STATEMENT OF
MS. SHEILA CULLEN
DIRECTOR, VA SIERRA PACIFIC NETWORK (VISN 21)
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
COMMITTEE ON VETERANS’ AFFAIRS
UNITED STATES SENATE
AUGUST 25, 2009

Mr. Chairman and Members of the Committee, mahalo for the opportunity to appear before you today to discuss VA health care in Hawaii and the Pacific region.  It is a privilege to be on Oahu to speak and answer questions about VA health care issues that are important to Veterans residing in Hawaii.  I am accompanied today by
Dr. James Hastings, Director of the VA Pacific Islands Health Care System (VAPIHCS), and Dr. Adam Darkins, Chief Consultant, Care Coordination, Office of Patient Care Services, Veterans Health Administration.

First, Mr. Chairman, I would like to thank you for your leadership and advocacy on behalf of our Nation’s Veterans.  During your tenure as Ranking Member and Chairman of this Committee, you have consistently demonstrated your commitment to Veterans by introducing legislation designed to meet the needs of Veterans.  As I will highlight later, your vision and support have led to an unprecedented level of health care services for Veterans, construction of state-of-the-art facilities here in Honolulu, and remarkable improvements in access to health care services for Veterans residing on the Hawaiian neighbor islands, American Samoa and Guam.  In addition, we appreciate your interest in and support of the Department of Veterans Affairs (VA).

Today, I will briefly review the operations of the VA Sierra Pacific Network that includes Hawaii and the Pacific region; provide an overview of VAPIHCS and the VA facilities here on Oahu; provide national and local information regarding telehealth programs; and highlight outreach and seamless transition activities between VAPIHCS and the State of Hawaii National Guard.

VA Sierra Pacific Network (VISN 21)
The VA Sierra Pacific Network (Veterans Integrated Service Network [VISN] 21) is one of 21 integrated health care networks in the Veterans Health Administration (VHA).  The VA Sierra Pacific Network provides services to Veterans residing in Hawaii and the Pacific region (including the Philippines, Guam, American Samoa and Commonwealth of the Northern Marianas Islands), northern Nevada, and central/northern California.  There were an estimated 1.1 million Veterans living within the boundaries of the VA Sierra Pacific Network in Fiscal Year (FY) 2008.

The VA Sierra Pacific Network includes six major health care systems based in Honolulu, HI; Palo Alto, CA; San Francisco, CA; Sacramento, CA; Fresno, CA; and Reno, NV, as well as an Independent Outpatient Clinic in Manila, PI.  In FY 2008, the Network provided services to 213,000 out of 350,000 enrolled Veterans.  There were about 3.2 million clinic visits and 25,800 inpatient discharges.  The cumulative full-time employment equivalents (FTEE) level was 9,607, and the operating budget was about $2.1 billion.

The VA Sierra Pacific Network is committed to ensuring the care Veterans receive is of the highest quality.  All six health care systems within the Network have major academic affiliations.  The Network hosts a significant number of Centers of Excellence in VHA and supports a large and broad research portfolio.  It also has expansive and collaborative relationships with the Department of Defense (DoD).  The VA Sierra Pacific Network has not only exceeded patient satisfaction goals (inpatient and outpatient), but its employee satisfaction scores are among the top five Networks for overall job satisfaction in VHA.  As reflected in the most recent employee satisfaction survey, the Network had the highest scores in VHA in several categories including leadership, supervisory support, customer service, conflict resolution, praise, and rewards.

Given the large and diverse geographic nature (i.e. rural or frontier lands and remote islands) of VISN 21, access to care is a priority.  In FY 2010, the Network will activate nine new sites of care in the Pacific (Hawaii and the Northern Mariana Islands), California, and Nevada.  Finally, VISN 21 is proud to operate one of four Polytrauma Rehabilitation Centers in VHA dedicated to addressing the clinical needs of the most severely injured Veterans.

