STATEMENT  BY
LYNN M. AYLWARD-BINGMAN, CAPT (NC) USNR (RET)
MEMBER, VETERANS ADVISORY COUNCIL
TO THE
VETERANS AFFAIRS PACIFIC ISLANDS HEALTH CARE SYSTEM (VISN 21)

BEFORE
THE SENATE COMMITTEE ON VETERANS AFFAIRS

REGARDING
THE STATE OF VA HEALTH CARE IN HAWAII
January 9, 2006
Lihue, Kaua'i, Hawaii

Chairman Craig, Ranking Member, Senator Akaka, and Members of this Hearing:   I am Lynn Aylward-Bingman.  I am a retired US Navy Nurse Corps Captain. Among other duty stations, I served at the Naval Hospital Guam in 1968 - 1969 caring for the air-evaced wounded from Viet Nam.  Subsequently, while stationed in San Diego, I received my law degree and was a trial attorney for 23 years.   I became involved with the Hawaii Veteran community when I came to Kaua'i, from California, nearly five years ago.  I am proud to represent our veterans as a member of the Veterans Advisory Council to the VA Pacific Islands Health Care System.  In that capacity, my colleagues and I communicate to, and address, concerns of our Hawaii veterans with the Director of the VAPIHCS and the Regional VISN Director.  We also liaison with the individual Island Veterans Councils.  I am honored to speak on behalf of our veterans, particularly the Kaua'i veterans, at today's hearing, and to express some of our concerns with the state of veterans' health care in Hawaii.

The citizens of Hawaii are the most patriotic and generous people I've ever known. This is exemplified by the fact that there are several Medal of Honor recipients among our Hawaii veteran community; and by the spirit of ?ohana,? which is particularly strong in our veteran community.  The ohana spirit is very important given the unique disparate and geographic nature of our Islands and the Pacific Region.  It is far more difficult for our veterans to obtain full health care services than it is for our fellow veterans on the Mainland.

We are very proud of the strides that have been made by the VA in Hawaii over the last few years, especially those on the Outer Islands such as establishment of Community Based Outpatient Clinics or ?CBOCs?.  Our Kaua'i CBOC staff are outstanding and do their best to provide a high quality of care to our veteran patient community.  However, they are limited in the care they can provide by limited funding.  We lack  ?on Island? VA specialists, certain equipment, and adequate staffing, among other things.  There are three areas of concern I would like to address today.

Specialized treatment/surgical care:
At present, when a veteran needs specialized care for a cardiac, orthopedic, or serious dermatologic condition, for example, one of three situations will occur after being evaluated by our CBOC staff.   The veteran will either: a) be flown to Honolulu to see a specialist; b) have to wait several months to get an appointment with one of the specialists who come to the CBOCs intermittently; or c) obtain authorization to be seen by a local health care provider in the community.  Telemedicine greatly assists our CBOC staff in evaluating some health issues, but does not eliminate the need for the veteran to actually be seen and treated by a specialist.  Each of the above scenarios costs the VA money and, in the first two, also costs the veteran valuable time.
We recognize that it is not practical, nor possible, to have a full complement of specialists on each Island to see veterans when needed.  However, it is also not acceptable to have to wait months, in pain, before a veteran is seen by a specialist who only comes to Kaua'i for a single day once every three or four months.  Nor is it acceptable to wait several months before the veteran is flown to the Mainland for hip replacement surgery.

When a veteran is flown to the Mainland for surgery, more problems are created.  First the VA incurs the transportation costs.  Second a sick or disabled veteran is forced to travel alone to a location where he, or she, has no friends nor family support, and undergo, again alone, what is frequently serious or even life threatening surgery or treatment.  Following the surgery or treatment, the veteran then travels alone again to return home.  He is not followed by his surgeon, nor is his post operative care or recovery monitored, or modified if needed, by anyone who actually did the surgery.  This is far from optimal care and, in some instances, would be considered negligent.  If post operative problems occur, other healthcare providers, who have no first hand knowledge of the surgery, are involved in the veteran's care.  The more providers involved, the greater the chance recovery problems will arise.  Additionally, it doesn't make good medical sense, or good care, to expect a person who has just been through major surgery to travel long distances.  Just navigating a large airport these days is stressful to a healthy person.

