[Congressional Record Volume 147, Number 59 (Thursday, May 3, 2001)]
[Senate]
[Pages S4233-S4235]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
COMMUNITY-BASED OUTPATIENT CLINICS IN THE DEPARTMENT OF VETERANS
AFFAIRS
Mr. ROCKEFELLER. Mr. President, Congress transformed the landscape of
health care delivery for veterans with the Veterans' Health Care
Eligibility Reform Act of 1996. This law eliminated barriers to
outpatient care and encouraged the Department of Veterans Affairs, VA,
to offer health care services to veterans in the most clinically
appropriate setting. VA responded by shifting its emphasis from
hospital-based treatment to outpatient care, and in just a few years
has opened more than 250 new community-based outpatient clinics.
I am enormously pleased that VA has opened community clinics in West
Virginia and throughout the country. It is critical to bring health
care services closer to veterans, especially as our veterans population
continues to age. But it is not sufficient merely to increase the
accessibility of care, we must also ensure that veterans receive the
highest quality of care possible. Just as I fought to secure outpatient
clinics for veterans, I will fight to ensure that these clinics are the
very best that they can be.
At my request, the Democratic staff of the Senate Committee on
Veterans' Affairs surveyed more than 200 VA community-based outpatient
clinics nationwide to evaluate the success, capacity, and quality of
care in these clinics. This self-reported information from individual
clinics offers Congress and VA an opportunity to assess services
provided by the various clinics, and to determine where improvements
can be made to ensure that veterans receive the best possible care. The
Democratic committee staff report concludes that, although all clinics
reported offering primary care, services varied markedly by clinic and
by geographic location.
VA's 22 regional network directors, rather than VA Headquarters, hold
responsibility for activating, operating, and overseeing the community
clinics. Although this provides flexibility to local VA managers, the
variations in services described by clinic staff appear to result from
varied management practices rather than deliberate adaptations to
community needs.
For example, staffing levels did not appear to be related to the
number of patients seen, and varied among clinics and among networks.
Some clinics served about 5,000 patients in the first half of fiscal
year 2000 with the equivalent of 15 full-time health care providers,
while others served the same number of patients with only six full-time
staff. Some clinics operated with fewer than two full-time employees.
Variations in staffing translated into differences in the types and
levels of services provided, including basic mental health care. Less
than half of the clinics surveyed offered even minimal mental health
care, an issue of concern as VA continues to close its inpatient mental
health care clinics. In several areas of the country, waiting times for
an appointment for primary care ranged from 30 to 150 days. More than
60 percent of the community clinics lacked equipment and personnel to
respond to a cardiac emergency, an issue of patient safety.
VA's lack of a consistent, nationwide system for collecting and
analyzing information on health care outcomes and treatment costs is an
obstacle to measuring the success of VA's outpatient clinics. VA must
develop tools to allow community clinics to monitor health outcomes, so
that veterans can depend on a system that not only meets their needs
but continues to improve their health status. Clinics must be able to
combine this information on health outcomes with accurate data about
costs of treatment, so that VA can ensure the effective and efficient
use of resources at all clinics.
I certainly do not expect community clinics to offer the full range
of services available in a large medical center. However, it is
reasonable to assume that a veteran seeking primary care through a VA
outpatient clinic should be able to expect a minimum standard package
of services and an acceptable quality of care, regardless of geographic
location. Oversight by VA headquarters and by Congress is essential to
ensuring consistency in the services and quality of care offered to
veterans through community clinics.
I have forwarded a copy of this report to VA Secretary Anthony
Principi, and I look forward to working with him to
[[Page S4234]]
make certain that veterans who turn to VA's community care clinics can
expect not just access, but excellence.
I ask unanimous consent that the text of the executive summary of the
Democratic committee staff report be printed in the Record.
There being no objection, the summary was ordered to be printed in
the Record, as follows:
Staff Report on Community-Based Outpatient Clinics in the Veterans
Health Administration, Department of Veterans Affairs
(Prepared by the Democratic staff of the Committee on Veterans'
Affairs, United States Senate, for Senator John D. Rockefeller IV,
Ranking member, May 3, 2001)
executive summary
Background--In 1996, Congress broke down the barriers to
developing an outpatient care network within the Department
of Veterans Affairs (VA) health care system. The Veterans'
Health Care Eligibility Reform Act of 1996 (Public Law 104-
262) simplified eligibility rules, mandated uniformity in
services offered to veterans, and eliminated legal barriers
to the sharing of health care resources with other providers.
