs within the Department of Veterans Affairs.
Serving all generations and focusing mostly on those with significant
wounds, illnesses, or injuries, we often assist those with the most
complex needs.
As one of the few organizations working exclusively within the
Veterans Health Administration, and as a caregiver to a Post 9/11
veteran myself, we have had a front row seat to witness and help others
utilize many of the programs and services available within the VA.
While we do NOT provide clinical recommendations of any kind, our role
is to ensure that veterans and caregivers are prepared for the PCAFC
process, assist in the drafting of clinical appeals to ensure the VA is
following its own regulations and directives, and assist veterans and
caregivers in navigating other programs and supports available to them.
In that role, we see the positive things that can happen when
veterans and caregivers are connected by caring and passionate
providers and social workers to the programs and services that enhance
their care and their quality of life. PCAFC, Respite, Veteran Directed
Care, and the Homemaker Home Health programs are just some of the
programs that support veterans in their homes and can serve as a
lifeline for veterans in need. Unfortunately, we also see what can
happen when those especially vulnerable veterans are not connected to
those resources, and, more often than not, poor or a complete lack of
care or case management is at the root of the problem.
In order to understand the problem, it is important to understand a
little bit of the history and terminology involved in this process.
After the Walter Reed scandal, the Department of Defense and the VA
stood up unprecedented levels of case management for injured veterans.
At one point, it was not uncommon to hear family caregivers say that we
needed a case manager for our case managers, ultimately resulting in
the creation and implementation of the Federal Recovery Care
Coordination program for those with multiple severe injuries and
complex needs. FRC's were Masters Level GS-15's nurses or social
workers reporting to the Deputy Secretary with broad referential
authority and, in the best of cases, the ability to created integrated
care plans and cut across program and agency lines to resolve issues
for the most vulnerable warriors and their caregivers.
Since the winding down of operations in Iraq and Afghanistan and
even before then, however, the case management programs seem to have
been minimized with some being removed, some being revamped, and still
others being renamed. Unfortunately, the case managers seem to have all
again been siloed in their efforts. While FRC's still exist, there are
very few of them and they have been relegated further down into VHA and
do not interact with veterans directly. Instead, they serve as
consultants upon request of the facility, when and if the facility
knows to call them--leaving those with the most complex needs, a
population that includes severe mental health issues, PACT act eligible
veterans, and those with long-term complex injuries and conditions with
no known case manager who can help them navigate resources across the
VA, access the Community Care Network, and develop a workable
coordinated care plan.
Every veteran in the VA is entitled to care coordination; this is
basic care coordination through the Primary Care Manager and a basic
treatment plan that the veteran is responsible for carrying out.
In our experience at QoLF, we see many veterans with care
managers--people who usually manage one clinical support or disease
specific program--but no overall case manager. A care manager does not
necessarily look at overlapping needs or outside the clinic in which
they are operating.
Care objectives in disease specific treatment plans may be
contradictory OR multiple disease/injury specific care plans may create
an overall higher burden on the veteran and caregiver for management.
With no higher oversight on the part of individual care managers,
veterans and caregivers have multiple plans to try to navigate and
multiple points of contact individual to each disease, injury, or
intervention.
Many of the veterans that QoLF serves have complex care needs. They
are in need of case managers. Case managers are trained to evaluate the
multiple care plans that a veteran has for each injury or condition,
look at the veteran's whole health needs--including environmental and
social needs, and develop a coordinated care plan. The coordinated care
plan will take into account each condition, set goals or targets for
each condition, list who is responsible for those goals/conditions, and
set target dates for completion. This gives the veteran and caregiver
ONE point of contact for issues that arise. Cases that need case
management are time-intensive, require coordination of care both inside
and outside the VA, and usually have psychosocial and environmental
needs as well.
In Ohio, we were contacted by an elderly veteran who had been
removed from the Caregiver Support Program. The veteran had been in
Home Based Primary Care, the Caregiver Support Program, and was
receiving support from Geriatrics and Extended Care. The caregiver was
using her stipend to pay for in home physical therapy, occupational
therapy, and extra homemaker home health aide hours. When it was time
to review the veteran, the caregiver was removed from the Caregiver
Support Program because the Caregiver Eligibility Assessment Team felt
that by removing the caregiver from the program, then the caregiver
could be given many more hours of support by Geriatrics and Extended
Care, something that is prevented by a case matrix tool that exists
between GEC and PCAFC.
However, and this is where case management would have been helpful,
upon the removal of the caregiver from the stipended portion of the VA
Caregiver Support Program, there were no steps put in place to
immediately increase the veteran's hours of care through Geriatrics and
Extended Care. Nor did VA send or coordinate more physical therapy or
wound care therapy at the home of the veteran which had been being paid
for by the caregiver from her stipend. The caregiver began calling the
local non-emergency line to help change and bathe the veteran after no
home health care workers were initially added to assist the caregiver.
Additionally, the caregiver suffered an increasing level of exhaustion,
as the VA contracted workers failed to show up for more than half the
hours for which they were contracted and the workers were a revolving
door of workers, some of whom did not speak any English in an only
English speaking home.
Once we asked for a higher level of case management to engage with
the VA, there were a higher number of hours that were granted for
homemaker home health aide hours, but they still were not filled. The
issue became that GEC said it was the agency's responsibility, and the
caregiver was supposed to take it up with the agency; the agency said
they did not have workers to fulfill it, and no one was able to support
the caregiver and veteran in their ever declining state.
When we first got the family, the veteran and caregiver needed more
support, but due to a lack of coordination between PCAFC's dismissal
and GEC's ability to actually get the necessary about of services into
the home that had been being provided by private care with the
caregiver stipend, the people who paid the price were the veteran and
caregiver. Unfortunately, while the hours were raised, they were still
unable to be met, and now the veteran is in the hospital. Had VA
coordinated the proper order of resource stand up and withdrawal, this
case may have had a better outcome. This is where an overall case
manager would have been helpful in aligning the order of how resources
could have been added and removed.
Additionally, no one is assisting the veteran to navigate Community
Care Network referrals and records management. This falls to the
veteran and caregiver, and those with these complex needs often cannot
do it because it involves multiple behind the scenes VA processes and
offices. Being a veteran with complex needs or an overwhelmed caregiver
often leads to complications in the veteran and caregiver's social,
emotional, and financial well-being. Having holistic long-term case
management and a case coordination plan allows an extra level of
support and management to improve the whole health of the veteran and
caregiver so that they can focus on simply getting through treatment
and recovery when possible.
