VA Health Care: VA's Efforts to Maintain Services for Veterans With
Special Disabilities (Testimony, 07/23/98, GAO/T-HEHS-98-220).

Pursuant to a congressional request, GAO discussed its ongoing work on
the Department of Veterans Affairs' (VA) efforts to comply with section
104 of the Veterans Health Care Eligibility Reform Act of 1996, focusing
on whether VA: (1) is maintaining capacity with reasonable access to
specialized care; and (2) has data that are sufficiently reliable to
monitor and report on compliance.

GAO noted that: (1) its work to date suggests that much more information
and analyses are needed to support VA's conclusion that it is
maintaining its national capacity to treat special disability groups;
(2) for example, while VA's data indicate that from fiscal year (FY)
1996 to FY 1997, the number of veterans served increased by 6,000, the
data also show that spending for specialized disability programs
decreased by $52 million; (3) VA attributes the decreased spending to
reducing unnecessary duplicative services and replacing more expensive
hospital inpatient treatment with outpatient care; (4) such aggregate
data and assertions may, however, mask potential adverse effects on
specific programs and locations; (5) for example, VA data also show that
the number of veterans treated systemwide in FY 1997 decreased for
amputees, and expenditures were reduced for veterans with amputations,
serious mental illness, and post-traumatic stress disorder; (6) in
addition, for substance abuse patients with serious mental illness, VA
data show that about 3,000 fewer veterans were served and $112 million
less was spent; (7) consistent with the Government Performance and
Results Act of 1993, VA plans to develop outcome measures over the next
2 to 3 years to track whether, among other things, the care provided to
disabled veterans is effective as a result of its shift from inpatient
to outpatient care; (8) VA intends to replace expenditure data with
outcome measures when they become available; (9) while outcome measures
are a valuable tool to evaluate program effectiveness and to help
monitor physical, psychological, and social services, retaining current
measures, such as dollars spent serving VA's special needs population,
are also important to measure legislative compliance; (10) beyond the
issue of how VA chooses to measure its capacity to serve veterans with
special disabilities, there are also questions regarding the reliability
of VA's data; (11) for example, in 1998, VA reduced its reported 1996
baseline expenditure data in all six specialized programs and services
by as much as 50 percent without explaining in its report the basis for
such changes; (12) VA's two advisory committees have also raised
questions about anomalies in the capacity data; and (13) VA has
acknowledged the need to improve its data systems and has several
efforts under way to do so.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  T-HEHS-98-220
     TITLE:  VA Health Care: VA's Efforts to Maintain Services for 
             Veterans With Special Disabilities
      DATE:  07/23/98
   SUBJECT:  Veterans
             Health care services
             Patient care services
             Veterans benefits
             Persons with disabilities
             Health care cost control
             Health care programs
             Data integrity
             Management information systems

             
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Cover
================================================================ COVER


Before the Subcommittee on Health, Committee on Veterans' Affairs,
House of Representatives

For Release on Delivery
Expected at 9:30 a.m.
Thursday, July 23, 1998

VA HEALTH CARE - VA'S EFFORTS TO
MAINTAIN SERVICES FOR VETERANS
WITH SPECIAL DISABILITIES

Statement of Stephen P.  Backhus, Director
Veterans' Affairs and Military Health Care Issues
Health, Education, and Human Services Division

GAO/T-HEHS-98-220

GAO/HEHS-98-220T


(406149)


Abbreviations
=============================================================== ABBREV

  ACPSDP - Advisory Committee on Prosthetics and Special Disabilities
     Programs
  CCSCMI - Committee on the Care of Severely Chronically Mentally Ill
  GPRA - Government Performance and Results Act
  PTSD - post-traumatic stress disorder
  VA - Department of Veterans Affairs'
  VHA - Veterans Health
  VISN - Veterans Integrated Service Networks
  VSO - veteran service organizations

VA HEALTH CARE:  VA'S EFFORTS TO
MAINTAIN SERVICES FOR VETERANS
WITH SPECIAL DISABILITIES
============================================================ Chapter 0

Mr.  Chairman and Members of the Subcommittee: 

