STATEMENT OF
DR. SUSAN PENDERGRASS
DIRECTOR, VA NORTHWEST NETWORK (VISN 20)
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
COMMITTEE ON VETERANS’ AFFAIRS
UNITED STATES SENATE
FIELD HEARING IN FAIRBANKS, ALASKA

FEBRUARY 17, 2010

Good Morning Senator Begich and Members of the Committee.  Thank you for the opportunity to appear before you today to discuss VA health care in the Northwest Network (Veterans Integrated Service Network (VISN) 20) and Alaska.  I am accompanied today by Mr. Alex Spector, Director of the Alaska VA Healthcare System (AVAHS). 

First, Senator Begich, I would like to thank you for your leadership and advocacy on behalf of Alaska’s Veterans.  During your tenure on the U.S. Senate Committee on Veterans' Affairs, you have consistently demonstrated your commitment to Veterans and to improving the care and benefits they receive.

Today, I will briefly review the VA Northwest Network and the Alaska VA Healthcare System.  I will also discuss several issues important to Alaskan Veterans, including telehealth, rural health outreach, and VA’s beneficiary travel program.

VA Northwest Network (VISN 20)
The VA Northwest Network (VISN 20) includes the states of Alaska, Washington, Oregon, most of Idaho, and one county each in Montana and California. Our 135 counties cover approximately 23 percent of the United States land mass.  Eighty-six (86) percent of our total counties are classified as medically underserved areas or containing medically underserved populations.

Our network of health care facilities is composed of 6 medical centers (including 2 complex care hospitals), 1 independent outpatient clinic (Anchorage), 1 rehabilitation center, 33 operational community-based outpatient clinics (CBOCs) or part-time outreach clinics and 2 mobile clinics.  Other services include 5 nursing home care units, 2 homeless domiciliaries and 16 readjustment counseling centers (Vet Centers), as well as 4 mobile Vet Centers operating in Washington, Idaho and Oregon.

Approximately 1,180,000 Veterans live in the Pacific Northwest and Alaska, 29 percent of whom received health care services from VA in fiscal year (FY) 2009.  Our medical centers currently operate approximately 1,655 inpatient beds, including acute medical/surgical, domiciliary, mental health, nursing home and rehabilitative care, and VISN 20 facilities recorded approximately 33,000 hospital admissions and 2.7 million outpatient visits in FY 2009.  VISN 20’s patient population has an average age of 60.8 years, and 46.6 percent of our patients are service-connected Veterans.  Approximately 9.5 percent of our patients are women.

The VA Northwest Health Network continuously strives to improve access, quality, patient satisfaction and wellness to better serve the Veterans of the Pacific Northwest.  Two of our health care systems have major academic affiliations and our Network hosts a significant number of Centers of Excellence, while also supporting a large and broad research portfolio that was funded in excess of $33 million last year.  We also have expansive and collaborative relationships with the Department of Defense (DoD), including two highly successful partnerships in Alaska.  

The VA Northwest Network has not only exceeded inpatient and outpatient satisfaction goals, but its employee satisfaction scores are also strong.  For each of the past several survey cycles, VISN 20 has received some of the highest scores in the country.  We recognize that employees who feel challenged and valued are more productive and healthier, and we continually strive to make VISN 20 an employer of choice.  For the second year in a row, VISN 20 ranked highest among networks for Diversity Acceptance.  Other top satisfiers included:  Type of Work, Coworkers, Senior Management, Work Conditions, Customer Satisfaction and Praise.

Given VISN 20’s large and diverse geographic nature (including rural or frontier lands and remote islands), access to care is a priority.  In FY 2010, the Network will activate five new sites of care in three states (California, Oregon and Montana).  In FY 2009, we also hired two new full-time employees to support Tele-Health and Rural Health efforts across the Network. 