In Arkansas, we have a 34 year old veteran with a cancer that has
necessitated the removal of is colon and rectum, severe PTSD that has
resulted in a behavioral flag being placed for outbursts, and a recent
diagnosis of sarcoidosis of the heart, lungs, and intestinal tract. The
veteran has additional complications of a severe allergy that permeates
his diet, nutritional and medicinal absorption issues due to his
missing colon and rectum, and social and environmental factors that
include a distrust of the medical system. The veteran has five children
aged 16 to 1. Complicating the care management, is that the veteran has
had 15 VA PCMs in the six-years that Quality of Life Foundation has had
this case. He has multiple outside providers, some Community Care
Network appointments and some providers that he uses his Medicare to
see, because often VA does not have a timely appointment and referral
process for him. His wife has never been accepted into the VA Caregiver
Support Program, and she works from home full time. Up until recently,
the family had had no case manager.
After attempted conversations with the facility and then with VACO,
a case manager was appointed through the M2VA office. Unfortunately,
the case manager is more a care manager. He is not used to working
complex case management that involves multiple conditions. The case
manager is hampered by the delay in CCN notes being returned to the VA.
The case manager is also assigned this veterans care on top of a very
large population that he serves simply for care coordination and care
management. When seeking answers about referrals or pieces of
information, or trying to get two doctors to have a discussion about a
patient, he has no authority to do so.
We have attempted to engage, through VACO and this committee for
multiple years, a complete care coordination and case management plan.
That has yet to happen. In fact on multiple occasions, my staff member
has been told that the case manager, assigned by VACO at the local
level, does not know how to do such a detailed case plan. As a result,
the veteran's care lags, referrals fall through the cracks, the
veteran's health declines, and an overall sense of dissatisfaction with
VA healthcare and anger over feeling discarded permeates his life. The
caregiver is angered that she has a management of the case manager that
has to occur when she already has such a heightened responsibility.
Overall the LACK of case management on a continued basis has caused the
VA to fail this patient.
We understand that the VA is implementing a new process to appoint
a ``lead coordinator,'' and as part of this initiative is specifically
looking at sites to further enhance the coordination of care through
the Community Care Network. While we have some concerns that the lead
coordinator role would not alone be sufficient to address these most
complex cases, it will be helpful to have a named individual who is
accountable for the provision of services. Our most pressing concern is
that the lead coordinator position becomes a collateral duty on top of
an already heavy case load. As the ``lead coordinator'' process
develops, QoLF recommends that the Subcommittee and the VA consider the
following:
The establishment of a cadre of specially trained case managers,
similar to the FRC program and potentially linked to the lead
coordinator who can take on the most difficult cases would benefit the
individual veteran as well as free up the care managers and other case
managers to serve more veterans. While most veterans can be
accommodated by a simple phone call to a social worker or care manager,
those with the most complex needs often need an individual with the
training, competency, desire and authority to request waivers, explore
options, and develop integrated care plans.
The establishment of a case management and social work lead at the
VISN level who could help to coordinate training, standardization of
services, and serve as a point of contact when challenges arise.
Ease the process of obtaining a case manager. While we have
hopefully made a good case for having a case manager for those who need
it, the fact remains that it is difficult to obtain one and very little
public information exists to educate the patient. For example, the
Richmond, Virginia VAMC homepage only mentions case management once as
a subheading for Post 9/11 M2VA Care. There is no mention of co-morbid
complex care case management or of disease specific case management. If
you click on Post 9/11 M2VA case management, the description is not
about multiple disease/condition/injury care, but more a description of
transitioning back into civilian life after serving in the military.
For those veterans that entered Afghanistan in 2001 or Iraq in 2003,
should they look for case management services for multiple complex care
needs, the description would not be one that would likely cause them to
connect with the M2VA program or case managers. For any other veteran,
not post 9/11, there is no mention of case or care management programs
on the front page for that facility. So how exactly does a veteran know
that these programs exist, know to ask for them, and know how to find
them?
Review the current process for entering records from outside
providers (CCN, TRICARE, Medicare, other private providers) and how it
impacts the ability to provide appropriate care and care management.
(This should occur system wide as the process varies facility to
facility and VISN to VISN.) While reimbursement for care is an issue,
the lack of a transparent process, including identifying who is
responsible for obtaining the records and the methods by which those
records are or are not uploaded into the VA system, delays care and
frustrates both doctors and veterans. This lack of record input and
management impacts patient care, eligibility for programs, and the care
manager's ability to effectively manage the case.
Review the current actual caseloads of the different care
management and social work teams across the VA to ensure proper
staffing and allow for incentives to fill needed vacant roles. In
addition, identify collateral duties that do not have a designated full
time employee (FTE).
Establish a ``Pathway to Advocacy'' for outside organizations to
officially assist veterans and caregivers within VHA. QoLF strongly
supports the recent Senate introduction of the CARE Act of 2023 which
includes a provision requiring the Secretary to develop a process to
train and recognize non-profit organizations to assist in the
navigation of programs and services within the Veterans Health
Administration. While QoLF currently uses Releases of Information to
advocate on behalf veterans and caregivers, such a process would allow
certified organizations to work more effectively WITH social workers
and care managers to better support the population we all serve.
In conclusion, Quality of Life foundation believes VA needs to
simply re-align their resources and bring back older, more robust
models of case management for those most severely impacted veterans.
These program models have existed in the past, and for some reason were
changed as the more recent conflicts wound down. As a result, care
management was siloed and veterans suffered. Correctly modeling,
training, and assigning case managers to complex cases would save time,
money, and resources. Allowing VSO's and NPO's to advocate for care
that exists within the system would also help veterans and facilities.
Veterans would get more timely appropriate care with the help of a
holistic full-time case manager with authority to cut through VA red
tape. Overall, this would save VA money if the veteran is able to get
timely, appropriate care that is managed across the spectrum of the
medical community; and veterans would have better health outcomes and
quality of life.
______
Prepared Statement of Matt Brady
Chairwoman Miller-Meeks, Ranking Member Brownley, and distinguished
members of the House Committee on Veterans' Affairs Subcommittee on
Health - thank you for inviting Wounded Warrior Project (WWP) to submit
this written statement for the record of today's hearing on care
coordination at the U.S. Department of Veterans Affairs (VA). Care
coordination is critically important to those who rely on VA for health
care, particularly for those with multiple conditions and providers,
and those who receive care within VA and its network of community-based
providers. We appreciate your attention to this topic and are pleased
to share our perspective.
Wounded Warrior Project was founded to connect, serve, and empower
our nation's wounded, ill, and injured veterans, Service members, and
their families and caregivers. We are fulfilling this mission by
providing more than 20 life-changing programs and services to over
190,000 registered post-9/11 warriors and 48,000 of their registered
family members. As our programs have evolved alongside those we support
over the past 20 years, filling gaps in government-provided services
has been an enduring focus that has fostered close familiarity with
VA's ability to coordinate care for veterans.
