STATEMENT OF
LINDA HALLIDAY, DEPUTY ASSISTANT INSPECTOR GENERAL
FOR AUDITS AND EVALUATIONS
OFFICE OF INSPECTOR GENERAL, DEPARTMENT OF VETERANS AFFAIRS
BEFORE
COMMITTEE ON VETERANS’ AFFAIRS, UNITED STATES SENATE
ON
AVAILABILITY OF MENTAL HEALTH AND ORTHOPEDIC SERVICES
AT THE VA PACIFIC ISLANDS HEALTH CARE SYSTEM
IN MAUI, HAWAII
JANUARY 7, 2010

INTRODUCTION

Mr. Chairman and Members of the Committee, thank you for the opportunity to testify today on the availability of mental health and orthopedic services for veterans served by the VA Pacific Islands Health Care System (VAPIHCS), with special emphasis on the Island of Maui.  I will focus on the results of our recently issued report, Review of Availability of Mental Health and Orthopedic Services at the VA Pacific Islands Health Care System.  Accompanying me today is Mr. Walter Stucky, Audit Manager, Seattle Audit Operations Division, Office of Inspector General (OIG), Department of Veterans Affairs.

BACKGROUND
Veterans living on Maui and the other Hawaiian islands face similar issues as veterans living in rural communities throughout the country obtaining timely access to all services, especially mental health services and specialty care services such as orthopedics.  Not only has VAPIHCS faced difficulties providing the services, they have also been limited by the short supply of community health providers.

In May 2006, the OIG issued a report titled, Review of Access to Care in the Veterans Health Administration, which included an assessment of the timeliness of orthopedic surgeries at the VAPIHCS.  Because no related Veterans Health Administration or other American medical timeliness standards were available at the time, the review used a foreign orthopedic surgery timeliness goal of 6 months.  This standard was based on evidence that suggested that deterioration of patients' health occurs when they wait more than 6 months for joint replacement surgeries.  The OIG’s review found that the average wait for elective orthopedic procedures at the VAPIHCS was 182 days, with wait times for individual cases ranging from 14 to 379 days.

In November 2007, a task force commissioned by the State of Hawaii found that community mental health resources on Maui were stretched to meet increasing mental health needs resulting from veterans returning from Iraq and Afghanistan, an aging population, and prevalent drug use.  VAPIHCS is also challenged in recruiting staff especially on the outer islands due to the high cost of living, both for housing and commodities; high relocation costs; and a cost of living adjustment that is not comparable to locality pay rates used in the continental United States and is not used in calculating Federal retirement benefits.

RESULTS
In late May/early June 2009, we conducted onsite work in Honolulu and Maui at VAPIHCS, Veterans Integrated Service Network 21, Tripler Army Medical Center (TAMC), and the Maui Community Based Outpatient Clinic (CBOC).  We interviewed managers and administrative and clinical staff and reviewed scheduling and workload data, recruitment information, and other pertinent documents related to patient complaints and wait times.  We found that:

• Since fiscal year (FY) 2006, VAPIHCS has made significant strides in reducing wait times for elective orthopedic surgery procedures, most notably by hiring two orthopedic surgeons.

• Although VAPIHCS has experienced challenges in providing mental health services to veterans on Maui and the other outlying islands, it is effectively using VA’s Mental Health Initiative funding to recruit additional staff and expand telehealth services.

Orthopedic Care
Our recent work noted significant improvement in elective surgery wait times since
FY 2006.  Both VA and TAMC orthopedic surgeons evaluate and treat VAPIHCS patients requiring orthopedic care.  Because VAPIHCS is not fully staffed or equipped to perform orthopedic surgeries, surgical procedures are performed at TAMC by VA and TAMC orthopedic surgeons under an interagency sharing agreement.  If TAMC cannot accommodate a VA patient, VAPIHCS Utilization Management staff refers the patient to a community provider on a fee-for-service basis.

Our discussions with VAPIHCS clinicians and TAMC managers indicated that TAMC has sufficient staff and resources to consistently accommodate VA patients without significant delays, but that some patients prefer later surgery dates or they are not medically ready to undergo surgery on the scheduled dates.  Our review of 15 elective orthopedic surgeries performed at TAMC in April and May 2009 found significant improvement in average wait times.  The time between the decision to operate and date of surgery ranged from 11 to 210 days and averaged 82 days.  We attribute the improvement in timeliness to three factors:

• VAPIHCS officials hired two orthopedic surgeons—one in February 2007 and the other in October 2008.  Prior to hiring these surgeons, VAPIHCS relied on orthopedic surgeons from TAMC and other VA facilities in the continental United States to provide services.  With these recruitments, VAPIHCS has established its own orthopedic clinics at both the Ambulatory Care Center and CBOCs.  Furthermore, one of the orthopedic surgeons also performs surgery at TAMC.

• TAMC dedicated one operating room day each week to VA orthopedic patients, in addition to its normal integrated scheduling of VA and TAMC patients for surgery.

• VAPIHCS and TAMC have improved their coordination of orthopedic surgery care.  For example, TAMC provides VAPIHCS monthly reports on availability of services and holds monthly coordination meetings with VAPIHCS Utilization Management officials to resolve problems and improve services.  In addition, a VAPIHCS orthopedic surgery nurse tracks the status of VA patients scheduled for surgery at TAMC to ensure patients meet all pre-operative requirements. 

Mental Health
Mental health staff at the Maui CBOC told us that they have been meeting the emergency needs of patients; yet, they continue to acknowledge challenges ensuring timely follow-up care due to staff shortages.  For example, in May 2009, the psychiatrist reported that his earliest available follow-up appointment was 7 weeks away and that he often worked additional hours to see patients.

Despite these challenges, we found that VAPIHCS leadership has been proactive about securing funding through VA’s Mental Health Enhancement Initiative to hire additional staff at the Maui CBOC and expand telehealth capabilities to assist other CBOCs.  In the past year, VAPIHCS has received approximately $4.7 million in Mental Health Enhancement Initiative funding and has used a portion of this amount to improve the availability of services at the Maui CBOC by hiring additional staff.  In February 2009, VAPIHCS officials hired a mental health social worker.  In addition, a clinical nurse specialist and a second staff psychiatrist joined the CBOC in late July/early August of this year.  VAPIHCS leadership and clinicians told us that, with this additional staff, they expect to meet both the urgent and follow-up mental health care needs of veterans served by the Maui CBOC.

SUMMARY

Our review found that VAPIHCS leadership continues to identify gaps and improve availability of orthopedic and mental health services to veterans on Maui and the other islands.  However, as with any rural health care system, VAPIHCS leadership must make difficult choices as to how best to use its resources to most effectively meet the needs of veterans in a large, geographically diverse area, while also addressing difficulties in recruiting qualified health care professionals.

Mr. Chairman, thank you again for this opportunity.  We would be pleased to answer any questions that you or other members of the Committee may have.