JAMES R. FLOYD, FACHE
NETWORK DIRECTOR, VA HEARTLAND NETWORK (VISN 15)
VETERANS HEALTH ADMINISTRATION
U.S. DEPARTMENT OF VETERANS AFFAIRS
COMMITTEE ON VETERANS’ AFFAIRS
UNITED STATES SENATE
NOVEMBER 5, 2009
Good Morning Mr. Chairman and Members of the Committee:
Thank you for inviting me here today to discuss the cooperation and collaboration between the Department of Veterans Affairs (VA) and its Veterans Health Administration (VHA) and the Department of Health and Human Services (HHS) and its Indian Health Service (IHS). Joining me today are Mr. W. J. “Buck” Richardson, the Minority Veterans Program Coordinator, Rocky Mountain Health Network and the Montana Healthcare System in Helena, Montana, and Dr. James Shore, Psychiatrist and Native Domain Lead, VA Salt Lake City Health Care System.
VA remains committed to working internally and in partnership with HHS to provide high quality health care for the thousands of American Indian/Alaska Native (AI/AN), and Hawaiian Native Veterans who have courageously served our Nation and deserve exceptional care. This commitment, in relation to AI/ANs, is principally fulfilled through VHA cooperation and collaboration with IHS. My testimony will provide general background information on our work with the IHS, review accomplishments secured because of our collaboration, and conclude with a discussion on the need for VHA and IHS to work together to take care of these Veterans. I would like to note at the outset that VHA looks forward to working with IHS to improve the quality and availability of care for Native American Veterans throughout the country. We will strengthen our existing partnerships and build new and even stronger associations between VHA and IHS.
VA and HHS signed a Memorandum of Understanding (MOU) on February 25, 2003. In summary, the MOU:
* Expresses the commitment of both Departments to expand our common efforts to improve the quality and efficiency of our programs;
* Provides policy support to local planning and collaboration; and
* Charges local leadership to be more innovative and engaged in discharging our responsibilities.
We expected at that time that most of our progress would be made with effective local partnerships formed between IHS, VHA, and Tribal governments, because these would be best suited to identify local needs and develop local solutions. In this regard, VHA field facilities have been encouraged to initiate and maintain effective partnerships at the local level especially in areas such as clinical service delivery, community-based care, and health promotion and disease prevention. We are also interested in promoting the management and prevention of chronic diseases, a challenge that confronts both VHA and IHS. We anticipated the MOU would lead to creative solutions in case management, home- and community-based care, and primary prevention activities to improve the health of AI/AN Veterans.
Whether success is achieved most effectively through the efforts of local partnerships or with a national mandate is assessed on a case-by-case basis. Both methods have been effective; the challenge is to use the appropriate tool, at the correct time, and in a suitable location. Many times, success is achieved with a combination of national and local efforts. We recently supported a collaborative expansion of home-based primary care (HBPC) that exemplifies how national initiatives can be implemented locally. In this effort, 14 VA medical centers have been funded to co-locate HBPC teams at Tribal and IHS clinics and hospitals. Our goals are to improve access to primary care services and to foster mentoring relationships between VHA staff with geriatric expertise and IHS and Tribal staff. In September, the first Veterans began receiving care through this project at two tribal sites, one in Jackson, MS and the other in Sacramento, CA. We expect the other facilities to be active by the end of the calendar year.
Much of the progress on the objectives outlined in the MOU has been accomplished through local partnerships. However national initiatives also influence collaboration between VHA and IHS. For example, a national focus on outreach and rural health has led VHA and IHS to develop improved strategies for sharing information and services such as educational resources, traditional practices, and information technology (IT) sharing.
Experts in information technology at the Department as well as the VHA and IHS levels are working together to enhance health-care information sharing. This April, representatives from the Office of Information Technology at IHS, VHA’s Office of Health Information, and VA’s Office of Information and Technology met to develop a comprehensive list of actions needed to strengthen the relationship. The group identified a list of specific activities for collaboration, and work continues to address the tasks identified on that list.
VHA and IHS, as the primary implementers, have used the MOU’s goals and objectives as a framework for establishing partnerships and accomplishing individual achievements. Our goals include improved access, communications, partnerships and sharing agreements, resources, and health promotion and disease prevention.