To be clear, there is no shortage of VA programs to support
veterans and their families. However, in that abundance, many in this
population remain confused by the number and types of VA services,
employee roles in their delivery, and eligibility criteria. As such,
WWP has often filled a void by assisting warriors and their families
with navigating the VA system to help better ensure positive outcomes
and coordination. This support- which can be provided through different
WWP programs - is particularly important for the specific population of
veterans that WWP serves.
Based on data from our 2022 Annual Warrior Survey, nearly four in
five WWP warriors have a VA disability rating of 70 percent or higher.
Typically, our warriors have multiple cooccurring diagnoses (94
percent), with the most common being sleep problems, post-traumatic
stress disorder (PTSD), anxiety, and depression. Over 90 percent of
warriors report having health care coverage through VA and nearly 60
percent use VA-only providers to receive their primary care. 55 percent
of those warriors who use VA providers for their primary care report
that VA was either extremely helpful or very helpful in coordinating
their primary care. Nearly 45 percent of warriors who use VA providers
for their primary care report that VA was either somewhat helpful or
not at all helpful in coordinating their primary care.
With these warriors in mind, WWP has purposefully set out to build
and maintain a series of programs to help increase the quality of
interactions with the VA health system and ensure the best results for
those we serve. Three of those programs stand out in particular.
Independence Program: Helping veterans live more independently and with
better quality of life in consideration of moderate to severe brain
injury, paralysis, or neurological/neurodegenerative conditions.
The Independence Program is a partnership between WWP, the warrior,
and his or her family or caregiver, and is uniquely structured to adapt
to their ever-changing needs. This program pairs warriors who rely on
their families and/or caregivers with a specialized case management
team, paid for by WWP, to develop a personalized plan to restore
meaningful levels of activity, purpose, and independence into their
daily lives. These teams focus on increasing access to community
services, empowering warriors to achieve goals of living a more
independent life, and continuing rehabilitation through alternative
therapies.
Services are highly individualized and supplement VA care,
including: case management, in-home care, transportation, life skills
coaching, traditional therapies (physical, occupational, speech, etc.),
alternative therapies (art, music, equine, etc.), and community
volunteer opportunities. These services are provided for free and
augment or complement what our warriors receive from VA. For many, this
is an opportunity to participate in the types of daily tasks and
meaningful activities others take for granted. It also provides
anecdotal evidence to indicate that veterans fitting this profile may
require more consistent care coordination service:
WWP assisted an Army veteran who, because of his
injuries, was honorably discharged after two deployments to Iraq. He
now requires supervision and assistance with his activities of daily
living, as well as instrumental activities of daily living due to a
severe neurological disorder. His caregiving situation became unstable
with his previous spouse not being able to provide care to him or their
children. The family moved in order to get support from the veteran's
mother, who is now the primary caregiver. Without the support from the
caregiver, the veteran would be at significant risk for
institutionalization. The Independence Program assisted the veteran
with transferring care to the new VA facility and implementing some
community support services so he can engage in meaningful activities at
home. Unfortunately, the veteran and his family became homeless after
they were evicted from their home. The Independence Program stepped in
to provide financial assistance and temporary housing for the family.
Additionally, the Independence Program staff contracted a local case
manager to assist the veteran with identifying primary care and mental
health providers at the local VA; supported the veteran with enrolling
his kids into school; placed mental health counseling referrals for the
kids; referred the veteran to a financial counseling program; and
assisted with application process for a new apartment. After a year in
the Independence Program, veteran is attending all medical appointments
at the VA, making timely payments on his bills, obtained his driver's
license, purchased a car, and is working with a community support
specialist to build structure and consistency at home.
WWP has also helped a 23-year-old Army veteran who was
injured in a fall resulting in a spinal cord injury, paraplegia and
traumatic brain injury (TBI). The soldier was residing in an ADA
accessible Barrick at the Soldier Recovery Unit in San Antonio, Texas
when the Independence Program connected with him. He required
assistance with activities of daily living including transfers and
bowel/bladder care. He also had undetermined cognitive deficits as a
neuropsychological evaluation had not yet been completed. He did not
have access to transportation and could not get to appointments,
grocery shop, or access his community independently. At the time of
discharge, he did not have a comprehensive discharge plan, ADA
accessible housing, or an identified caregiver. This veteran was at
significant risk of homelessness, institutionalization or further
injury without supervision and supports put in place. The Independence
Program connected this veteran to a community-based case manager who
supported the veteran in securing ADA housing, setting up VA Homemaker
and Home Health Aide (HHA) in-home supports, and Community Support
Specialists to assist the veteran in scheduling and attending medical
appointments. The veteran also engaged in recreational therapy to
address his reintegration into his community and participated in
financial counseling. WWP also collaborated with the veteran's VA
social worker to ensure physical therapy was conducted in his home,
that he was provided a shower chair, had access to VA transportation
and ensured a neuropsychological evaluation was scheduled with his
local VA. His community-based case manager, provided by WWP, continues
to work with the VA to ensure these in home supports are managed by the
VA moving forward.
In addition to these specific case studies, WWP also surveyed our
veteran and caregiver population to gather insight about how care and
services might be better coordinated at VA, specifically with the VA's
Program of Comprehensive Assistance for Family Caregivers (PCAFC). In
May 2022, WWP surveyed a subset of veterans and caregivers (13,000) who
previously indicated: a need for aid & attendance services, being
housebound, requiring instrumental support or currently participating
in WWP's Independence Program. Data from this survey strongly supports
the idea that veterans and caregivers benefit from enhanced care
coordination and that more effective communication about VA's
programmatic offerings is needed.
Over half of respondents reported they never participated in PCAFC
(51.2 percent) or were denied (11.3 percent). For those that never
participated in PCAFC, 67 percent were not aware of PCAFC and their
potential eligibility. Nearly 24 percent were ineligible under the
previous PCAFC rules. The lack of awareness about PCAFC eligibility in
our sample population, despite disclosing a disability rating of 70
percent or higher, where a significant majority reported a need for 50
hours per week of caregiver assistance due to physical injury and/or
mental injury, is concerning. Additionally, we surveyed our
constituents about utilization of other VA entitlement programs that
can support aid & attendance, such as VA special monthly compensation
(SMC). SMC is a benefit paid directly to veterans that specifically
supports aid & attendance. Despite the high disability rating, the
requirement for aid & attendance, and the reliance of our population on
a caregiver, 71.8 percent do not receive SMC. In sum, we believe these
findings suggest improved care coordination and commitment to raising
awareness of programs for more severely wounded, ill, or injured
veterans would result in better utilization among those who would
qualify for them.