Thank you for the opportunity to be with you today to discuss our
ongoing work on the Department of Veterans Affairs' (VA) efforts to
comply with section 104 of the Veterans Health Care Eligibility
Reform Act of 1996 (P.L.  104-262, Oct.  9, 1996).  This provision
reflects concerns that budgetary pressures and ongoing reorganization
within VA might make VA's specialized programs and services for
disabled veterans vulnerable to cost cutting.  The provision requires
the Secretary of VA to (1) ensure that the systemwide capacity of the
department to provide specialized treatment and rehabilitative
services is not reduced below its October 1996 capacity and (2)
provide veterans with reasonable access to such needed care and
services.  The provision identified four disabling conditions; VA,
after consulting with stakeholders, identified two additional
conditions.\1 Further, VA is required to report to the House and
Senate Committees on Veterans' Affairs annually on its compliance
with section 104 from fiscal years 1997 through 1999. 

You asked that I focus my remarks on whether VA (1) is maintaining
capacity with reasonable access to specialized care and (2) has data
that are sufficiently reliable to monitor and report on compliance. 
My comments are based on meetings we have held with VA officials
responsible for administering the special disability programs,
officials of veteran service organizations (VSO) that represent the
veterans receiving specialized care, and representatives of two
advisory committees with which VA is required to consult in
responding to this legislation.\2 We are also reviewing VA and
advisory committee reports, relevant policies and manuals, and other
data and documentation.  We will be continuing our work over the next
several months and expect to issue a report next spring. 

In summary, our work to date suggests that much more information and
analyses are needed to support VA's conclusion that it is maintaining
its national capacity to treat special disability groups.  For
example, while VA's data indicate that from fiscal year 1996 to
fiscal year 1997, the number of veterans served increased by 6,000
(or 2 percent), the data also show that spending for specialized
disability programs decreased by $52 million (or 2 percent).  VA
attributes the decreased spending to reducing unnecessary duplicative
services and replacing more expensive hospital inpatient treatment
with outpatient care.  Such aggregate data and assertions may,
however, mask potential adverse effects on specific programs and
locations.  For example, VA data also show that the number of
veterans treated systemwide in fiscal year 1997 decreased for
amputees, and expenditures were reduced for veterans with
amputations, serious mental illness, and PTSD.  In addition, for
substance abuse patients with serious mental illness, VA data show
that about 3,000 fewer veterans were served and $112 million less was
spent. 

Consistent with the Government Performance and Results Act (GPRA) of
1993,\3 VA plans to develop outcome measures over the next 2 to 3
years to track whether, among other things, the care provided to
disabled veterans is effective as a result of its shift from
inpatient to outpatient care.  VA intends to replace expenditure data
with outcome measures when they become available.  While outcome
measures are a valuable tool to evaluate program effectiveness and to
help monitor physical, psychological, and social services, retaining
current measures, such as dollars spent serving VA's special needs
population, is also important to measure legislative compliance. 

Beyond the issue of how VA chooses to measure its capacity to serve
veterans with special disabilities, there are also questions
regarding the reliability of VA's data.  For example, in 1998, VA
reduced its reported 1996 baseline expenditure data in all six
specialized programs and services by as much as 50 percent without
explaining in its report the basis for such changes.  VA's two
advisory committees have also raised questions about anomalies in the
capacity data.  VA has acknowledged the need to improve its data
systems and has several efforts under way to do so.  We will be
examining data reliability issues in more detail as we complete our
study. 


--------------------
\1 The four conditions identified in the statute are spinal cord
dysfunction, blindness, amputations, and mental illness.  VA limited
its program for mental illness to veterans with serious mental
illness and added two other conditions--traumatic brain injury and
post-traumatic stress disorder (PTSD). 

\2 The two committees are the Advisory Committee on Prosthetics and
Special Disabilities Programs and the Committee on Care of Severely
Chronically Mentally Ill Veterans. 

\3 GPRA requires agencies to prepare annual performance plans
covering program activities set out in their budgets beginning in
fiscal year 1999. 


   BACKGROUND
---------------------------------------------------------- Chapter 0:1

VA has taken steps to fundamentally change the way it delivers health
care to the nation's veterans.  In recent years--and consistent with
major changes in the national health care industry--VA has moved
toward providing more services to veterans on an outpatient basis. 
Also, VA's Veterans Integrated Service Networks (VISN) have greater
discretion for determining the mix of services to be provided.  In
House Report 104-690, which accompanied the Veterans Health Care
Eligibility Reform Act of 1996, considerable discretion is given to
the Secretary of VA in managing the provision of health care services
to veterans.  However, the report pointed out that the uniqueness of
VA's specialized treatment programs requires a far more prescriptive
response in the legislation.  The report noted that providing
specialized treatment and rehabilitative services is vital to VA's
health care mission.  Due to the recognized high cost of these
programs, budgetary pressures, and restructuring within the Veterans
Health Administration (VHA),\4 the House Committee on Veterans'
Affairs was concerned that "VA's costly specialized programs may be
particularly vulnerable and disproportionately subject to budget
cutting."