VA Pacific Islands Health Care System (VAPIHCS)
As noted above, VAPIHCS is one of six major health care systems in VISN 21.
Dr. James Hastings is the director and a practicing cardiologist at VAPIHCS.  VAPIHCS is unique in several important aspects:  its vast catchment area covers 2.6 million square-miles (including Hawaii, Guam, American Samoa and Commonwealth of the Northern Marianas); its remote island locations create access challenges; and it enjoys the cultural richness of the Pacific Islands with an ethnically diverse patient and staff population.  In FY 2008, there were an estimated 118,000 Veterans living in Hawaii, and at least 10,000 additional Veterans located beyond Hawaii in the VAPIHCS catchment area.

VAPIHCS currently provides care in ten locations, with two more soon to be added.  Our current facilities include an Ambulatory Care Center (ACC) and a Community Living Center (CLC) on the campus of the Tripler Army Medical Center (TAMC) in Honolulu; community-based outpatient clinics (CBOC) in Lihue (Kauai), Kahului (Maui), Kailua-Kona (Hawaii), Hilo (Hawaii), Hagatna (Guam) and Pago Pago (American Samoa); and outreach clinics on Molokai and Lanai.  The two planned facilities include a new interim CBOC to serve Leeward Oahu Veterans (approved in FY 2008 with an expected opening in early FY 2010) and a new outreach clinic in Saipan set to open this fall.  The inpatient post-traumatic stress disorder (PTSD) residential rehabilitation unit is in its interim location on the campus of TAMC, pending construction and activation of a new VA-funded facility ($9.56 million), also at TAMC, during FY 2011.  VAPIHCS also received approval for a VA-funded project ($6.95 million) to build a Joint VA/DoD Ambulatory Surgery facility on the grounds of TAMC.  The project is nearing design completion and is scheduled for construction and activation in FY 2011.

VAPIHCS is also constructing a new replacement CBOC in Guam that will offer expanded capacity.  It will be located along the perimeter of the Guam Naval Hospital, and we expect it to open in March 2010.  VHA operates a total of six Vet Centers in Honolulu, Lihue, Wailuku, Kailua-Kona, Hilo and Guam.  These facilities provide counseling, psychosocial support, and outreach.  A Vet Center staff member was also added in American Samoa during FY 2008.

In FY 2008, VAPIHCS provided services to nearly 24,000 Veterans, an increase of over seven percent from FY 2007.  Of these Veterans, 19,000 reside in Hawaii.  There were 162,000 clinic stops in Hawaii during FY 2008.  The cumulative FTEE in FY 2008 for the health care system was 540 employees.  The operating budget for VAPIHCS (i.e., General Purpose allocation from appropriated funds) increased from $128.0 million in FY 2007 to $142 million in FY 2008, an increase of 11 percent.  

VAPIHCS provides or contracts for a comprehensive array of health care services.  VAPIHCS directly provides primary care, including preventive services and health screenings, and mental health services at all locations.  VAPIHCS does not operate its own acute medical-surgical hospital and as a result faces some challenges in providing specialty services.  VAPIHCS has hired specialists in orthopedics, ophthalmology, nephrology, infectious disease and inpatient medicine (“hospitalist”), and is providing selected specialty care in Honolulu and to a lesser extent at CBOCs.  VAPIHCS also added a neurologist in FY 2008 to improve the treatment of traumatic brain injury (TBI).  VAPIHCS is actively recruiting additional specialists and expects to have a newly hired cardiologist and endocrinologist this fall.  Veterans with spinal cord injuries receive care from VAPIHCS dedicated staff, which provides a multidisciplinary approach to care.  The team, located on Oahu, is planning to travel and care for patients on the neighbor islands during FY 2010.  Veterans requiring other specialty care continue to be referred to DoD and community facilities.

Inpatient long-term and acute rehabilitation care is available at the Community Living Center (CLC).  Inpatient mental health services are provided by VA staff on a 20 bed ward within TAMC and at the 16 bed Post-traumatic Stress Disorder (PTSD) Residential Rehabilitation Program (PRRP).  VAPIHCS contracts for care with DoD (at TAMC and Guam Naval Hospital) and community facilities for inpatient medical-surgical care.