Based on the experience of our Independence Program, we have the
following calls to action for the subcommittee to consider:
Ensure that policies are in place to increase awareness
and accessibility of programs for those with heightened needs. WWP
supports the Elizabeth Dole Home Care Act (H.R. 452, S. 141),
particularly key provisions that would instruct VA to provide informal
Geriatrics and Extended Care (GEC) program assessment tools to help
veterans and caregivers identify expanded services they are eligible
for, and assist caregivers denied or discharged from PCAFC into other
VA-provided home-cased care and support. Such support can also be found
in the community and advanced through measures like Section 2 of the
Caregiver Application and Appeals Reform Act of 2023 (S. 1792), which
WWP also supports. Improving veteran and caregiver knowledge of VA
program intricacies and providing clearer direction of how they can be
used is a less formal variety of care coordination that should help
many.
Additionally, WWP has found that establishing treatment and
support programs may simply not be enough. Overlapping
resources and nonuniform availability of federal, state, and
local resources require a broad community effort to connect
those in need with the services created for them. For this
younger generation, VA's nomenclature has an impact. The word
``Geriatric'' - in reference to VA's GEC program office - can
be a source of confusion or deterrence for both the veteran and
their case manager or social worker to seek services even as
veterans under the age of 65 already represent 27 percent of
those served by VA's long term support services.\1\
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\1\ U.S. DEP'T OF VET. AFFAIRS, FISCAL YEAR 2024 BUDGET SUBMISSION,
Medical Programs and Information Technology Programs at VHA-198,
https://department.va.gov/administrations-and-offices/management/
budget/ (last visited June 9, 2023).
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To overcome even this most basic barrier as well as others, a
menu of available program options tailored to the veteran/
family and based on his or her needs and eligibility would
maximize the use and impact of those services. In addition,
younger veterans with long term care needs and their caregivers
are often overlooked for programs like Veteran Directed Care
and Home-Based Primary Care because they are a small - but
vulnerable - portion of the eligible population. In many cases,
they are in desperate need of these services but simply are not
aware they exist. Because this population is relatively small
and geographically diverse, increased training to identify
younger veterans in need of long-term support services may be
needed.
Continue to foster VA collaboration with community-based
non-profit organizations, and State and local governments to increase
the availability of care coordination services in the community. WWP
was pleased to advocate for passage of the Commander John Scott Hannon
Veterans Mental Health Care Improvement Act (P.L. 116-171) that signed
into law in 2019. Section 201, the Staff Sergeant Parker Gordon Fox
Suicide Prevention Grant Program, established a 3-year grant program to
provide grants for upstream community-based suicide prevention efforts.
These grants are awarded to organizations working to provide or
coordinate suicide prevention efforts within their communities,
including by providing case management services. WWP supports these
ongoing efforts and encourages continued collaboration between VA,
community organizations, and state and local governments to collaborate
and provide additional case management services to veterans.
While the Fox Grant Program is focused on suicide prevention
services and expressly includes case management service as a
(see Hannon Act, Sect. 201 (q)(11)(A)(v)), this model of
collaboration between VA and community may also find success in
a program dedicated specifically to care coordination.
Complex Case Coordination: Helping veterans in need of immediate mental
or physical health care access high quality VA or community-based
services as soon as possible.
Wounded Warrior Project's Complex Case Coordination (C3) team
serves warriors with complex challenges that are often multi-faceted
and require urgent action. They connect warriors to internal and
external resources and treatment options to provide them with immediate
assistance. When working with warriors, the C3 team assesses each of
their unique needs and works with them to develop an individualized
plan. They work to identify the resources that will best meet the
warrior's needs and often act as a liaison between VA, the Department
of Defense (DoD), and private community resources throughout the course
of the warrior's treatment.
The C3 team works a case in three phases. First, they work to
ensure the warrior is safe and stable, conducting an assessment and
determining their needs. The second is to maintain the situation while
they work to build an action plan, mobilize resources, and advocate for
the warrior's needs. The third is the transition, where the team
coordinates wrap around services and conducts follow-up.
As VA is one of our most critical partners, C3 has a strong record
of collaborating with VA's Central Office (VACO), every Veteran
Integrated Service Network (VISN), and nearly every VA Medical Center
(VAMC). The C3 team works with VA providers and social workers to not
only coordinate care, but to facilitate the resolution of complex
needs, including housing insecurity, justice involvement, military
sexual trauma (MST), substance use, and mental health, or cognitive
challenges. With over 1,200 cases over the last four years, we have
seen the impact and efficacy of case coordination result in improved
outcomes and often, a restored confidence for the veteran in VA
healthcare.
When working a case, the C3 team assesses what VA resources may be
available to immediately address a warrior's needs. Whether it's a
mental health social worker, Military2VA Case Manager, MST, or U.S.
Department of Housing and Urban Development-VA Supportive Housing
(HUDVASH) program lead, these dedicated VA employees work in
coordination with WWP to assist warriors. In some extremely complex
cases, C3 will enlist assistance from VISN Chief Mental Health Officers
or even VACO when clinical care needs are not being met, there is
inconsistent policy execution, or care plan execution is unable to be
resolved. In the past, they have been extremely helpful in elevating
these issues and working with WWP to find a quick resolution.
Based on our experience of helping wounded veterans through C3 and
the associated perspectives of working with VA to advocate for their
needs, we have the following recommendations for the subcommittee:
Create a system that helps centralize care coordination
and patient advocacy - particularly for those with complex needs.
Wounded Warrior Project supports the creation of a system to help
centralize care coordination and patient advocacy, especially for those
veterans with the most complex needs. This approach should include a
mechanism to help identify those most in need of assistance with care
coordination, through screening during enrollment, identification by
providers and social workers of current enrollees, and a process for
veterans and caregivers to self-identify as in need of these services.
Additional elements should include a central hub for coordinating care
across different healthcare settings to ensure that all providers
involved in the veteran's care have access to the necessary information
and can collaborate effectively, as well as the ability for health
advocates (like WWP) to intervene and assist with necessary appeals.
WWP would also recommend the designation of a VA social worker,
at each VAMC, with enhanced authority to serve as the subject
matter expert for the facility. This social worker would
provide mentorship, oversight, and assistance to other social
workers executing care coordination at the service level and
would have the authority to expedite needed care across all
service areas while facilitating communication between
different providers, and helping veterans navigate the
healthcare system. An additional consideration may be for
training and accreditation for veteran service organizations
(VSOs) to be able to engage directly with this designated
social worker on behalf of a veteran. It is also essential that
we empower veterans (or their designated advocates) to actively
participate in their care by providing them with adequate
information, resources, and education about their health
conditions, treatment options, and available support services.
This allows veterans to make informed decisions, effectively
communicate their needs, and take ownership of their health.