To address these concerns, a provision of the act directed the
Secretary to ensure that VA maintain its capacity to serve veterans
with special disabilities.  This provision also requires VA to
consult with the Advisory Committee on Prosthetics and Special
Disabilities Programs (ACPSDP) and the Committee on the Care of
Severely Chronically Mentally Ill (CCSCMI) Veterans in fulfilling the
requirements of the act.\5 Primarily, ACPSDP advises the Secretary on
issues affecting the delivery of prosthetic services to amputees and
other special disability groups.  The mission of CCSCMI Veterans is
to assess VA's efforts to meet the treatment and rehabilitation needs
of severely and chronically mentally ill veterans.  VA coordinated
with the committee and incorporated its input on the care of
seriously mentally ill veterans.  In addition, both committees worked
with VA to identify the six special disability groups and to define
measures of capacity and access.  VA also established a Special
Disability Programs Work Group to work with a number of
stakeholders--including national and state VSOs, VHA networks and
facilities, and special disability program managers--on issues such
as identification of the six special disability groups, their
definitions, and definitions of capacity and access. 

While consensus was not reached among stakeholders, VA established an
initial set of 1996 baseline capacity measures consisting of the
number of veterans served and dollars spent on veterans with these
specialized needs.  For veterans disabled by blindness and spinal
cord dysfunction, capacity is also measured by the number of
specialized beds and staff resources dedicated to these disabilities. 
VA defines access as timeliness in providing services to veterans for
their specialized needs.  VA is currently developing outcome measures
to reflect the overall effectiveness of its programs. 


--------------------
\4 VHA has decentralized its management structure to coordinate the
organization of its medical facilities into 22 networks.  This was
done in an effort to improve efficiency by reducing unnecessarily
duplicative services and shifting services from inpatient care to
less costly outpatient care. 

\5 ACPSDP members are from veteran service organizations,
universities, and private sector health care providers.  In
accordance with P.L.  104-262, members of CCSCMI Veterans must be VHA
employees with expertise in the care of the chronically mentally ill
and be appointed by VA's Under Secretary for Health. 


   UNCLEAR IF VA HAS MAINTAINED
   CAPACITY AND ACCESS TO
   SPECIALIZED SERVICES
---------------------------------------------------------- Chapter 0:2

VA's data show that from fiscal year 1996 to fiscal year 1997, there
was an increase in the number of disabled veterans served--despite an
overall decrease in dollars expended for the six programs and
conditions.  Overall, 2 percent--or about 6,000--additional veterans
were served with 2 percent--or $52 million--less spending.  VA's data
also indicate that access improved nationally for most programs. 

For five of the six programs and conditions, VA served more disabled
veterans in fiscal year 1997 than it did in 1996 for a total increase
of about 6,000 more disabled veterans served.  Only in the amputee
program was there a reduction in the number of veterans
served--approximately 2 percent.  Three of the six programs had
higher expenditures during the same time period.  The traumatic brain
injury, blindness, and spinal cord injury programs experienced 68,
24, and 3 percent increases, respectively, in expenditures, although
they served many fewer veterans than programs for mental conditions. 
(See table 1.)



                                     Table 1
                     
                       Percent Change in Number of Veterans
                       Served and Dollars Spent From Fiscal
                                Years 1996 to 1997

                  Individuals served             Dollars expended (thousands)
          ----------------------------------  ----------------------------------
Program/
conditio                             Percent                             Percent
n            FY 1996     FY 1997      change     FY 1996     FY 1997      change
--------  ----------  ----------  ----------  ----------  ----------  ----------
Spinal         8,598       8,922           4    $199,848    $206,228           3
 cord
 injury
Blindnes       9,726      11,726          21      43,855      54,426          24
 s
Traumati         175         251          43       3,735       6,271          68
 c brain
 injury
Amputati       4,765       4,684          -2       5,953       5,856          -2
 ons
Serious      269,009     272,229           1   2,080,240   2,015,642          -3
 mental
 illness
PTSD          39,653      40,027           1     101,882      95,223          -7
================================================================================
Total        331,926     337,839           2  $2,435,513  $2,383,646          -2
--------------------------------------------------------------------------------
Note:  We did not independently verify these numbers. 