Alaska VA Healthcare System
The Alaska VA Healthcare System (AVAHS) provides access to health care to eligible Alaskan Veterans through an integrated delivery system consisting of clinical care sites, joint venture DoD facilities and contract care.  By FY 2009 estimate, there were over 76,400 Veterans living in Alaska; 26,708 are enrolled in VA.  AVAHS has continued to increase the number of Veterans seeking health care, growing by 13.6 percent since FY 2005.  In FY 2009, AVAHS provided services to more than 15,000 Veterans; this consisted of 142,246 outpatient visits and more than 60,000 visits to private sector providers.  This latter effort amounted to approximately 38 percent of the FY 2009 budget for VISN 20.  AVAHS was home to 488 full-time employees in FY 2009 and received a five percent increase in its operating budget for a total of $118.1 million, with a 5.44 percent increase for FY 2010.

The AVAHS provides medical care to Alaska Veterans through VA clinics in Anchorage, Fairbanks, Kenai and Wasilla.  These cities are also home to VA Readjustment Counseling Centers, or Vet Centers, which provide counseling, psychosocial support and outreach to Veterans and their families.  AVAHS provides or contracts for a comprehensive array of health care services.  AVAHS directly provides primary care, including preventive services and health screenings, and mental health services at all locations.  AVAHS inpatient care is provided through the VA/DoD Joint Venture Hospital located on Elmendorf Air Force Base, as well as through a contract with Providence Alaska Medical Center in Anchorage.  Inpatient care in outlying communities is provided through purchased care from local hospitals.  AVAHS has hired specialists in general surgery, podiatry, orthopedics, urology, cardiology, ophthalmology, and inpatient medicine.  Specialists in dermatology and neurology travel from the Lower 48 and hold clinics at the Anchorage VA facility.  The Anchorage facility also has a small dental clinic and an audiology clinic.  Audiologists travel to VA CBOCs and Coast Guard clinics in Southeast Alaska to provide better and more convenient care to Veterans.

In addition, we provide care through two VA outreach clinics in Homer and Juneau, Alaska.  The Homer outreach clinic is an extension of the Kenai CBOC and serves Veterans once a week at the South Peninsula Hospital under a contract agreement for space and ancillary services.  The second VA outreach clinic provides care once a month under a sharing agreement with the Coast Guard in the Juneau Federal Building.  Currently, Anchorage-based primary care providers travel to Juneau to staff this clinic.  Additional space for the Juneau VA outreach clinic is currently under construction, and VA expects this will be completed by mid-summer.  The expanded space will allow for a full-time primary care and mental health staff and be operational on a daily basis.  AVAHS also is constructing a new replacement clinic in Anchorage that will offer expanded capacity.  It will be located just outside the Muldoon Gate entrance to Elmendorf Air Force Base, and it will be connected to the Third Medical Group Hospital by a secure, enclosed access point.  Access to the VA clinic will be outside the Air Force Security checkpoint, and the clinic is scheduled currently to open in May 2010.  VA has located its sites of care in areas of the state with the largest concentration of Veterans.  By the end of FY 2010, more than 88 percent of enrolled Alaskan Veterans will reside in a borough with a VA clinical presence. 

Area FY 2009 Vet. Pop. FY 2009 Enrollees % Veterans Enrolled
Anchorage 31,301  12,426  39.7%
Fairbanks  13,182  4,200 31.9%
Mat-Su  10,157  3,414  33.6%
Southeast  7,798  1,827  23.4%
Kenai  5,951  3,414  57.4%
West/SW Alaska  4,308  804  18.7%
Northern Alaska  1,144  112  9.8%
Kodiak  1,343  320  23.8%
Valdez/Cordova  1,259  337  26.8%

AVAHS also participates in one of nine nationally recognized VA/DoD joint ventures at the 3rd Medical Group (MDG), Elmendorf Air Force Base, and an Inter-Service Sharing Agreement with Bassett Army Community Hospital at Fort Wainwright.  If a Veteran requires care that is unavailable at an AVAHS clinic or a VA/DoD facility, VA refers the patient to the nearest VA facility, the VA Puget Sound Health Care System (VAPSHCS) in Seattle, WA, or contracts for care with a local provider.  VA is required by law to ensure such fee-for-service care is consistent with the care provided in the contiguous United States. 