Inspiration for additional improvements to case management,
especially for those with more complex needs, can be found in
the Federal Recovery Coordination Program (FRCP) that
previously assigned recovering Service members with recovery
care coordinators responsible for overseeing and assisting the
Service members through their entire spectrum of care,
management, transition, and rehabilitation services available
from the federal government. This model which developed a
holistic care plan for the veteran, with the authority to see
it through, was more effective in our experience, than the
current model of indirect liaisons.
Given how often veterans receive care outside of VA facilities,
it is also necessary to ensure that medical information is
appropriately communicated, and that care coordination exists
between all primary, specialty, and residential care providers.
Care plans, treatments, and the availability for continuing
pharmaceutical support of treatments must be communicated
effectively to those provider teams involved in an individual's
care, whether inside or outside of VA.
Establish a consistent access standard for VA's Mental
Health Residential Rehabilitation Programs. Another way to address care
coordination at VA is by establishing a consistent access standard for
VA's Mental Health Residential Rehabilitation Programs (MH RRTPs).
Currently, the access standards established by the VA MISSION Act (P.L.
115-182 Sec. 104) and memorialized in the Code of Federal Regulations
(38 C.F.R. Sec. 17.4040) do not, in practice, extend to mental or
substance use disorder (SUD) care provided in a residential setting. VA
has maintained adherence to access standards for this type of care
through Veterans Health Administration (VHA) Directive 1162.02, which
establishes a priority admission standard of 72 hours and, for all
other cases, 30 days before a veteran must be offered (not necessarily
provided) alternative residential treatment or another level of care
that meets the veteran's needs and preferences at the time of
screening.
Unfortunately, this policy has not been uniformly applied
across the VA system and WWP has seen many examples of veterans
forced to wait longer than 30 days for residential treatment,
and not being offered care in the community as required.
Interim care offerings have included telehealth and virtual
intensive outpatient programs that are less than what the
veteran ultimately needs and desires. These care options tend
to be less intensive, less effective, and have poorer outcomes
than the residential care options they are intended to
supplant. Other issues WWP has seen involving care within MH
RRTPs includes poor communication of records between VA and
community residential care, lack of appointment follow-up, and
prescription updates.
We believe by establishing a consistent access standard for MH
RRTPs, veterans will not only receive more standardized,
quality, and timely care, but we will also see an improvement
in some of these other issues currently associated with RRTP
care more generally. To that end, WWP appreciates and supports
Section 2 of the Veteran Care Improvement Act (H.R. 3520),
which would codify an access standard for RRTP programs.
However, we would also recommend expanding the terms of that
section to include other varieties of RRTP care like its
specialty tracks for PTSD, MST, and severe mental illness.
Warrior Care Network: Helping reduce gaps and inefficiencies in mental
health care delivery through innovation and collaboration.
Wounded Warrior Project's Warrior Care Network (WCN) is a two-week
intensive outpatient program where warriors learn how to minimize the
interference of mental health issues in their everyday lives. WWP
partners with four academic medical centers across the country to
provide this treatment to help warriors manage their PTSD, traumatic
brain injury (TBI), SUDs, and other mental health conditions.
WCN academic medical center (AMC) partners provide veteran-centric
comprehensive care, share data and best practices, and coordinate care
in an unprecedented manner. This program's partnership with VA has
helped create a broad continuum of support that is critical to
successful outcomes for veterans. In 2016, the VA and WWP created a
first-of-its-kind partnership, signing a Memorandum of Understanding
(MOU) aimed at ensuring continuity of care and successful discharge
planning for Warriors receiving treatment from both WCN and VA. This
partnership included providing VA staff to assist part time at each AMC
facilitating coordination of care and integrating the AMC care team.
The MOU and partnership were expanded and enhanced in 2018,
establishing four full time VA Liaison positions, embedded at each AMC.
The VA Liaisons are responsible for ensuring that medical records are
seamlessly shared between VA and WCN, that warriors are fully
registered with VA, and that they get follow-up care appointments after
WCN graduation at the VA. In 2022, the VA renewed the MOU for a third
time, continuing to fund one VA Liaison at each AMC site. Each VA
liaison facilitates national referrals throughout the VA system as
indicated for mental health or other needs. During 2022 alone, VA
Liaisons served 708 warriors. Over the FY 18-22 period (beginning when
VA Liaisons were assigned):
88 percent of veterans served by Warrior Care Network
took advantage of connecting with a VA Liaison.
More than 3,000 referrals for VA care were opened. Among
the most requested appointments were mental health care, VA benefits,
and primary care.
More than 19,000 hours of collaborative hours between VA
Liaisons and academic medical center employees and veterans.
In sum, Warrior Care Network results and collaboration with VA has
validated our belief that community-based, veteran-centric, intensive
mental health and substance use care can lead to exceptional health
improvements and increased engagement between veterans and VA when
properly structured and managed. While we realize that this level of VA
interaction and embedding with community care providers may not be
reproducible at large scale, we remain committed to the following calls
to action:
Leverage innovation programs and investments to explore
long term solutions for improved care coordination. One approach could
be to elevate VA's commitment to exploring innovative programming
approaches by elevating the Center for Care and Payment Innovation
(CCPI) to the Secretary's office rather than an entity within VHA, as
outlined in Section 206 of S. 1315, the Veterans' Health Empowerment,
Access, Leadership, and Transparency for our Heroes Act. The bill would
also require CCPI to establish pilot programs for the development of
innovative approaches to testing payment and service delivery models,
expand CCPI's mandate to include pilot programs that increase
productivity and modernization, and accelerate CCPI's operational
tempo. Strengthening CCPI may allow for VA to transform and improve
veteran care, while reducing costs and administrative burdens.
Additional Calls to Action that can Improve Care Coordination
Continue Drive Toward Electronic Health Record Modernization (EHRM)
As DoD and VA continue push toward interoperability, we cannot lose
sight of the goal of widespread and efficient adoption of electronic
health record (EHR) systems. This will ultimately allow for seamless
sharing of medical information, treatment plans, and progress updates.
It also mitigates the risk of fragmented care. We believe a successful
deployment of a fully integrated and user-friendly EHR will create
efficiencies and result in better quality of care, improved
identification of high-risk patients, an overall higher quality of life
for veterans, and most significant to today's discussion, improved care
coordination.
Wounded Warrior Project continues to share the larger communities'
concerns with the ongoing delays and issues surrounding the EHRM
efforts. WWP was pleased to see the recent announcement that VA
renegotiated their EHR contract with Oracle Cerner to include
additional performance metrics and accountability measures. We are
encouraged to see Congress playing a larger role in oversight and
believe all stakeholders must be held accountable to ensure high levels
of interoperability and data accessibility between VA, DoD, and
commercial health partners.