One solution to this problem, and to obviate the VA incurring the costs of the local health care provider on a fee basis, is to increase and implement more long term arrangements with the local healthcare providers on Kaua'i, and the other Islands.  Through the use of  Memoranda of Understanding (MOU), or other long term contracts, more veterans could receive care locally, at a reduced cost to the VA.  This would also benefit the veteran in that he would not have to leave his home Island, or family, for surgeries.  It would also improve the overall quality of the care rendered as the veteran's progress would be monitored by the provider preforming the surgery.  If adequate facilities exist at Tripler, another alternative is for the VA to hire board certified specialists who can treat and/or perform surgery on veterans as inpatients at Tripler.

Funding for the VA needs to be significantly increased to meet the increased demand for care, not just by our older veterans, but also to ensure that good care is available to our service men and women who are, and will be, returning from the middle East.  We also want to ensure that the VA obtains maximum value for the monies budgeted for healthcare.  MOUs with local providers will help accomplish this goal.

Staffing:
Interrelated with the above is our concern that the CBOCs have sufficient staff.  Adding another physician would allow for more diagnostic evaluations to be done ?in house.? In turn, some of the fee based costs incurred by the VA for referrals to local providers would be eliminated or, at least,  reduced.
At present, we still have a need for at least one more clinic staff, preferably an LVN or person certified to draw blood.   The Kaua'i CBOC does have a part time person who is in the clinic three days a week to draw blood, and collect other specimens, which are then sent off Island for processing.   Obviously, this creates a delay in getting results, and in treatment when indicated.  It also requires a return visit by the veteran if they come on a day the ?lab? person isn't there.  Emergency laboratory work is done locally on a fee basis.  Again, use of an MOU would be useful in reducing the costs to the VA.

The individual who does the tele-medicine support at the CBOC is, inaccurately, ?counted? as Kaua'i CBOC ?staff;? but is, in fact, a Honolulu staff person who could be recalled at any time.  If any one of the current staff become ill, or are even on vacation, it creates an immediate staff shortage.  The Kaua'i CBOC staff is very devoted to providing optimal care to the veterans they serve, and they do an excellent job.  However,  insufficient staff translates into delays for patients, and the inability to see more patients.

One problem with determination of staff needs is that an outdated model, based solely on the numbers of patients, is utilized to assess physician, nursing, and support staff needs.  Our CNP not only sees patients and assists our physician.  She also is responsible for all the patient education, supervision of the staff, dispensing medications, doing follow-up phone evaluations and many other duties.  However, the CBOCs needs for additional nursing personnel are based only on the number of patients she sees.  All the other hours she expends on the care of our veterans, including preventative care through education, are not counted.  The methods used to evaluate the healthcare needs and, hence, determine the amount of funds needed and allocated requires immediate revision and updating.

Of equal import is the long time need for a Home Health nurse.  Monies for this position were budgeted and approved; but the monies were utilized for other health care matters.  However, the need for a Home Health care nurse still exists.  Hawaii, and the Pacific Islands in general, have significant numbers of elderly veterans.  Many of these veterans have reached the age when they can no longer drive or tolerate the trip from their homes to the CBOC.  The obligation to these aged veterans cannot be ignored or forgotten.  Once again the inability to meet these healthcare needs is due to lack of adequate funding to provide these services. Long term care facilities are non existent, but greatly needed, for Kaua'i veterans.  Similarly, Kaua'i's homeless veterans are in need of attention.  Extension of the O'ahu outreach and other programs, even on a part time basis, is needed.

Funding:
As noted at the outset, VA Pacific Islands Healthcare System encompasses a vast, and disparate, geographic area.  The very composition of the System mandates additional monies be allocated for rendering health care, and other, services simply to meet the costs of transportation and the necessity of utilizing community resources more frequently than a similar Mainland veteran population.  Our healthcare providers primary goal is to render quality care for our veterans.  Although some increases have occurred, the VA budget is still seriously short of it's needs.  Providers are doing the best they can, but cannot work miracles...with limited staff, resources and equipment, the care rendered is also limited.

On behalf of the veterans we represent, I thank the Members of this Committee for the time you have taken to hold these hearings and listen to the concerns of our Islands.  Your efforts and commitment to our Veteran community is greatly appreciated.  Mahalo, and Aloha,
Lynn M. Aylward-Bingman