Access. A mutual goal of IHS and VHA is to improve beneficiaries’ access to quality health care and services. As a tool to ensure steady and effective progress, VHA established a performance monitor for Veterans Integrated Service Networks (VISNs) with significant American Indian/Alaska Native (AI/AN) populations to track and monitor how VISNs were achieving the goals and objectives of the MOU.1 Examples from the performance monitor reports of how VA’s local facilities have brought about easier access to VA services include:
* Establishing transportation programs;
* Using home visits to provide both clinical care and assistance with claims processing;
* Providing supplies and equipment to clinics on Reservations;
* Expanding VA community-based outpatient clinic hours and services; and
* Using fee basis care to facilitate more timely, accessible care, when necessary.
In fiscal year (FY) 2009, the Office of the Deputy Under Secretary for Health for Operations and Management established a new template for VISN semi-annual reporting of VHA/IHS activities. There appears to be steady, incremental expansion of certain types of initiatives across the country demonstrating an increased alignment with current national priorities. These initiatives include:
* Increased interest in, training for, and development of the Tribal Veteran Representative (TVR) role across the country;
* Expanded use of information technology and telecommunications efforts, particularly to support telehealth initiatives and tele-mental health;
* Increased number of “Welcome Home” events for Operation Enduring Freedom and Operation Iraqi Freedom Veterans, as well as education and outreach efforts;
* Steady expansion of rural health care initiatives with progress toward bringing services closer to the Veterans being served;
* Continued growth in culturally specific, holistic approaches that address the unique physical, spiritual, economic, age and gender specific needs of the population served; and
1 Four of the 21 VISNs are exempt from this monitor because of the small size of their AI/AN Veteran populations. These include VISNs 4, 5, 9 and 10.
• Coordinated efforts between local VHA and IHS entities to increase awareness and communication regarding Veterans’ needs and available VHA services, as well as cooperative and creative outreach efforts.
Another tool that VHA and IHS use to improve access is telehealth. Telehealth uses information and communication technologies to provide health care services in situations in which patient and provider are separated by geographical distance. Telehealth, thus, provides a means of providing health care services directly to Tribal communities, obviating the need for AI/AN Veteran patients to travel long distances to receive services. It also supplements health care services available within Tribal communities.
VA has been collaborating with the IHS and other federal agencies to provide telehealth services in Alaska since 1997, when the Alaska Federal Health Care Access Network began. Subsequent to that first effort, the functionality of the telehealth and telecommunications technologies has improved, and research has substantiated the benefits of telehealth as a means of providing health care to the AI/AN Veterans VA serves. Currently there are seven operational telehealth programs providing services to Tribal communities and nine programs in deployment. VHA telehealth programs to Tribal communities predominantly involve clinical video-conferencing to provide mental health services and home telehealth services for diabetes and mental health conditions.
A cultural competency training program also has been developed and is in use to ensure that providers are sensitive to the particular circumstances of using telehealth to reach into Tribal communities to deliver services. In addition to cultural awareness, other critical success factors to implementing and sustaining telehealth services to Tribal communities include adequate telecommunications bandwidth and meeting appropriate credentialing and privileging requirements.
Using shared providers is yet another way to improve access. At the local level, several VHA and IHS facilities are sharing providers, including appropriate shared access to VA’s electronic health records for joint patients; this is demonstrated through the partnership between VHA’s Black Hills Health Care System and the Rosebud IHS facility. Nationally, VA and IHS conducted a one-year pilot to test the feasibility of using VA’s electronic credentialing system, VetPro, to credential IHS providers. Both VA and IHS participants believed the pilot met its stated goals of ensuring a consistent credentialing process that met all regulatory and agency requirements for IHS facilities and demonstrating the feasibility of national sharing agreements for information sharing between VA and IHS. Decisions about expanding the pilot are pending.
Communications. There have been accomplishments in efforts to improve communications among VA, VHA, AI/AN, HHS, IHS, and Tribal governments and other organizations with assistance from IHS. Sharing information and improving cultural awareness and competencies are crucial to achieving this goal. Relevant information is shared through several methods, including:
* Participation at VHA/IHS conferences and VHA/IHS/Tribal Veteran Service Organization (VSO) meetings, as well as Pow Wows and local community events;
* Outreach to IHS organizations and Tribal Governments, including liaison with VA staff and leadership; and
* Attendance at AI/AN cultural events.