National and Local Telehealth Programs
National Telehealth Programs
Telehealth involves the use of information and telecommunication technologies as a tool in providing health care services when the patient and practitioner are separated by geographical distance.  The benefits of telehealth to health care systems include: improving access to care, making specialist services available in rural and remote locations, and supporting patients to live independently in their own homes and local communities.  Because of the support of telehealth by VA and Congressional leadership, more Veterans are able to realize these benefits. 

Over the past 6 years telehealth in VA has transitioned from use in a range of discrete local projects and programs toward a unified, enterprise level approach that provides routine telehealth services that are mission critical to the delivery of care to Veterans.  In 2009 over 230,000 Veteran patients received care via VA’s telehealth programs.  Telehealth takes many forms.  VA’s enterprise telehealth programs deliver care to Veteran patients in their homes via home telehealth; telehealth care is also provided in VA medical centers (VAMCs), CBOCs and Vet Centers via clinical videoconferencing.  In addition, VA routinely exchanges clinical images via store-and-forwards telehealth. 

I would like to briefly highlight some of the direct benefits these services are providing to Veterans.  Almost 40,000 Veterans are receiving home-telehealth-based care that supports care delivery to them in their own homes.  These care coordination/home telehealth (CCHT) services have reduced hospital admissions by 25 percent, hospital stays by 25 percent, and have high levels of patient satisfaction (86 percent mean score). In 2008 almost 50,000 Veterans received care via clinical videoconferencing (CCGT), the majority receiving mental health care services that reduced hospital admissions by 20 percent.  In 2008 over 100,000 Veterans were screened to prevent avoidable blindness by VA’s teleretinal imaging programs (CCSF).

The successful implementation of robust and sustainable telehealth services that VA entrusts to provide care to Veteran patients must satisfy stringent clinical, technological and business requirements that ensure they are appropriate, effective and cost-effective.  These requirements include acceptance by patients and practitioners as well as staff training and quality management systems.  Mr. Chairman, you and the Committee understand how the geography of Hawaii and the Pacific region poses particular challenges in implementing telehealth that are not encountered on the U.S. mainland.  Services to Guam and American Samoa not only need to bridge a physical distance of 3,820 and 2,300 miles respectively, they also need to bridge between patients and clinical communities that are distant and distinct from one another.  Bridging these distances and linking these communities to enable them to integrate requires telecommunications bandwidth.  VA is currently seeking to embrace Hawaii and the Pacific region within its clinical enterprise video conferencing network (CEVN) and in doing simplify the linkage to specialist services from medical center assets on the U.S. mainland. 

VA recognizes the pioneering role that Hawaii and the Pacific region have played in the development of telehealth solutions that range from teleretinal imaging to home telehealth. These innovations have included partnerships with DoD and the University of Hawaii within the collaborative framework of the Pacific Telehealth and Technology Hui (partnership, or “Hui.”). VA appreciates the support of Congress in the establishment of VA’s Office of Rural Health with sufficient resources that enable us to focus on extending current enterprise telehealth solutions as well as developing new telehealth solutions to serve Veterans, not only those in Hawaii and the Pacific region Islands, but also Veterans elsewhere in the nation for whom geographical distance from VA’s physical health care assets presents a challenge to receiving care.  In considering future innovation for local and enterprise portfolios of telehealth services, VA is looking toward new iterations of a familiar technology – the telephone.  Currently the telephone has meant that eight patients a month from Hawaii and the Pacific region have been able to access VA’s suicide hotline and receive support from Canandaigua, New York.  The transition of health applications onto mobile technologies such as cell phones promises to further revolutionize how telehealth can serve Veterans in areas such as Hawaii and the Pacific region.

Mr. Chairman, I used the word Hui earlier.  As you know, Hui describes a partnership, a union or a gathering.  All health care is ultimately local, and my discussion so far has focused on the clinical, technological and business issues of implementing telehealth across the VA health care system.  My attention will now turn to local telehealth initiatives that support Hawaiian Veterans and those living on other Pacific Islands.