AVAHS offers a comprehensive continuum of care for homeless Veterans.  VA provides outreach and a 50 bed Domiciliary for Homeless Veterans, along with programs in Compensated Work Therapy and Veterans Industries, Compensated Work Therapy Transitional Residence, and the Department of Housing and Urban Development-VA Supportive Housing (HUD/VASH) program in Anchorage.  This program expanded to Fairbanks in December 2009.  AVAHS also provides oversight for two grant and per diem programs awarded to the Salvation Army Adult Rehabilitation Program in Anchorage and the Rescue Mission located in Fairbanks.

Inpatient mental health services are provided through contract care in local community psychiatric facilities and hospitals, as well as specialized programs at VA facilities in the Lower 48.  There is an active contract nursing home program and other non-institutional care programs, including adult day care, respite, homemaker/home health aide, and skilled nursing.  AVAHS started a Home-Based Primary Care program in July 2009 that serves more than 60 Veterans within a 20 mile radius of the Anchorage VA Clinic.   

 
Access   
AVAHS exceeded VA’s national performance goals for primary care access in FY 2009.  Nationally, VA requires that 99 percent of Veterans will be scheduled within 30 days of the desired date for an appointment.  AVAHS has continually exceeded this measure, as less than 0.12 percent of Veterans waited more than 30 days in FY 2009.  In FY 2010, AVAHS has continued to exceed these standards.

For most of FY 2009, AVAHS was not meeting the national performance measure for mental health access.  VA’s national standards require prompt evaluation of new patients (those who have not been seen in a mental health clinic in the last 24 months) with mental health concerns.  New patients are contacted, within 24 hours of the referral being made, by a clinician competent to evaluate the urgency of the Veteran’s mental health needs. If it is determined that the Veteran has an urgent care need, appropriate arrangements, e.g., an immediate admission, are to be made. If the need is not urgent, the patient must be seen for a full mental health diagnostic evaluation and development and initiation of an appropriate treatment plan within 14 days.  Across the system, VA is meeting this standard 95 percent of the time.  However, AVAHS was not meeting this performance measure for most of FY 2009.  In response, AVAHS performed an analysis to identify barriers and conducted a systems redesign to remove obstacles and provide timely care for these patients.  After implementing these corrective action plans, AVAHS met or exceeded the measure for the last few months of FY 2009, and through January in FY 2010, 100 percent of new mental health patients are seen within 14 days of their initial evaluation and 97 percent of established mental health patients are seen within 14 days.

Telehealth
Coordinated Care Home Telehealth – AVAHS has an active Coordinated Care Home Telehealth (CCHT) program with 223 enrolled Veterans throughout the state.  Thirty-one (31) percent of telehealth users live in highly rural areas, 16 percent live in rural areas and 53 percent live in urban areas.  Veterans enrolled in the CCHT program receive a device that uses a standard phone connection to send information from their home to CCHT staff in Anchorage.  Types of information sent by patients include blood pressure, pulse, weight, blood sugar, and oxygen measurements.  Patients also answer health-related questions.  The CCHT registered nurse staff reviews the information on a daily basis and can identify early warning signs or “out of bounds” measurements before the patient even begins to be symptomatic.  Initially, CCHT was focused on working with Veterans with chronic diseases such as diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease or depression.  In recent months, however, AVAHS has explored uses of home telehealth to monitor other conditions such as post-traumatic stress disorder (PTSD), substance abuse and bipolar disorder.  Additionally, Veterans who are at risk of losing their independence are receiving special attention from CCHT care coordinators. 

Through the daily use of the home telehealth technology, Veterans are improving their ability to live in their own home safely, healthfully, and for a longer period of time.  CCHT results have been impressive.  Ninety-five (95) percent of CCHT users with diabetes have improved their blood sugar control and 93 percent with high blood pressure have improved blood pressure control.