In response, VA has shifted emphasis from providing hospital-
based care to treating more veterans in outpatient clinics.
Much of the new outpatient care is being provided in
Community-Based Outpatient Clinics (CBOCs), local, often
small clinics, some operated by VA staff, others managed by
contractors for VA.
Responsibility for activation, operation, and oversight of
CBOCs rests with VA's 22 Veterans Integrated Service Networks
(VISNs) directors, contingent upon congressional approval.
Between 1996 and 2001, more than 250 CBOCs have been
activated, with the goal of improving access to care for many
veterans. CBOC staff may treat veterans in the community
clinic or refer them to the parent VA medical center for more
intensive treatment and then provide followup care through
the clinic.
As a consequence of the establishment of the CBOCs and
other changes in response to the Eligibility Reform Act of
1996, more veterans are accessing primary care in the
outpatient setting. VA estimates that the total number of
annual outpatient visits (in all facilities) has increased
from 26 million to 42 million in the last 5 years. Of the 229
clinics that completed surveys for this report, total
outpatient visits in the first half of FY 2000 increased more
than 20% over the equivalent period in FY 1999.
Democratic Staff Project--At the direction of Ranking
Member John D. Rockefeller IV, the Democratic staff of the
Senate Committee on Veterans' Affairs undertook an oversight
project to determine whether CBOCs have fulfilled their
potential to deliver high quality care to veterans in an
effective and efficient manner.
To carry out this project, staff members designed a survey
questionnaire intended to obtain information regarding
capacity and performance directly from the clinics. This
survey requested information on operation and management
issues, staffing, hours of operation, patient load,
availability and timeliness of care, costs, and quality of
care. Staff mailed surveys directly to the 257
congressionally approved clinics for which valid mailing
addresses could be obtained--rather than to VISN offices or
to parent medical center directors--and compiled the
results for federal FY 1999 (October 1, 1998-September 30,
1999) and the first two quarters of federal FY 2000
(October 1, 1999-March 31, 2000).
Based on this self-reported information from individual
clinics, this report is intended to offer an opportunity to
assess services provided by the various clinics and to
determine where improvements can be made to ensure that
veterans receive the best possible care.
Data Collection and Validity--VA programs frequently suffer
from flawed data collection and monitoring, and outpatient
care provided by CBOCs is no different. No single VA source
could provide Committee staff with accessible and objective
information on clinic services systemwide. Thus, the validity
of the information received via the surveys must rely solely
upon the precision and accuracy with which clinic staff
completed the questionnaire. Despite Committee staff efforts
to design unambiguous questions regarding basic operational
parameters, the responses lacked uniformity. Some respondents
indicated that the requested data for specific questions had
never been properly collected or could not be accessed.
Because a site audit of each clinic was beyond the scope of
Democratic Committee staff resources, this report relies
solely on self-reported data, with caveats for incomplete or
subjective responses noted.
Findings and Conclusions--While community-based clinics
appear to offer an appropriate avenue for increasing
veterans' access to care, the unevenness of responses to the
staff survey precludes any generalized conclusions on the
collective success, capacity, and quality of these clinics.
The available data show wide variety in every possible
parameter of clinic function, both within and among networks.
This variability, which suggests a significant lack of
uniformity among the CBOCs, prevents easy summaries or simple
solutions for possible deficits.
The flexibility inherent in the decentralized VA health
care system has allowed network and medical center directors,
rather than VA Headquarters, to map the course of VA's
community-based outpatient care. While this arrangement does
not preclude provision of excellent health care in individual
clinics and does present the opportunity to tailor services
to each community's demands, the significant variations in
operational standards described by clinic staff appear to
reflect varied management practices rather than deliberate
adaptations to community needs.