Source:  VA Report to Congress, Maintaining Capacity to Provide for
the Specialized Treatment and Rehabilitative Needs of Disabled
Veterans (Department of Veterans Affairs, May 1998). 

Much of the change in expenditures involved veterans with serious
mental illness, who in fiscal year 1997 accounted for 81 percent of
the veterans served and 85 percent of expenditures for the six
specialized programs and conditions.  VA data indicate that it
provided services to an additional 3,000 seriously mentally ill
veterans, while it reduced spending by about $65 million.  VA
attributes these changes to efficiencies gained from shifting the
treatment emphasis from inpatient to outpatient care.  It is unclear,
however, whether VA's data are comprehensive enough to quantify the
effect on capacity of changes in service delivery methods.  Moreover,
other data not used by VA, such as numbers and types of specialist
providers and beds, may also be useful indicators of capacity. 

Substance abuse services for veterans with serious mental illness
illustrate the need for more comprehensive information to assess
whether capacity is being maintained.  For example, from fiscal years
1996 to 1997, substance abuse expenditures declined by 20 percent, or
over $112 million, and VA treated about 3,000 fewer veterans with
this condition.  (See table 2.) Some VA networks believe that such
numbers give an incomplete picture of actual services rendered
because patients who are "mainstreamed" into general care programs
may be receiving care outside the special programs.  While improved
efficiencies can account for some expenditure reductions, they do not
appear to explain the large regional drops and variations in the
number of patients served.  In fact, it seems reasonable to expect
that a shift to less costly outpatient delivery modes should result
in significant increases in the number of patients treated for the
same expenditures. 



                                     Table 2
                     
                       Percent Change in Number of Veterans
                      Served and Dollars Spent for Seriously
                     Mentally Ill Programs From Fiscal Years
                                   1996 to 1997

                Individuals served             Dollars expended (in thousands)
        -----------------------------------  -----------------------------------
Progra
m for
seriou
sly                           Actual change                        Actual change
mental                             (percent                             (percent
ly ill    FY 1996    FY 1997        change)    FY 1996    FY 1997        change)
------  ---------  ---------  -------------  ---------  ---------  -------------
Substa    107,074    104,441         -2,633   $575,902   $463,372      $-112,530
 nce                                   (-2)                                (-20)
 abuse
Homele     24,539     24,613             74     75,071     72,765         -2,306
 ss                                     (0)                                 (-3)
PTSD       32,142     32,575            433     99,705     92,667         -7,038
                                        (1)                                 (-7)
Other\    105,254    115,600    10,346 (10)  1,329,562  1,386,838         57,276
 a                                                                           (4)
================================================================================
Total     269,009    272,229          3,220  $2,080,24  $2,015,64       $-64,598
                                        (1)          0          2           (-3)
--------------------------------------------------------------------------------
Note:  We did not independently verify these numbers. 

\a These are veterans who currently have or at any time during the
past year had a diagnosed mental, behavioral, or emotional disorder
of sufficient duration to result in a disability, excluding those who
have PTSD or substance abuse problems or are homeless. 

Source:  VA Report to Congress, Maintaining Capacity to Provide for
the Specialized Treatment and Rehabilitative Needs of Disabled
Veterans. 

With regard to reasonable access to care and services, VA's data
indicate that access has improved for five of the six special
disability programs.  (See app.  I.) For example, VA's data indicates
that the proportion of veterans receiving psychiatric outpatient care
within 30 days of hospital discharge increased by 0.6 percent in
fiscal year 1997.  This increase was accompanied by a 2-day average
decrease in the number of days from discharge to the first outpatient
visit.  In contrast, monthly waiting times for admission to the
inpatient blind rehabilitation program increased by 1 to 8 weeks for
11 months of the year.  VA attributes increased waiting times, in
part, to delays in filling vacant positions and increased demand for
services. 

