STATEMENT OF
ALAN M. MELLOW, M.D., PH.D.
DIRECTOR, MENTAL HEALTH SERVICE LINE
VETERANS INTEGRATED SERVICE NETWORK (VISN) 11
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
AND
ASSOCIATE PROFESSOR OF PSYCHIATRY
UNIVERSITY OF MICHIGAN
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES

June 1, 2000

Mr. Chairman and Members of the Committee, I have been invited to discuss the Mental Health Service Line in Veterans Integrated Service Network (VISN) 11 and as it relates to the VA Northern Indiana Healthcare System (NIHCS).

Historical Background

A network-based approach to mental health services was prioritized soon after the formation of VISN 11. In 1996, a Mental Health Task Force was charged by the Network Director with examining the current provision of mental health care in our network and making recommendations concerning how it could be improved, consistent with the Veterans’ Health Administration’s six domains of value: Quality, Cost, Access, Satisfaction, Functional Outcomes and Community Health. That group recommended a sustained effort throughout all facilities within the network to develop a continuum of care for patients with psychiatric disorders, and specifically, consistent with current trends in healthcare, to move the sites of care from traditional inpatient settings to outpatient and community-based venues.

Implementation of these recommendations resulted in VISN 11, from FY 1996 through FY 1999, successfully reinvesting $12 million recouped from mental health and substance abuse inpatient program changes into alternative venues of mental health and substance abuse care for our veteran patients, allowing us to treat 20% more mental health patients with essentially the same level of expenditures. This has been achieved through a combination of enhanced outpatient programming, community-based case management, implementation of residential and partial hospital/day treatment programs and a variety of contractual agreements.

Mental Health Service Line

Although the changes mentioned above are significant, positive changes that are continuing, our reengineering efforts are far from complete. In order to sustain momentum in improvements in mental health care, the network leadership decided, in 1997, to plan for the development of a formal network-based Mental Health Service Line ( MHSL); along with a parallel effort in Geriatrics and Extended Care. The service line was initiated in October, 1998 with the establishment of a MHSL Board, and formally operationalized in March, 1999 with the recruitment of a full-time MHSL Director.

The strategy of the MHSL is to provide excellence in mental health services throughout VISN 11, by organizing all mental health care, education and research into an integrated delivery system with consistency in clinical practice, process and outcome measures and with a unitary budget and management structure, consistent with the strategic goals of the network. The network’s MHSL provides mental health care to approximately 30,000 veterans with expenditures of approximately $100 million, or 15% of the network’s appropriated budget. Within the network there are three academic Mental Health Services (Ann Arbor, Detroit and Indianapolis), where the bulk of the research activities in mental health are conducted, as well as training of new mental health professionals. In addition, educational and research activity occurs at the other facilities in the network. Long-term inpatient mental health care is provided at three facilities (Battle Creek, Danville and NIHCS). All facilities provide specialized treatments for patients with Post-traumatic Stress Disorder ( PTSD) and Substance Abuse Disorders, and all have developed enhanced outpatient programming over the past several years, including intensive case-management programs for patients with persistent, severe psychiatric disorders.

MHSL Initiatives

In the short time since the inception of the MHSL, the establishment of an organizational structure involving the mental health leadership at each facility has allowed for a sharing of information and best practices not previously achieved. In addition, several initiatives have been undertaken:

• A task force on PTSD has recommended the consistent implementation of interdisciplinary team evaluations for all patients with PTSD in the Network; implementation is ongoing.

• An advisory group on substance abuse has recommended and is now implementing the development of standardized functional outcomes measures for all patients with substance abuse disorders in our Network as well as a network-wide educational initiative in substance abuse.

• The service line has conducted an analysis of the mental health needs of veteran patients in the geographic areas surrounding the community-based outpatient clinics (CBOCs) in our network and is working with ambulatory care leadership to deploy mental health services to all CBOCs.

• A telepsychiatry initiative, involving consultations between medical centers in the network as well as to CBOCs will be implemented by the end of the current fiscal year.

• The MHSL has implemented a network-wide action plan to address network performance on the National Mental Health Program Performance Monitoring System (see below).

• The MHSL is currently developing a unified budgetary structure for mental health in the network.

In addition to its strategic focus, the MHSL provides operational leadership for mental health activities in the network, as well as consultation and advice to facility top management. For example, the service line organized the focused review of the recent patient assault incident at NIHCS.

Performance Improvement

The MHSL has achieved some quantitative performance improvement since its implementation:

• A 15% increase in the number of patients screened for Major Depressive Disorder in primary care clinics.

• A 10% increase in the number of patients receiving outpatient follow-up within 30 days after a psychiatric hospitalization.

• A 20% decrease in cost per capita for outpatient mental health treatment.

National Mental Health Program Performance Monitoring System

Since 1995, VHA, through the Northeast Program Evaluation Center ( NEPEC), has monitored its mental health programs on a variety of measures, covering the domains of population coverage, inpatient care, outpatient care, economic performance and customer satisfaction. NEPEC publishes a yearly report card, ranking each of the twenty-two VISN’s in VHA on these domains, with data available for each facility within every VISN. VISN 11 has ranked in the bottom quartile of this ranking since these reports became available. Although we have made significant progress in our rankings with respect to outpatient care, we have seen a decrement in our performance on measures of inpatient care, relative to the rest of VHA. We have made major changes in our inpatient care processes, but we have not moved as quickly as the rest of the system, leading to a drop in our ranking. In addition, our economic performance remains near the bottom of the system. Both of these are directly related to our long-term mental health activity.

Long-term Mental Health Care

One of the most challenging aspects of the Veterans’ Health Administration’s mission to provide modern mental health care to veterans involves the provision of long-term care to those patients with the most severe forms of psychiatric illness, such as schizophrenia, bipolar disorder, and dementia complicated by psychiatric disturbance. VA neuropsychiatric facilities throughout the country were established to provide long-term, inpatient care for the vast majority of these patients, often in hospitals isolated from the communities of origin of the patients. It is true that there are many veterans whose illness renders them so functionally disabled that they require permanent inpatient care. There is however, a growing body of evidence that many of these patients can be treated in outpatient, community-based settings, with better outcomes and more efficient use of resources. In order to develop plans for managing the resources for long term mental health care, the VA’s Serious Mental Illness Treatment, Research and Evaluation Center ( SMITEC) located in Ann Arbor was asked to conduct a preliminary review of these programs at Battle Creek, NIHCS and Danville. This information will be used to evaluate staffing levels and patterns of care, needed community-based services, discharge planning efforts and the number and types of VA programs.

Closing Comments

The challenges to our system to implement these fundamental transformations in our clinical care are enormous, and involve the development of new staff competencies, cultivation of community-based resources as well as a cultural change among dedicated staff. In our network we have made great strides in this transformation, but we have much more to accomplish. As one of the major mental health facilities in our network, NIHCS is critical to our mental health mission, but consistent with the standard of care at its founding, its focus has been long-term inpatient mental health care. Although this is and will continue to be an important part of our spectrum of mental health care, it is no longer the standard of care for many patients. We look forward to continuing to creatively channel the expertise of the NIHCS staff into these new forms of care, so NIHCS and VISN 11 can continue to provide first-rate mental health care for all of our veteran patients.