Local Telehealth Programs
In partnership with DoD, specifically TAMC, VAPIHCS began to develop this capability in 2001 with the support of Senator Daniel K. Inouye.  The Pacific Telehealth and Technology Hui formed in 1999 allows joint development of telemedicine technologies for both organizations in the Pacific.  This partnership (known as “the Hui”) fielded many demonstration projects that have enabled both Departments to develop ongoing telehealth activity for our beneficiaries. 

For VAPIHCS, this partnership allowed us to begin developing telemedicine capabilities in collaboration with the local information technology (IT) department that developed the telecommunications network infrastructure and supported the deployment of video teleconferencing to VA CBOCs on the islands of Hawaii, Maui, Kauai, Guam, and American Samoa.  Connectivity to Molokai and Lanai is also available, and we are presently studying connectivity for our newly approved Outreach Clinic in Saipan.  Additionally, this initial investment allowed the development of procedures, practices, and protocols to support video teleconference clinical visits for primary care, mental health, and subspecialty care.  Funds were provided for purchasing telemedicine "carts," that allow the use of peripheral medical equipment (stethoscopes, otoscopes, cameras and other attachments), as well as teleretinal imaging equipment to permit screening for diabetic eye disease.  Automated Drug Dispensing System (ADDS) machines were installed in CBOCs in 2003 allowing pharmacists in Honolulu to dispense medications and, through the use of video conferencing, to provide medication counseling to Veterans at the time of their clinic visits.  The VAPIHCS also began tele-home care projects in 2003 by deploying home telemedicine units.  This partnership and initial funding has helped us establish a foundation of experience upon which we continue to build to enhance the medical care provided in our facilities throughout the Pacific Region.  Additionally, this early experience has allowed our facilities to compete for research dollars to further develop telemedicine and tele-mental health activities.

The Hui also provided support for TAMC projects, including support for store and forward telemedicine for adult and pediatric care to the Western Pacific, cardiac sonography from TAMC to Guam and Japan, intensive care unit telemetry and consultation from TAMC to Guam Naval Hospital and Korea, speech therapy and other projects. 

Beyond the Hui, VAPIHCS and TAMC are working together to develop joint telemedicine capabilities in American Samoa to support co-location of TAMC personnel at a VA CBOC.  This arrangement would extend clinical expertise from TAMC to American Samoa to serve Veterans and active duty service members, as well as members of the National Guard and Reserve who have experienced a traumatic brain injury (TBI).

Recently, VA expanded mental health programs, including significant growth in tele-mental health activities.  VA recruited a clinical psychologist to fill a new position for a dedicated tele-mental health coordinator based in Maui.  This new position expanded tele-psychology services equitably throughout the CBOC.  Additionally, VA has begun conducting tele-mental health Compensation and Pension (C&P) examinations to expedite the assessment of Veterans for appropriate benefits.

During fiscal year (FY) 2009, telehealth has been extremely helpful in delivering mental health services and dispensing medications to Veterans.  A snapshot of relevant data, current through July 2009, includes:
• Over 2,000 telehealth patient encounters in VAPIHCS, 1,300 of which were for mental health and 52 of which were for mental health C&P evaluations for patients in Guam or the Commonwealth of the Northern Mariana Islands; and
• Over 9,000 prescriptions filled at CBOCs on Kauai, Maui, Hilo, Kona, American Samoa and Guam using ADDS machines. 

VAPIHCS has other Telehealth services that are available to Veterans, including:
• Care Coordinated General Telehealth clinics (CCGT), which offer
o Individual and group psychology and psychiatry support;
o PTSD group research clinic;
o Individual and family nutrition information;
o Mental health C&P examinations;
o Geriatric psychiatry;
o General surgery and neurosurgery through the San Francisco VAMC;
o Treatment for spinal cord injury through the Palo Alto VAMC;
o Wound care;
o Nephrology care; and
o Participation in VA’s ‘MOVE!’ (weight loss) program;
• Care Coordinated Store Forward clinics (CCSF):
o Teledermatology through the San Francisco VAMC; and
o Teleretinal Imaging;
o Care Coordination Home Telehealth, utilizing home telehealth devices to support the care of Veteran patients in their own homes on Oahu, Maui and Hilo.
   