VA is currently developing outcome measures to track the quality and
effectiveness of care provided to disabled veterans.  Outcome
measures, such as functional status, provide an opportunity to
examine the effectiveness of innovations in service delivery, which
could lead to a higher degree of patient satisfaction.  Outcome
assessments also provide benchmarks for goal setting and facilitate
comparisons among programs and facilities from year to year. 
Although VA has identified preliminary outcome measures for each
special disability program, it estimates that 2 to 3 years will be
required to fully develop and collect data to include outcome
measures in its monitoring system.  (See app.  II.)

As it did in its first two reports to the Congress, VA plans to use
individuals served and the dollars expended for their care as its
measure of capacity in its final report in 1999.  However, when
outcome measures are developed, VA plans to measure capacity using
them and only the number of individuals treated in specialized units. 
While VA will continue to collect information on costs and
expenditures for special disability programs, this information will
not be used to measure capacity. 


   MORE RELIABLE INFORMATION
   NEEDED
---------------------------------------------------------- Chapter 0:3

VA is working to develop more reliable information on its special
disability programs.\6 However, we and others are concerned about the
reliability of VA's data and VA efforts to improve it.  For example,
VA used different 1996 baseline capacity data in its 1997 and 1998
reports to the Congress.  (See app.  III.) VA reduced all baseline
program expenditure figures in its 1998 report, with changes ranging
from a high of $56.5 million to a low of $300,000.  While VA
attributed these changes to data refinement, it did not provide any
specifics in its reports as to what prompted such refinements. 

Baseline expenditures for the amputee program--which VA reduced about
50 percent ($5.8 million) in the 1998 capacity report--illustrate
potential problems with VA's data.  According to VA officials, the
reduction occurred because the 1997 report inadvertently included in
the amputations workload the amputations of toes other than the great
toe, which is considered more likely to lead to a disabling condition
than other toe amputations.  It seems questionable, however, that
this would result in baseline expenditure reductions of 50 percent in
each VISN and all facilities, as VA reported. 

VA's two advisory committees have also questioned the accuracy of
VA's data.  CCSCMI Veterans (comprised of VA employees) indicated
that data problems hampered its ability to evaluate VA's capacity to
treat seriously mentally ill veterans and that it is using other
sources of data to aid in its assessment of capacity.  ACPSDP did not
endorse VA's 1998 report to the Congress because it believed the
costs were questionable and raised concerns as to the overall
accuracy of the report.  They noted that one facility showed more
than a 100-percent increase in (or 156) individuals treated for
blindness from fiscal years 1996 to 1997, with an increase of over
$2.3 million in expenditures--from $66,000 to $2.4 million--or 3,500
percent.  VA has been unable to explain the increase in expenditures. 

As VA strives to measure compliance with the requirements of section
104 of the Veterans Health Care Eligibility Reform Act, it needs to
develop more comprehensive data and improve the reliability of
existing information.  VA acknowledges the need to improve its
information systems and has several initiatives under way.  We will
continue to assess these efforts as we complete our study. 


--------------------
\6 Specifically, VA developed a methodology for identifying special
disability program patients from existing registries and in some
instances, created new registries.  Additionally, workloads were
defined using diagnostic and clinical procedure codes.  Program costs
for specialized inpatient and outpatient care are identified using
VA's cost distribution report. 


-------------------------------------------------------- Chapter 0:3.1

Mr.  Chairman, this concludes my prepared remarks.  I will be happy
to answer any questions you or other members of the Subcommittee may
have. 


VA'S ACCESS MEASURES FOR SPECIAL
DISABILITY PROGRAMS
=========================================================== Appendix I


   SPINAL CORD INJURY--ACUTE CARE
--------------------------------------------------------- Appendix I:1


      MEASURE
------------------------------------------------------- Appendix I:1.1

Waiting time for transfer of patients to spinal cord injury center. 


      GOAL
------------------------------------------------------- Appendix I:1.2

All patients requiring acute care receive same-day transfers to a
spinal cord injury center. 


      PERFORMANCE
------------------------------------------------------- Appendix I:1.3

In fiscal year 1996, 41 percent of VISNs met the goal; in fiscal year
1997, 91 percent met the goal. 


   SPINAL CORD INJURY--SEMIURGENT
   CARE
--------------------------------------------------------- Appendix I:2


      MEASURE
------------------------------------------------------- Appendix I:2.1

Waiting time for transfer of patients requiring semiurgent care to
spinal cord injury center. 


