STATEMENT OF BRIAN G. STILLER
CENTER DIRECTOR TOGUS VA MEDICAL CENTER
AUGUSTA, MAINE
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE SUBCOMMITTEE ON HEALTH OF THE
HOUSE COMMITTEE ON VETERANS' AFFAIRS

April 21, 2008

Mr. Chairman and members of the Subcommittee, on behalf of the 1300 employees and 400 volunteers at the Togus Veterans Affairs Medical Center (Togus) in Maine, I thank you for this opportunity to discuss the care and services we provide to veterans in Maine.

Togus has experienced many positive changes in the delivery of healthcare services to veterans in Maine. One of the most significant changes has been an increase in numbers of enrolled veterans selecting Togus as their preferred choice for healthcare services and support. In 1999, total enrollment for healthcare was 19,000. Currently, 52,000 veterans are enrolled. Of those enrolled, 38,500 have received healthcare services.

I want to focus my remarks today on three key factors in the delivery of healthcare in Maine. First, I will speak on the challenge of providing access to care in a largely rural setting. Next, I want to share our progress in meeting the demands in the mental health area. Finally, I will conclude with remarks on our current efforts in serving the expanding female veteran population.

Community Based Outpatient Clinics
During the last two decades, Maine has experienced a remarkable and sustained shift in the delivery of healthcare services, particularly access to rural healthcare. Today, there are six full-service Community-Based Outpatient Clinics ( CBOC) in Maine. Five of six CBOCs have expanded more than once to meet increased demand. Our CBOCs are located in Bangor, Calais, Caribou, Lincoln, Rumford and Saco.

The new Bangor CBOC includes physical therapy, dental, optometry, radiology, part-time and limited specialty services as well as Compensation & Pension rating exams. Four of our six CBOCs now offer on-site phlebotomy services and all CBOCs have contracted locally for X-rays and immediate lab services. To minimize travel, tele-retinal imaging services are available at Caribou. VA recently changed the reimbursement rate from 11 cents to 28.5 cents per mile to help offset some of the travel cost.

CBOCs are an essential part of primary care and they provide preventive health services, health promotion and disease prevention programs, as well as mental health services. A part-time primary care access point is located in Fort Kent. To further provide care in rural or residential settings, Home-Based Primary Care teams operate out of Togus and Portland. These teams provide primary care and support services to veterans requiring short term care, as well as veterans seeking to maintain an independent living situation. New Home-Based Primary Care teams are authorized for Caribou and Lincoln. Recruitment for these new positions is ongoing.

Rural Health
VA recently instituted the Office of Rural Healthcare ( ORH) to specifically identify and address the needs and challenges of providing healthcare to veterans living in rural areas. ORH is leveraging rural health expertise from the public and private sectors and is currently working on several initiatives such as the Veterans Rural Health Advisory Committee, Veterans Integrated Service Network ( VISN) Rural Consultant Program and Rural Health Resource Centers. ORH recently completed an analysis of outreach clinics and a Mental Health and Long Term Care Plan. These initiatives are a few of the additional mechanisms to enhance effectiveness and efficiency of health care delivery to rural areas including Maine.

Affiliations
Togus continues to enhance existing affiliations with state and national medical education facilities as well as establishing new affiliations. We see the need to help grow and nurture the medical educations of students in Maine, to encourage them to stay and to practice rural healthcare. To that end, Togus is working with the Maine Medical Center, a private facility in Portland to provide clinical positions for Maine medical students attending Tufts University for their rotations or residency. Similarly, Togus is working with the University of Southern Maine for nurse practitioner students and the University of New England for physician assistant and pharmacist students. As Husson College institutes its new pharmacist program, Togus will offer training opportunities to those students. Similar training opportunities are currently available for other clinical disciplines such as dental, psychology, social work, and nursing. In October 2008, we plan to host a "Medical Education and Research" symposium for medical education, healthcare and research organizations.

Additional Initiatives
Togus continues to be a leader in health care by identifying and employing new technologies such as the latest improvements in home healthcare monitoring. Maine recently received a $25 million Federal Communications Commission grant to develop telemedicine services throughout Maine. Togus is coordinating with other Maine healthcare organizations to determine how best to further deploy and utilize this healthcare technology.

Currently, over 150 veterans receive adjunct care via home telehealth using a variety of devices. VA staff use these devices to review medications, assess wounds, complete psychosocial assessments, conduct follow-up reviews for medication changes and determine if there are changes in health status when medications are changed. Areas of focus are primary care, Spinal Cord Injury, specialty or acute care and patients discharged from inpatient medical or mental health units. These devices provide timely, accurate data to allow providers to provide some health care remotely while minimizing veteran travel.