Our expanding and diverse experience with telehealth has provided many “lessons learned” to further shape the development of our VAPIHCS Telehealth Program.  For example, numbers (i.e. encounters) alone do not tell the complete story of how technologies may be used to improve the health care of Veterans.  In addition to increasing access to specialty services for Veterans, VAPIHCS has found telehealth technologies also allow CBOC providers to learn from telemedicine experiences (with distant providers), which can improve the skills of local physicians.  VAPIHCS continually evaluates the use of telehealth services that are provided to Veterans within our service area and changes the program as necessary to meet the needs of the Veterans we serve.  There is a new opportunity to expand the use of telehealth as we develop new outreach clinics to meet the needs of Veterans in highly rural areas.  

This increased "hands-on" care allows us to pursue new telehealth opportunities in even more remote locations to benefit Veterans.  We are providing more care in the home, using VA's Care Coordination Home Telehealth (CCHT) protocols.  This will provide us with patient data and information from the home that can be used to maximize our ability to manage medically complex patients in conjunction with our chronic disease team to improve the quality of life for Veterans.

There are some local challenges with telehealth.  We are adding additional staff, including telehealth nurses, to our sites so our clinics can both provide direct patient care and staff telehealth clinics as well.  We anticipate that by this fall, we will have sufficient support for telehealth activities at each CBOC in the area.

This table provides data about telehealth usage in the following facilities:
Number of Unique Patients by Site (VA Pacific Islands Health Care System)
Facility FY 2006 FY 2007 FY 2008 FY 2009 (YTD)
Honolulu 298 253 186 230
Maui 53 65 60 (includes Molokai 5) 272 (includes Molokai 17)
Kauai 70 71 73 100
Hilo 128 59 65 96
Guam 0 18 40 117
Kona 6 1 14 33
Am Samoa 0 0 0 7
TOTAL 555 467 438 855

The total numbers of VA’s patients using telehealth decreased in FY 2007 when VA received permission to begin sending patients to TAMC, rather than using telemedicine to support patient transfers to California.  Some of this change can also be explained in part by additional staff hires, particularly in mental health, at some of these facilities.  We anticipate a growth in telehealth in FY 2010 as dedicated telehealth nurses are added to our facilities this fall.

Oahu Facilities
VA operates the Spark M. Matsunaga VA Medical Center in Oahu, located on the campus of TAMC at 459 Patterson Road, Honolulu, HI, 96815.  The VAMC consists of the Ambulatory Care Center (ACC), a 60-bed Community Living Center (CLC) and administrative space (located in the E Wing of TAMC).  Additionally VA operates both a 20-bed acute psychiatry inpatient unit and a 16-bed PRRP within TAMC.  A Veterans Benefits Administration (VBA) Regional Office is co-located with VHA on this campus.  The Honolulu Vet Center is located nearby at 1680 Kapiolani Boulevard in Honolulu.

VA estimates the Veteran island population for Oahu in FY 2008 was 73,000.  In
FY 2008, 27,000 Veterans on Oahu were enrolled for care, and of these 14,070 received VA care (“users”).  The market penetrations for enrollees and users are 37 percent and 19 percent, respectively and compare favorably with rates within VISN 21 and VHA.

The average FTEE level on Oahu in FY 2008 is 468.  With this staff, VAPIHCS provides a wide range of outpatient services, including primary care, several medical subspecialties (e.g., cardiology, gastroenterology, geriatrics, nephrology, orthopedics, pulmonary and women’s health), mental health, and dental care.  In addition, VAPIHCS provides diagnostic services such as laboratory, echocardiography and radiology.  If Veterans require services not available at the ACC or CLC, VAPIHCS arranges and pays for care at TAMC, local community providers, or VA facilities in California; for those referred to a facility in California, VA can cover the costs of transportation if the veteran is eligible for beneficiary travel.