      GOAL
------------------------------------------------------- Appendix I:2.2

All patients requiring semiurgent care receive transfer within 2
weeks of referral. 


      PERFORMANCE
------------------------------------------------------- Appendix I:2.3

In July 1997--the period for which data were available--89 percent of
transfers occurred within 2 weeks. 


   SPINAL CORD INJURY--OUTPATIENT
   CARE
--------------------------------------------------------- Appendix I:3


      MEASURE
------------------------------------------------------- Appendix I:3.1

Waiting time for an appointment for outpatient care. 


      GOAL
------------------------------------------------------- Appendix I:3.2

All patients requiring outpatient care receive an appointment within
7 days of referral to a spinal cord injury center. 


      PERFORMANCE
------------------------------------------------------- Appendix I:3.3

In fiscal year 1996, 87 percent of VISNs met the goal; in fiscal year
1997, all met the goal. 


   BLINDNESS
--------------------------------------------------------- Appendix I:4


      MEASURE
------------------------------------------------------- Appendix I:4.1

Waiting time for admission to VA inpatient blind rehabilitation
program. 


      GOAL
------------------------------------------------------- Appendix I:4.2

None specified. 


      PERFORMANCE
------------------------------------------------------- Appendix I:4.3

In fiscal year 1997, monthly waiting times (1) averaged 27 to 34
weeks and (2) increased in 11 of 12 months over fiscal year 1996
waiting times. 


   TRAUMATIC BRAIN
   INJURY--INPATIENT CARE
--------------------------------------------------------- Appendix I:5


      MEASURE
------------------------------------------------------- Appendix I:5.1

Waiting time for admission to a designated traumatic brain injury
bed. 


      GOAL
------------------------------------------------------- Appendix I:5.2

None specified. 


      PERFORMANCE
------------------------------------------------------- Appendix I:5.3

In fiscal year 1997, waiting times for inpatient care (1) ranged from
1 to 5 days and (2) improved over fiscal year 1996 performance in 12
of 14 VISNs with traumatic brain injury programs. 


   TRAUMATIC BRAIN
   INJURY--OUTPATIENT CARE
--------------------------------------------------------- Appendix I:6


      MEASURE
------------------------------------------------------- Appendix I:6.1

The number of days to obtain first appointment after discharge with a
rehabilitation professional team member in the rehabilitation clinic. 


      GOAL
------------------------------------------------------- Appendix I:6.2

None specified. 


      PERFORMANCE
------------------------------------------------------- Appendix I:6.3

In fiscal year 1997, waiting times for outpatient care (1) ranged
from 1 to 14 days and (2) improved over fiscal year 1996 performance
in eight VISNs that had outpatient programs in 1997. 


   AMPUTATIONS (PROSTHETICS)
--------------------------------------------------------- Appendix I:7


      MEASURE
------------------------------------------------------- Appendix I:7.1

Percentage of prosthetic orders that are delayed--that is, not
processed within 5 work days because of incomplete management or
administrative action. 


      GOAL
------------------------------------------------------- Appendix I:7.2

Delays should not be in excess of 2 percent of total orders
(workload). 


      PERFORMANCE
------------------------------------------------------- Appendix I:7.3

In fiscal year 1996, 1.3 percent of all orders were delayed; in 1997,
delays were 0.7 percent of orders. 


   SERIOUSLY MENTALLY ILL
--------------------------------------------------------- Appendix I:8


      MEASURES
------------------------------------------------------- Appendix I:8.1

(1) Percentage of patients receiving outpatient visits for primary
disorder within 30 days after discharge. 

(2) The days elapsed between discharge and the first outpatient visit
in the 6 months after discharge. 


      GOAL
------------------------------------------------------- Appendix I:8.2

None specified. 


      PERFORMANCE
------------------------------------------------------- Appendix I:8.3

(1) The percentage of seriously mentally ill patients who received
outpatient care within 30 days of discharge increased from 52.1
percent in 1996 to 52.7 percent in fiscal year 1997--an increase of
0.6 percent. 

(2) In fiscal year 1997, seriously mentally ill patients experienced
a 2-day decrease in the number of days from discharge to the first
outpatient visit. 