As the EHRM process continues to play out, WWP encourages Congress
to look at the lessons learned from the DoD implementation of MHS
GENESIS. The DoD MHS GENESIS electronic health record will provide
DoD's 9.6 million beneficiaries and over 200,000 medical providers with
a single, common record of medical and dental information. It is
deploying in 23 ``waves'' and is currently 81 percent complete with
full deployment expected by the end of 2023. While the initial
deployment was not without its challenges, it is now expected to fully
deploy within budget and on time. One aspect of the deployment that
proved successful for DoD throughout this process was a system
integrator approach. This approach involves using a government
contractor to coordinate the integration and implementation of the
single, common record. We encourage Congress to evaluate the
differences in these implementation efforts and consider additional
models, including this system integrator approach.
Continue to Leverage Telehealth
Wounded Warrior Project continues to believe in the importance of
telehealth and asks that you continue to leverage its benefits for the
veteran community. Telehealth and telemedicine services should be
expanded to improve access to care, especially for veterans in remote
areas. Telehealth enables virtual consultations, remote monitoring, and
the delivery of healthcare services, reducing the need for veterans to
travel long distances for appointments.
While telehealth has been critical to expanding access to health
care services; telehealth cannot simply replace in-person service
delivery. Consumers, in consultation with their providers, must be able
to choose whether telehealth or in-person services are most appropriate
for their needs. Some plans have implemented strategies to limit
consumers' options by offering ``telehealth only'' or ``telehealth
first'' coverage, which bars or limits access to in-person care. For
individuals who need a higher level of outpatient care, residential
care, or inpatient care to treat their MH/SUD condition(s), a
``telehealth only'' option can negatively impact treatment options,
further delay an appropriate level of care, and can be a significant
financial barrier if individuals find they must pay out-of-pocket for
additional services.
We support telehealth provisions in S. 1315, the Veterans Health
Empowerment, Access, Leadership, and Transparency for our Heroes Act of
2023, and H.R. 3520, the Veteran Care Improvement Act of 2023. Both
bills include measures that would require VA to discuss telehealth
options for care, both at VA and in the community, if telehealth is
available, appropriate, and acceptable to the veteran. We ask that
Congress continue to work with VA and other stakeholders to ensure that
the necessary balance is found between the efficiencies of telehealth
and veteran preference.
Stabilize the Clinical Care Workforce
WWP has been encouraged by recent efforts to address the workforce
shortage and high turnover rates at VA. In the first five months of
fiscal year 2023, nearly 10,000 new employees were hired at VHA and as
of March, they were 44 percent of the way toward their goal of hiring
52,000 new employees \2\. However, we continue to be concerned by
reports of high numbers of vacancies, often resulting in long wait
times and disjointed care for veterans. We believe that more can be
done to help recruit and retain the best talent to ensure veterans are
receiving timely and quality care.
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\2\ Eric Katz, VA Is Hiring at a Record Rate. Employees Say It's
Still Not Enough, GOVERNMENT EXECUTIVE (March 21, 2023), available at
https://www.govexec.com/workforce/2023/03/va-hiring-record-rate-
employees-say-its-still-not-enough/384257/.
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Congress can address some of these issues by passing S. 10, the VA
CAREERS Act. This bill would set higher base pay caps for VA
physicians, podiatrists, optometrists, and dentists, making VA a more
competitive option for providers. The bill would also improve VA's
ability to hire at rural VA facilities by providing them with the
ability to buy out the contracts of some private-sector health care
professionals in exchange for employment at rural facilities.
Additionally, it would allow VA to pay for licensure exam costs for
future clinicians participating in VA scholarship programs and expand
eligibility for health care staff to be reimbursed for professional
education costs.
To ensure veterans are receiving the best possible care, with
minimal interruptions, WWP believes it is essential that VA be given
the resources necessary to adequately recruit and retain top talent to
care for veterans. We encourage Congress to monitor this issue and
ensure VA has the resources they need to achieve this goal.
Focus on PACT Act-related Care Needs
For two decades, Service members who were deployed to post-9/11
battlefields were exposed to dangerous fumes from burn pits and other
toxic chemicals. After the 117th Congress passed the Sergeant First
Class Heath Robinson Honoring our Promise to Address Comprehensive
Toxics (PACT) Act of 2022 (P.L. 117-168), many veterans now suffering
from respiratory conditions, cancers, and other serious illnesses have
access to VA care for those disorders. Under the PACT Act, recently
discharged combat veterans now have a 10-year enhanced enrollment
period (up from 5 years), and veterans who were discharged more than 10
years ago have a limited one-year period to enroll for care (October 1,
2022, to September 30, 2023). Even more may now seek care for
conditions that are now more likely to be service connected.
While VA deserves praise for all of its implementation efforts,
expansion of health care under the PACT Act has highlighted gaps in
care coordination for cancer care. As noted in a recent Government
Accountability Office report and experienced by WWP's C3 team, VHA does
not have a policy that addresses cancer surveillance or assign
responsibility for cancer care coordination.\3\ Given the success that
VA has had using social workers in fields like traumatic brain injury
and spinal cord injury to coordinate ancillary care for patients, we
believe a similar policy should be in place for oncology patients.
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\3\ OFF. OF INSP. GENERAL, U.S. DEP'T OF VET. AFFAIRS, INADEQUATE
COORDINATION OF CARE FOR A PATIENT AT THE WEST PALM BEACH VA HEALTH
CARE SYSTEM IN FLORIDA iii (Mar. 2023).
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CONCLUSION
Wounded Warrior Project thanks the Subcommittee on Health and its
distinguished members for inviting our organization to submit this
statement. We are grateful for your attention and efforts to ensure
that veterans receive the best possible care and outcomes through the
Veterans Health Administration, particularly through well-coordinated
care. We look forward to continuing to work with you on these issues
and are standing by to assist in any way we can toward our shared goal
of serving those that have served this country.
______
Prepared Statement of Roscoe Butler
Chairwoman Miller-Meeks, Ranking Member Brownley, and members of
the Subcommittee, Paralyzed Veterans of America (PVA) would like to
thank you for the opportunity to submit our views on the Department of
Veterans Affairs' (VA) efforts to coordinate veterans' care. No group
of veterans better understands the importance of having timely access
to a full continuum of coordinated health care than PVA members--
veterans who have incurred a spinal cord injury or disorder (SCI/D).
Veterans with complex healthcare conditions like SCI/Ds receive
care from primary care physicians, a wide range of specialists,
visiting nurses, and caregivers--many of whom are family members.
Additionally, this care is provided through a number of service points.
It may be provided at one of VA's 25 SCI/D centers, through VA's six
long-term care centers, or at other VA facilities. It may also be
provided through community care providers, in state veterans or
community nursing homes, or in the veteran's residence. This often
poses a Herculean challenge to the many dedicated professionals who are
working tirelessly to ensure that the delivery of high-quality acute
and long-term care is administered by the right providers in order to
achieve optimum care outcomes for veterans.