In FY 2008, VA facilities in Oahu recorded about 162,000 clinic stops.  In the face of increasing demand for primary care services in Honolulu, VAPIHCS unexpectedly lost the services of two primary care physicians, resulting in a large number of Veterans being placed on our wait list.  To address this need, we have identified potential replacements for our primary care provider vacancies and established several new primary care positions, including a physician solely dedicated to women’s health care and another for spinal cord injuries.  We believe these steps will eliminate our primary care appointment wait list by October 1, 2009.  In FY 2008, the combined average daily census (ADC) in the mental health ward was 11 and was 53 at the CLC.  VAPIHCS spent about $15 million for clinical services for Veterans at TAMC and another $30 million for non-VA care in the community.

VA Resources Available to the Hawaii National Guard
VAPIHCS has served the needs of almost 3,400 total Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans through July 2009, including 1,089 Hawaii National Guard members, 800 of whom reside on Oahu, with the rest residing throughout the Hawaiian neighbor islands.  Experience to date has shown that about one in four OEF/OIF Veterans avail themselves of VA enrollment and health care.   

VAPIHCS has a dynamic OEF/OIF Program led by a Program Manager who, along with three staff including two Care Managers and one Transition Patient Advocate, partner effectively with the Hawaii National Guard, the Army Reserve, and active duty military to serve the Veterans’ health care needs related to these organizations. 

These program staff members coordinate care and services for OEF/OIF Veterans and their families throughout the VAPIHCS.  Specifically, they ensure comprehensive preventive mental and physical health evaluations are performed, provide outreach services to Veterans who are not currently VA users, and assist in the case management of severely injured Veterans who require complex care.  VA program staff also work collaboratively with Army Wounded Warrior staff to coordinate care and services for these individuals.

VAPIHCS OEF/OIF staff members meet and communicate frequently with Hawaii National Guard leadership and exchange data and information about troop status, including force deployment and return.  VA is presently anticipating the health care needs from an estimated 1,158 returning members of the Guard during August 2009.

The program is also decentralizing its staff during this period of time, locating them on a full and part time basis as appropriate to work on military bases on Oahu including Ft. Shafter, Kaneohe Marine Air Station, Schofield Barracks, and with the Hawaii National Guard at Kalaeloa.  We expect that integrating VA staff with these military units will increase the visibility and level of service VA provides to individuals within these units and supports continued seamless transition activities between the organizations.
 
In addition, VA program staff members regularly attend and participate in Guard Post Deployment Health Assessment Screenings and Yellow Ribbon Events, organized for service members and their families.
 
As mentioned previously, VAPIHCS has the resources to provide members of the Hawaii National Guard quality primary and mental health care, and specialized medical care.  The PRRP, TBI and SCI team capability further enhances the services available to all Veterans.

Conclusion
In summary, with the support of the Senate Committee on Veterans’ Affairs and the Hawaiian Congressional delegation, VA is providing an unprecedented level of health care services to Veterans residing in Hawaii and the Pacific region.  VA has state-of-the-art facilities and enhanced services in Honolulu, as well as robust staffing on the neighbor islands along with expanded or renovated clinics in many locations.  VA continues to enhance its staff with added mental health providers and specialists to meet Veterans’ needs.  These services are also available to Veterans who are Hawaii National Guard members

VAPIHCS still faces several challenges including timely access to health care services (in part due to the topography of its catchment area and lack of an acute medical-surgical hospital), an aging Veteran population, and the special needs of our newest Veterans.  VAPIHCS will meet these challenges by working with DoD and community partners, activating an ambulatory surgery center, utilizing telehealth technologies, and opening new clinics as necessary.  I am proud of what VA has accomplished in Hawaii and the Pacific Islands region and look forward to our future endeavors on behalf of Veterans.

Again, Mr. Chairman, mahalo for the opportunity to testify at this hearing.  My colleagues and I would be delighted to address any questions you may have for us.