   POST-TRAUMATIC STRESS DISORDER
--------------------------------------------------------- Appendix I:9


      MEASURES
------------------------------------------------------- Appendix I:9.1

(1) Percentage of patients receiving outpatient visits for the
primary disorder within 30 days after discharge. 

(2) The days elapsed between discharge and the first outpatient visit
in the 6 months after discharge. 


      GOAL
------------------------------------------------------- Appendix I:9.2

None specified. 


      PERFORMANCE
------------------------------------------------------- Appendix I:9.3

(1) The proportion of PTSD patients receiving outpatient care
increased 1.6 percent in 1997. 

(2) Days elapsed from discharge to the first outpatient visit
decreased about 2 days. 


SELECTED OUTCOME MEASURES BY
SPECIAL DISABILITY PROGRAM
========================================================== Appendix II

Special
disability      Description of outcome
program         measure\a                       Status
--------------  ------------------------------  --------------------------------
Spinal cord     Patient satisfaction survey     Implemented
dysfunction

                Assessment of functional        Under development
                status

                Discharge to community living   Under development

Blindness       Patient satisfaction survey     Implemented

                Rehabilitation outcome survey   Testing instruments

Traumatic       Assessment of functional        Testing instruments
brain injury    status\b (percent of first-
                admission traumatic brain
                injury patients discharged
                from traumatic brain injury
                network, and acute medical
                rehabilitation beds to the
                community)

Amputations     Assessment of functional        Under development
                status (such as percent of
                lower extremity amputee
                patients discharged from
                inpatient rehabilitation units
                to community setting)

Seriously       Assessment of functional        Some are implemented, others are
mentally ill    status (such as comparing       under development; software to
                early and late global           capture functional status data
                assessment of functioning       estimated to be completed by
                (GAF)\c scores for each         early FY 1999
                individual during the year or
                comparing FY 1997 and FY 1998
                scores, if only one is
                available)

PTSD            Assessment of functional        Some are implemented, others are
                status (GAF scores and data     under development; software to
                such as percent of veterans     capture functional status data
                scoring equal or better in      estimated to be completed by
                PTSD symptoms 4 months after    early FY 1999
                discharge)
--------------------------------------------------------------------------------
\a VA reports that outcome measures will also facilitate comparisons
among programs and facilities from year to year to assess the
progress of special disability programs in meeting goals of quality
care.  Two to 3 years will be required to fully develop and collect
data for all outcome measures. 

\b The Uniform Data System for Medical Rehabilitation criteria
separate placement outcomes into categories such as community,
long-term care, return to acute facility, and other.  These
categories are determined through functional assessment--the percent
of patients maintaining cognitive and physical functional gain at 3-
and 12-month follow-up. 

\c GAF rates a client's overall functioning, including psychological,
social, and occupational rating. 

Sources:  VA's Report to Congress, Maintaining Capacity to Provide
for the Specialized Treatment and Rehabilitative Needs of Disabled
Veterans, and several of VA's preliminary program reports on outcome
measures. 


REDUCTIONS IN FISCAL YEAR 1996
BASELINE EXPENDITURE DATA FOR VA
SPECIALIZED SERVICES
========================================================= Appendix III

Special
disabili                            Baseline used in May   Actual differences in
ty          Baseline used in May             1998 report    baseline (percentage
program   1997 report (millions)             \(millions)            differences)
--------  ----------------------  ----------------------  ----------------------
Spinal                    $211.2                  $199.8                   $11.4
 cord                                                                        (5)
 dysfunc
 tion
Blindnes                    48.0                    43.9                     4.1
 s                                                                           (9)
Traumati                     4.0                     3.7                     0.3
 c brain                                                                     (8)
 injury
Amputati                    11.8                     6.0                     5.8
 on                                                                         (49)
Seriousl                 2,136.7                 2,080.2                    56.5
 y                                                                           (3)
 mentall
 y ill
Substanc                   597.3                   575.9                    21.4
 e abuse                                                                     (4)
Homeless                    79.1                    75.0                     4.1
                                                                             (5)
PTSD                       100.8                    99.7                     1.1
 (seriou                                                                     (1)
 sly
 mentall
 y ill
 only)
PTSD                       103.0                   101.9                     1.1
                                                                             (1)
--------------------------------------------------------------------------------
Source:  VA Report to Congress, Maintaining Capacity to Provide for
the Specialized Treatment and Rehabilitative Needs of Disabled
Veterans. 


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