Veterans with SCI/D who are enrolled in and using VA care generally
have an easier time with care coordination than those individuals who
are receiving care solely outside the VA system. Appendix D of Veterans
Health Administration (VHA) Directive 1176(2) on the SCI/D system of
care lists the wide range of doctors, nurses, social workers,
psychologists, therapists, and other specialists that serve as part of
the interdisciplinary team for each SCI/D center. They include the
members of the Patient Aligned Care Team (PACT) who are responsible for
care coordination within VA, including at SCI/D spoke sites; in long-
term care settings (e.g., VA Community Living Centers and community
nursing homes); outreach; and virtual care. Ensuring they have the
appropriate staff on their payroll allows VA to more quickly and
completely coordinate its care for SCI/D veterans. An example of this
coordinated care is a PVA member from Maryland who receives much of his
care through his local VA Medical Center, but also utilizes VA's
community care network and the Department of Defense's TRICARE program.
Since a spinal cord injury in 2006, his VA care team has managed
hundreds of dermatology, gastroenterology, hematology, immunology,
neurology, occupational and physical therapy, oncology, primary care,
pulmonology, rheumatology, and surgical visits both in and out of VA
facilities. This veteran and many others like him are thriving because
proper coordination of care ensures they are able to receive the right
care at the right time and in the right place.
Within the VA's SCI/D system of care, knowing how to care for a
veteran with these injuries or illnesses isn't optional, it's a
requirement. Unfortunately, a serious knowledge deficit about SCI/D
care exists in the private sector. Civilian facilities are simply not
equipped or properly staffed to handle SCI/D patients' acute and long-
term care needs, so most will not accept them. That number is growing
as facilities and agencies decide to drop this capability as staffing
shortages persist. Outside of VA, the ability to coordinate care drops
dramatically for several reasons.
Caring for veterans with SCI/D requires sharp assessment, time-and
labor-intensive physical skills, and genuine empathy. Nurses who work
in SCI/D must possess unique attributes and specialized education. All
medical providers, Registered Nurses, Licensed Practical Nurses,
Certified Nursing Assistants, and Nurse Practitioners working with the
SCI/D population are required to have increased education and knowledge
focused on health promotion and prevention of complications related to
SCI/D. This includes the prevention and treatment of pressure injuries,
aspiration pneumonia, urinary tract infections, bowel impactions,
sepsis, and limb contractures. Unlike VA, few facilities in the private
sector have the highly trained personnel on staff to properly care for
SCI/D patients.
Partly due to the lack of proper education and training, many
private sector hospitals, agencies, and nursing homes are not able to
properly care for veterans with SCI/D. As a result, SCI/D care
coordinators must spend a considerable amount of time searching for
ones that do. Sometimes SCI/Ds interrupt communication between the
brain and the nerves in the spinal cord that control bladder and bowel
function. This can cause bladder and bowel dysfunction known as
neurogenic bladder or neurogenic bowel. Other veterans may have
tracheotomies that allow air to flow in and out of the windpipe. Some
veterans may need a feeding tube due to difficulty swallowing, an
eating disorder, or other feeding issues. Each of these conditions
require close management and regular physical interventions that
private sector facilities often cannot adequately provide. Most private
sector facilities cannot provide long-term care for the same reasons. A
few private sector health care facilities do a good job of providing
acute SCI/D recovery care, but only VA is able to provide the full,
lifelong continuum of services for veterans with SCI/D that can
increase their lifespan by decades. That is why PVA places tremendous
emphasis on preserving and strengthening VA's specialized systems of
care.
Although VA is able to best provide care for veterans with SCI/D,
there are still challenges. These challenges include difficulties in
coordinating with other VA services and lack of resources to assist
special populations of SCI/D veterans. Also, the lack of facility-based
long-term care in VA and in the community causes significant issues in
care coordination.
Challenges in Coordinating with Other VA Services
Prosthetics
VA's SCI/D centers and their spoke sites are intentionally designed
and staffed so the coordinated, lifelong continuum of services that
SCI/D veterans need are readily available. Prosthetics is often cited
as one area within VA where coordinating individual veterans' needs can
be difficult. Here, timeliness is often an issue as requests for
equipment move slowly within the system. Sometimes orders are not
placed or they are dropped without any apparent cause. Unfortunately,
accountability for these systemic failures is lacking. Supply shortages
can aggravate matters further. The inability to receive needed
prosthetics in a timely manner frequently prevents veterans from
returning home quickly and stimulates preventable increased workloads
when VA's care coordination team must do multiple follow ups just to
ensure a veteran receives the devices or other equipment they need.
A wheelchair is an extension of the body of a veteran with an SCI/
D. Thus, they can typically tell when a part is wearing out or is
broken. Sometimes a part is visibly in need of repair or replacement,
but even if veterans report these types of problems, some facilities
make them wait until a vendor is dispatched to their residence and
confirms its broken before initiating repairs. In these instances,
veterans are not being well served by an antiquated process that could
hold them hostage for several days or weeks. It also increases the VA
care coordination team's workload as they are forced to intervene on
behalf of frustrated veterans.
At a small number of VA facilities (2-3), support for prosthetics
is essentially ``available on demand.'' Unfortunately, these locations
can be described as ``unicorns'' because that level of support is
rarely available in most other facilities. The VA should study the
policies and process at the locations were access to prosthetics is
working well, and have them implemented system-wide.
Care for Special Populations
Determining if a veteran can return home is usually the starting
point for the care coordination team and accommodating the needs of
homeless SCI/D veterans can be particularly challenging. Occasionally,
homeless veterans with SCI/D receive treatment at one of VA's acute
SCI/D centers and once they are stabilized there is nowhere to send
them because they have no residence. Finding affordable, accessible
housing in the veteran's community often proves to be difficult for
VA's SCI/D care coordinators. Resolving these types of cases are very
labor intensive and can take months to resolve. There does not appear
to be formal guidance to handle these types of situations and their
resolution is often the result of the ingenuity and skill of the SCI/D
care coordination team. Congress should examine VA's existing policies
and ability to care and house such veterans.
The population of veterans with SCI/D has undergone substantial
changes over the last 50 years. Increasing numbers of women have been
serving in the military and they now represent about 5 percent of the
veteran SCI/D population. Additional considerations when coordinating
their care usually include the use of a single patient room and the
availability of gender-specific care in properly staffed and fully
accessible buildings. These qualifications are rarely found in tandem
in the private sector. Additionally, in-resident care of SCI/D veterans
with substance use disorders (SUD) is virtually nonexistent within VA
and the private sector. They may be able to receive counseling but at
the end of each day return to home where the potential for a relapse is
high. These individuals are not normally housed in acute care centers
until the SUD is resolved due to security and safety concerns. Until VA
gains the ability to provide this level of care, these veterans will be
trapped in a vicious cycle that threatens their health and well-being.