IHS and VA continue to have regular communications at the national level with a working group that meets regularly to exchange information and track the status of several national programs, such as a recent initiative to establish a pilot partnership between VHA’s Consolidated Mail Outpatient Pharmacy (CMOP) and IHS' pharmacy program. This pilot will enable IHS beneficiaries to have access to pharmacy services through VHA’s nationally recognized CMOP program to process outpatient prescriptions, based upon the electronic prescription data provided from the IHS facilities. The possibility of IHS decreasing capitalization costs, the reduction of needed space to house more drugs and personnel in a centralized space, reduction of outdated medications, and reduction in the numbers of patients entering IHS facilities on a daily basis will make the use of the CMOP programs an attractive technology for dispensing refills within the IHS. Rapid City, South Dakota and Phoenix Indian Medical Center are currently identified as the participating IHS locations. The coordinating CMOP is in Leavenworth, KS. The necessary service agreement is in place, and IT connectivity and testing have been accomplished. A formal interagency agreement (IAA) is being developed. The pilot will commence as soon as the IAA is in place. The working group ensures that projects such as this remain on track and also identifies other new collaborations that would lead to improvement of services.
The Tribal Veteran Representative (TVR) program is another example of developing and maintaining effective communications at the local level. This program uses volunteers who receive training on VA’s health care services and benefits to educate their Tribal members. The concept used in the TVR program has been quite successful. VA and IHS held several coordinated training sessions this spring for IHS Community Health Representatives and the Contract Health Service program to bring the TVR concept to them. The annual TVR training was held at the Naval Reserve training facility at Ft. Harrison, MT during the last week of April 2009. Seventy-two participants from VA, IHS, and different Tribal organizations attended. Also, in May, VISN 7 held a training session for VA's Transition Patient Advocates using the TVR model.
Partnerships and Sharing Agreements. Encouraging partnerships and sharing agreements among VA Central Office and VA facilities, IHS headquarters and IHS facilities, and Tribal governments in support of AI/AN Veterans has been an important to improving access. Local VHA facilities use sharing agreements and partnerships to operate clinics, provide social work, offer laboratory services, and make available other benefits. Again, the success of these projects depends on the strength of local relationships. Building a strong partnership or sharing agreement depends on fostering a trust relationship between the AI/AN community and VHA facility staff and leadership. Meeting the specific needs of a particular community is best done by fostering communications at the local level.
Resources needed to support programs for AI/AN Veterans include more than just funding projects and services. Time and staffing resources are essential elements to supporting these endeavors and helping AI/AN communities to identify needs, devise mutually agreeable solutions that meet local requirements, and implement projects effectively. In FY 2009, VA, through the Office of Rural Health, acknowledged the need for increasing resources in this area by funding specific projects and establishing a Native American Resource Center.
In October 2008, the Veterans Rural Health Resource Center-Western Region established a Native Domain, an infrastructure with a Native American focus. It is a national resource on issues related to health care for rural Native American Veterans. It conducts policy analysis, collects best practices, supports clinical demonstration projects, establishes collaborations with agencies and Native communities, and disseminates information about these populations.
Health Promotion and Disease Prevention. The final part of the official MOU goal and objective framework is to improve health promotion and disease prevention services to AI/ANs. This has been addressed at the local level with projects ranging from health fairs to diabetes prevention and other educational efforts.
Medical Care of Dual Eligible Veterans
VHA and IHS need to continue to work together to ensure, within current legal authority, that Veterans who are eligible for health care from both VA through VHA and HHS through IHS receive all needed care. VHA and IHS continue to discuss changing the existing policies and processes in regard to payment for Veterans’ health care. A resource sharing provision was included in the MOU to encourage the development of responsible sharing of services to meet the needs of patients and communities.
There are circumstances where VA, through VHA and its local facilities, contracts with or enters into sharing agreements with IHS, Tribal governments, or Tribal organizations to provide health care services to AI/AN Veterans. Many of these Veterans also are eligible for services from IHS or through Tribal governments or organizations. VA endorses the use of sharing agreements in these circumstances.
Thank you again for the opportunity to discuss the importance of establishing and maintaining strong relationships, programs, and services between VHA and IHS at both the national and local levels to effectively meet the health care needs of AI/NA. VHA is strongly committed to continuing to make VA health care services more accessible to AI/AN, and Hawaiian Native Veterans. In this regard, it may be time to update the MOU and identify additional opportunities for collaboration between VA, IHS, Tribal governments and organizations. We are ready to do whatever it takes to find the best ways to serve the needs of these Veterans. Thank you again for the opportunity to testify. My colleagues and I are available to answer your questions.
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