Tele-Retinal Imaging - AVAHS implemented a tele-retinal diabetic screening program in FY 2009.  This program allows Veterans with diabetes to be screened for diabetic eye disease.  Images are captured at the Anchorage, Fairbanks or Kenai clinics and forwarded to analysts at the VA Puget Sound Health Care System for interpretation.  These analysts later forward a consultative report with recommendations back to the patient's primary care provider for implementation.  During FY 2009, 280 patients received these services, and through January FY 2010, 108 patients have been cared for through this technology.

Tele-Dermatology - AVAHS started a tele-dermatology program in November 2009.  This program employs technology to facilitate timely dermatology care to Veterans in Alaska.  Images of skin lesions are captured while the patient is in clinic. Those images, along with a request for consultation, are forwarded to the VA Puget Sound Health Care System for interpretation. There, a dermatologist writes a consultative report with recommendations and forwards this information to the primary care provider. Interpretations and recommendations are received within 24 to 48 hours. Thus far, 37 consults have been completed this fiscal year.

Tele-Mental Health – During FY 2009, AVAHS successfully recruited a psychiatric nurse practitioner for a new position as a tele-mental health provider.  Currently, a Tele-Mental Health Clinic is held with the Kenai CBOC by videoconference 3 to 5 days per month.  Approximately 60 unique patients are being seen through this clinic, and four to six additional Veterans are being seen each month.

VA will open a new Tele-Mental Health this month to connect Anchorage and the Fairbanks CBOC to allow a VA neuropsychologist to screen Veterans for traumatic brain injury (TBI).  A PTSD Tele-Mental Health Group Clinic was initiated on
January 7, 2010 by a VA psychologist/PTSD specialist for Veterans in the Anchorage DeBarr Clinic and the VA Domiciliary in mid-town (Anchorage).  As a result of the successful deployment within the city, AVAHS plans to expand this service to its CBOCs in the near future.  In addition, AVAHS has assembled a working group to explore the best method for expanding group counseling opportunities to its CBOCs.

AVAHS tele-mental health services have been offered to the Yukon-Kuskokwim Health Corporation (YKHC) in Bethel, AK.  A video-conference for staff consultation between Anchorage and Bethel has been held with educational and screening instruments shared.  YKHC has requested peer-to-peer consultation with VA professional staff as needed.  VA has visited both YKHC and Maniilaq Health Corporation in Kotzebue to educate local health care providers about AVAHS’ tele-mental health resources.

A recent VA presentation to the Alaska Federal Healthcare Partnership Telehealth and Technology committee resulted in positive contacts with staff from the Alaska Native Tribal Health Consortium, Bristol Bay Area Health Corporation, and Maniilaq Health Care Corporation.  This venue holds promise for spreading the message about
tele-mental health resources at AVAHS.

Rural Veterans
AVAHS has initiated several programs to meet the needs of Veterans living in rural Alaska, including:

Rural Veteran Liaison – This is a 3-year pilot program to hire a full-time VA employee to be a local community-based contact for VA questions on health care and benefits.  In June 2009, VA hired a Bethel-based liaison to perform outreach to the Yukon-Kuskokwim area.  AVAHS has continued to recruit for a Kotzebue-based position since December 2008 and recently added Nome to the recruitment announcement.  So far, there have been no qualified applicants for the position to cover the northern area of the state, but VA continues to advertise and respond to inquiries.

Rural Health Care Pilot Project – This project is a 1-year pilot program that began in August 2009.  The goal of the pilot is to enhance primary care for rural Veterans through contract care.  The pilot areas are the Bethel census area, Bristol Bay Borough, Dillingham Census Area, Nome Census Area, Northwest Arctic Borough, Wade Hampton Census Area, and the City of Cordova.  Under the pilot, Veterans may be authorized three primary care visits and two mental health visits within a 6 month period.  If the Veteran requires additional visits, the Veteran or health care provider may contact VA to request additional care as needed.  VA sent letters to 548 enrolled Veterans in the pilot areas inviting them to participate, and through January 2010, approximately 20 percent have enrolled and 10 have requested appointments (eight for primary care and 2 for mental health care).