We hope that this Subcommittee will work with VA to determine how the
Department can better serve these cohorts of veterans.
Limited Long-Term Care Services
VA's lack of long-term care beds is severely impairing its ability
to coordinate care for veterans with SCI/Ds. More than half of the
veterans on VA's SCI/D registry are over the age of 65 and most of
their caregivers are aging as well. As indicated previously,
nationwide, very few long-term care facilities are capable of
appropriately serving veterans with SCI/D. VA operates just six SCI/D
long-term care facilities; only one of which lies west of the
Mississippi River.
According to VHA Directive 1176(2), the VA is required to operate
at least 181 of its 198 authorized long-term care beds at SCI/D
centers. Recently, only 168 beds were either available for or in use.
This number fluctuates depending on several variables like staffing,
women residents, isolation precautions, and deaths. When averaged
across the country, that equates to about 3.4 beds available per state.
In 2012, VA's own research \1\ warned that a wave of elderly
veterans with SCI was coming and the Department should prepare for
them. At the time, aging veterans, new cases of SCI from recent
conflicts, and increasing numbers of women veterans were dramatically
changing the profile of VHA's SCI/D population. If the Department
heeded its own warning back then and increased its SCI/D long-term care
capability, we might not be in the dire situation we are today.
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\1\ ``Who are the women and men in Veterans Health Administration's
current spinal cord injury population?'' https://
www.rehab.research.va.gov/jour/2012/493/pdf/page351.pdf.
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A pair construction projects will add roughly 50 more SCI/D long
term care beds to VA's inventory in the next few years. Other projects
have been identified but need funding allocated in order to progress.
Until then, a high number of aging veterans with SCI/D who need long-
term care services will be occupying acute care SCI/D center beds or be
forced to reside in nursing care facilities outside of VA that are not
designed, equipped, or staffed to properly serve veterans with SCI/D.
Others will remain in precarious situations in their homes and VA care
coordinators will continue its struggle to find appropriate agencies or
individuals to deliver their care. PVA strongly supports H.R. 3225, the
Build, Utilize, Invest, Learn and Deliver (BUILD) for Veterans Act of
2023, which seeks to improve staffing to manage construction of VA
assets and ensure that there are concrete plans to improve the
planning, management, and budgeting of VA construction and capital
asset programs.
The lack of capacity to provide long-term care for SCI/D veterans
within VA and the private sector mean VA care coordinators spend a
tremendous amount of their time attempting to locate providers,
facilities, or agencies in the private sector to meet SCI/D veteran's
long-term care needs. Truth be told, access to long-term care was
extremely scarce prior to COVID, and VA's SCI/D care coordinators worry
that it is getting scarcer. We understand that nursing homes and home
health agencies often pursue contracts with VA, but many don't maintain
them long. Most lack, and are unwilling to achieve, the necessary
training to perform the critical tasks like bowel and bladder care or
tracheostomy care that some veterans with SCI/D need. Facilities
lacking proper staffing are often unwilling to procure additional
personnel for SCI/D veterans whose greater care needs consume a larger
than anticipated share of their existing workforce's time. Even if they
are willing to hire additional personnel, nationwide provider and
nursing shortages will often preclude them from finding the personnel
that they need. These ``starts and stops'' are frustrating to veterans
and those who coordinate their care.
Most veterans with Amyotrophic Lateral Sclerosis (ALS) and some
with a spinal cord injury will eventually require ventilator care. VA
has an extremely limited number of vent-capable beds for SCI/D veterans
and they are often maxed out with patients. In most states, this level
of care for SCI/D patients does not exist outside of the VA; thus, it
is a daily occurrence that care coordinators are combing the country
looking for an available bed. We work regularly with VA to assess its
SCI/D system of care and those we speak with during our annual visit to
each SCI/D center agree that the Department desperately needs to expand
its ventilator capability.
The 65 percent statutory cap on what VA can pay for home care can
also impact care coordination because it limits care options which may
contribute to unfortunate results. Recently, a PVA member in Texas with
ALS whose home care was limited by the VA cap developed a problem with
his gallbladder bag. Since he wasn't receiving the much-needed
assistance from VA at home, the family sought help from the local
private sector medical system because they believed VA had already
demonstrated an inability to meet his needs. While there, the veteran
developed complications due to an undiagnosed pneumonia which led to
him being intubated. Mentally and physically, his condition
deteriorated rapidly, and the veteran passed away.
In light of the limited access to VA facility-based long-term care
and the desire of many veterans with SCI/D to receive non-institutional
long-term care, VA must expand access to home and community-based
services (HCBS) to meet the growing demand for long-term services and
supports. Facility-based long-term care services are expensive, with
institutional care costs exceeding costs for HCBS. Studies have shown
that expanding HCBS entails a short-term increase in spending followed
by a slower rate of institutional spending and overall long-term care
cost containment.\2\ Reductions in cost can be achieved by
transitioning and diverting veterans from nursing home care to HCBS, if
they prefer it, and the care provided meets their needs.
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\2\ Do noninstitutional long-term care services reduce Medicaid
spending?
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Passage of H.R. 542, the Elizabeth Dole Home and Community Based
Services for Veterans and Caregivers Act, would improve care
coordination for SCI/D veterans by making critically needed
improvements to VA HCBS including raising the cap on non-institutional
care, expanding the Veteran Directed Care program, creating a pilot
program to address direct care worker shortages, and improving family
caregiver supports. We cannot stress enough how important it is for
Congress to pass this important legislation sooner rather than later.
PVA appreciates the Subcommittee's interest in this critical area,
and I would be happy to answer any questions you may have.
Information Required by Rule XI 2(g) of the House of Representatives
Pursuant to Rule XI 2(g) of the House of Representatives, the
following information is provided regarding federal grants and
contracts.
Fiscal Year 2023
Department of Veterans Affairs, Office of National Veterans Sports
Programs & Special Events----Grant to support rehabilitation sports
activities--$479,000.
Fiscal Year 2022
Department of Veterans Affairs, Office of National Veterans Sports
Programs & Special Events----Grant to support rehabilitation sports
activities--$ 437,745.
Fiscal Year 2021
Department of Veterans Affairs, Office of National Veterans Sports
Programs & Special Events----Grant to support rehabilitation sports
activities--$455,700.
Disclosure of Foreign Payments
Paralyzed Veterans of America is largely supported by donations
from the general public. However, in some very rare cases we receive
direct donations from foreign nationals. In addition, we receive
funding from corporations and foundations which in some cases are U.S.
subsidiaries of non-U.S. companies.
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