Mental Health
I'd now like to share with you some of our accomplishments and successes in the mental health area. Togus Mental Health Service saw sustained growth in the number of unique veterans served from 4,230 to 5,854 - a 38 percent increase from FY 04 to FY 07. Through the VA Mental Health Initiative process, during the same period, our mental health staff grew from 54 to 74, an increase of 39 percent. With additional staffing, we are able to care for the increased number of veterans and develop new programs and areas of treatment. New services include an opiate substitution (buprenorphine) treatment program, a Suicide Prevention program, a recovery program, our first Grant and Per Diem homeless facility, an integrated mental health and primary care team located in the primary care area at the Togus campus, three new clinicians for our Post Traumatic Stress Disorder ( PTSD) Clinical Team and a vocational rehabilitation staffer for a supported employment program. Care for veterans in rural Maine improved with all of our northern CBOCs having telemental health connectivity and many having in-home video phone connections. All Maine CBOCs now have on-site specialized mental health providers. There are two VA mental health clinics located in Bangor and Portland.

To better serve combat veterans returning from Iraq or Afghanistan, Togus reorganized its PTSD program into a one week intensive outpatient program that uses a new evidenced based treatment approach: Acceptance and Commitment Therapy. With clinical experience in that area, we were asked to be consultants to the national roll-out of Acceptance and Commitment Therapy for VA. This program focuses on the needs of new veterans who have careers, families and cannot attend a longer program. This program provides the basis for follow-on care in another PTSD class and individual or group treatment as well as a dual diagnosis treatment. This new program has been very well received by Operation Enduring Freedom/Operation Iraqi Freedom ( OEF/ OIF) veterans with favorable feedback. Moreover, two programs were conducted solely for women veterans to appropriately support their needs.

We are striving to provide more intensive or specialized mental health care and residential support for veterans in rural areas, particularly veterans who are homeless, who are in extended treatment for PTSD, or who have substance abuse problems.

Partnership with Vet Centers
PTSD treatment is readily available at Togus VAMC, six CBOCs, two mental health clinics and all five Vet Centers located in Bangor, Caribou, Lewiston, Portland and Sanford. Togus works in partnership with the five Vet Centers to provide mental health services to combat veterans throughout the state. Maine's Vet Centers have outreach locations to provide mental health services to more rural locations.

Special Need Population
Design is nearly complete and construction will begin this fall on the relocation and expansion of our 16 bed inpatient psychiatry unit. The new unit will have 24 beds, with special care areas for geriatric veterans and those more acutely ill. These improvements will ensure care is provided in accordance with latest industry standards to minimize risk and ensure safety for this vulnerable patient population.

Women Veterans
Women comprise about 14 percent of active duty Guard and Reserve forces. The ratio of enrollment for female to male veterans has increased over the last decade. In FY 2007, women comprised 5.2 percent of all veteran users nationwide and it is projected the percentage will increase to 8.1 percent of all veteran users by 2011. Approximately 42 percent of OEF/ OIF women veterans are enrolled for VA healthcare services and 28.5 percent used VA healthcare services in 2007. Of these, 78.5 percent were under the age of 40, which presents new challenges in addressing their unique healthcare needs. In Maine, there are approximately 1700 women veterans receiving VA healthcare.

VA is committed to identifying and meeting the various needs of women veterans of all ages and at all levels. Togus' women's clinic provides primary care, gynecology and mental health services and a bone densitometer to screen for osteoporosis. Maternity care is provided via Fee-Basis by a community provider of the veteran's choice. Mammography is provided via Fee-Basis at any FDA-approved site near the veteran's home. VA has two Performance Measures which are specific to women's health: breast cancer screening and cervical cancer screening. In both of these measures, Togus exceeded the national benchmark. All veterans are surveyed with a clinical reminder regarding Military Sexual Trauma and dedicated treatment services are available through Togus and its various clinics, Vet Centers or Fee-Basis as appropriate.

We plan to purchase additional equipment to expand care to women veterans this year. VISN 1 primary care is evaluating women's healthcare educational and equipment needs at CBOCs with the goal of providing increased access to routine healthcare that is gender specific. Togus has a dedicated Women Veterans Program Manager who is also the Lead MVPM for VISN 1. To enhance outreach efforts, Togus hosts an annual Women Veterans Information Fair and provides a site for Women Veterans of America meetings.

Mr. Chairman, to better serve Maine veterans, we must continue to closely monitor and meet their needs. America's veterans have earned the best care we can possibly provide and it is our privilege to provide them with the highest levels of customer service. We appreciate your interest and support in helping VA to successfully accomplish our mission of providing world-class care to all those who have so honorably served our great country.