Tribal Veteran Representative (TVR) Program – The TVR program uses local community volunteers to assist VA in reaching out to Alaska Native Veterans.  A TVR is an Alaska Native Veteran or recognized individual appointed by an Alaska Native health organization, tribal government, tribal council, or other tribal entity to act as a liaison with local VA staff.  The representative is a volunteer unless paid by the Alaska Native entity who selects the individual to represent them.  Collaborative training is provided by VA health care and benefits staff.  VA has completed two annual trainings, one in Anchorage and the other in Southeast Alaska, and as of January 25, 2010, 12 people have completed the TVR training. 

Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Outreach – AVAHS made special efforts to reach out to Alaska Native Tribal Health Consortium organizations upon the first major deployment of the Alaska National Guard in OEF/OIF.  A multi-disciplinary group of VA staff traveled to rural areas to provide education on PTSD, TBI, and Suicide Awareness and Prevention.  Audiences included providers, nurses, mental health staff, community health aides, behavioral health specialists, and village-based counselors.  In addition to the educational aspect of these sessions, VA staff and Alaska Native Tribal health staff focused on providing a pathway of care for each system to work together to ensure returning service members and other Veterans living in rural areas could seamlessly access their Alaska Native health benefits as well as access their benefits through the VA health care system.  The presentations on the pathway of care focused on the VA enrollment, eligibility, and fee authorization process to assist Veterans in accessing VA health care and how to bill for reimbursement from VA should their health corporation seek authorization to provide services to Veterans.  Packets of information with contact names and phone numbers were given to each participant, and information tables were staffed in community settings such as post offices, grocery stores, and community gatherings to raise awareness within the general community.

AVAHS has a signed a memorandum of understanding with the State of Alaska Department of Military and Veterans Affairs that outlines a partnership to work together to meet the needs of returning soldiers.  OEF/OIF staff members regularly attend Post Deployment Health Re-Assessment (PDHRA) events and Yellow Ribbon Reintegration Program events to deliver information about VA benefits to service members and their families.  AVAHS actively participates in pre- and post-deployment events for active duty service members.  VA also participates in outreach with the National Guard’s “Reconnection Veterans” program, which has a goal of sending its liaisons to all 237 villages in Alaska within a single year.  The Rural Veteran Liaison and OEF/OIF staff members have accompanied these liaisons on a number of trips to rural Alaska to provide information about various VA programs and benefits.

Beneficiary Travel
Beneficiary travel benefits are a limited benefit for Veterans who meet specific eligibility criteria outlined in federal statute.  In FY 2009, AVAHS spent $4 million for travel for Alaskan Veterans.  Types of travel include ambulances, cabs, wheelchair vans, mileage reimbursement, and air travel.  Approximately 50 percent of travel expenses were for airline tickets for travel within (77 percent) Alaska and to VA facilities in the Lower 48 (23 percent).  VA purchased almost 3,900 tickets at an average cost of $552 per ticket.

Veterans are eligible for beneficiary travel benefit if they:
– Are rated 30 percent or more service-connected;
– Are rated less than 30 percent service-connected, but only for travel in connection with treatment or care of their service-connected condition;
– Are receiving VA pension;
– Have an annual income below the maximum applicable annual rate of pension ($11,830 for a single Veteran); or
– Are traveling for a scheduled compensation and pension examination.

Conclusion
In summary, AVAHS has continued to increase access to meet the needs of Veterans residing in Alaska.  These have included not only clinical services but additional sites of care.  AVHAS has maintained a high performance rating in quality of care, access standards, patient satisfaction, and employee satisfaction.  Senator Begich, thank you again for the opportunity to testify at this hearing.  At this time, I am happy to answer any questions.