Based on the variability in services--and in the vocabulary
for describing operational standards--the Democratic
Committee Staff can only infer that VA has not established a
systemwide baseline for the minimum acceptable service levels
in CBOCs. Community clinics should not be expected to offer
identical or completely inclusive services. However, veterans
accessing primary care through VA outpatient clinics should
be able to depend upon a minimum standard package of
services, regardless of geographic location, and on an
acceptable level of quality of care. Also, the Congress
should be able to expect an effective and efficient use of
resources at all CBOCs.
Specific findings include the following: The number of FTEE
(full-time employee equivalents) providing primary care
varied markedly among clinics and did not appear to be linked
consistently to the patient load. Staffing levels for clinics
serving about 5,000 patients in the first half of FY 2000
ranged from 6 to 15 FTEE. Some clinics operated with fewer
than two FTEE, raising significant concerns about the ability
of such a limited staff to offer high quality health care
while performing administrative tasks and monitoring quality
of care.
VA does not provide the same services in all clinics.
Variations in staffing translate into variations in the types
and levels of services provided, including basic mental
health care, both preventive and counseling services, and
overall hours of service. Veterans in different regions
should be able to expect a standard basic package of
services.
Community clinics have not eliminated long waiting times to
obtain an appointment and to receive treatment in every
network in accordance with VA goals. The longest actual
waiting time for an appointment exceeded 30 days in 18
networks. Only a few clinics reported having a defined policy
for accepting and scheduling ``walk-ins.''
Many community clinics lacked equipment and personnel to
respond to a cardiac emergency, an issue of patient safety.
Each clinic should have, at minimum, an automated external
defibrillator and staff trained in its use. Only 38% of
clinics reported having the staff and equipment necessary in
the case of a cardiac emergency.
Community clinics have not offered sufficient outpatient
mental health care to compensate for the loss of VHA
impatient programs. The number of VA medical facility beds
available for impatient mental health care has declined
steadily over the last two decades. By the end of FY 2001, VA
anticipates reducing the numbers of patients treated in
inpatient psychiatric care programs by 56% from the level
treated in FY 1995. Outpatient mental health care programs
provide a complement to (although not a substitute for) acute
inpatient care, and can serve as a valuable community-based
tool in a comprehensive mental health care maintenance
regimen.
If outpatient programs are to play a part in maintaining
systemwide capacity for mental health care treatment of
veterans, they must be accessible to veterans at the sites of
outpatient care. Yet, less than half of the clinics
surveyed reported offering any mental health care. Of the
229 clinics that responded to the staff survey, only 50
reported that they provided PTSD treatment, and only 42
reported offering substance abuse treatment of any kind.
Mental health care FTEE constituted only a small fraction
of the total clinic staff in most networks.
Clinics report a range of costs per patient visit, with the
average cost per visit within a network in FY 1999 ranging
from $27 to $290. Calculating the cost-effectiveness of
outpatient treatment requires a uniform method of calculating
actual costs, which VA currently lacks. Whether the variation
in patient visit costs reported by clinics represents varying
staff efficiency or differences in treating ``revenue-
generating'' insured patients cannot be determined from the
data here.
The lack of a coherent system for collecting, monitoring,
and analyzing quality of care data prevents evaluation of
community care success. Almost all clinics reported that they
document and monitor the quality of health care provided, but
the clinic staff who completed the surveys had widely varying
perceptions of what constituted a quality of care assessment.
The materials presented for documenting quality of care
ranged from medical checklists to patient satisfaction
surveys that focused largely on aspects of patients' physical
and emotional comfort in the clinic setting, rather than
health care-related criteria. None documented health
outcomes. Only 130 clinics reported sending any quality of
care reports (regardless of content) to the parent
facilities, and none received written feedback specific to
that clinic from the parent facilities. The complete lack of
a shared vocabulary for measuring quality of care prevented
any compilation of the data. One clinic operated by a
contractor responded that monitoring quality is not part of
its contract.
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The poor or absent measures of quality of care make the
effectiveness of the care provided by the clinics, variations
between contracts- and VA-operated clinics, and the effect of
staffing inequities impossible to judge. VA needs a
consistent set of tools that can be employed in outpatient
clinics systemwide to obtain meaningful quality of care
outcomes.
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