STATEMENT OF THOMAS L. GARTHWAITE, M.D.
UNDER SECRETARY FOR HEALTH
VETERANS HEALTH ADMINISTRATION
BEFORE THE
SUBCOMMITTEE ON HEALTH
COMMITTEE ON VETERANS' AFFAIRS
U. S. HOUSE OF REPRESENTATIVES

June 20, 2001

Mr. Chairman and Members of the Subcommittee:

The Department of Veterans Affairs ( VA) provides mental health services for veterans across a continuum of care, from intensive inpatient mental health units for acutely ill persons to residential care settings, outpatient clinics, Day Hospital and Day Treatment programs, and intensive community care management programs. VA views mental health as an essential component of overall health and offers comprehensive mental health services, including programs for substance abuse, as part of its basic benefits package.

In FY 2000, the Veterans Health Administration ( VHA) treated 678,932 unique veterans in a comprehensive array of mental health programs. This represents a 1.1 percent increase from the previous year. Only 11.2 percent of these patients required an inpatient stay, demonstrating VHA emphasis on providing care in the least restrictive, most accessible way that meets patients' needs. The clinical care costs for these services was $1,659,709,000. For FY 2001, it is estimated that VA will treat 687,000 unique patients at a cost of more than $1,735,000,000.

This statement describes VHA mental health clinical services, education and research initiatives, program monitoring efforts, and special programs for homeless veterans.

Clinical Care Services

Treatment for mental disorders in VA rests essentially on two main approaches, pharmacotherapy and psychosocial rehabilitation (including psychotherapy). It is our practice to provide the latest medications for mental disorders to veterans who need these drugs and to prescribe them in accordance with the latest medical evidence. VHA formulary for psychotropic medications is one of the most open in organized health care. It includes virtually all the newer atypical antipsychotic and anti-depressant drugs. In virtually every instance, medications alone are not enough to bring patients with serious mental disorders to their optimal level of functioning and well being. The application of psychosocial rehabilitation techniques, designed to optimize patients' strengths and correct behavioral deficits are essential. These interventions include patient and family education, cognitive and behavioral training, working and living skills training, and intensive case management. Treatment settings are both inpatient and outpatient settings and can include supervised living arrangements in the community.

VHA clinical services are increasingly being structured to accommodate mental health participation in medical and geriatric primary care teams and medical capabilities in mental health primary care teams. An informal survey has identified over 30 VA facilities with mental health primary care teams. In FY 2000, a multidisciplinary task force of mental health, primary care, and geriatric clinicians identified examples of program criteria and best practices in mental health, primary care, and geriatric integration. Twelve sites were identified as best practice models based on criteria that included patient clinical improvement, prevention, screening activities, and patient satisfaction. Innovative uses of technology such as tele-mental health are also being implemented to enhance mental health services to distant sites (e.g., CBOCs) and provide psychiatry support to Veterans Outreach Centers. By disseminating information about best practices across the system, program development will be encouraged, and higher quality, more cost-efficient care will be delivered to VA patients. Also, FY 2001 strategic plans for several Networks include plans for expansion of mental health capabilities in new or existing CBOCs.

VA has identified several particular target populations and has developed special emphasis programs designed to serve those populations. They include veterans with serious mental illness (e.g., those suffering from schizophrenia); the homeless veterans with mental illness; veterans suffering from Post-traumatic Stress Disorder ( PTSD); and those with substance abuse problems. A significant percentage of all veterans receiving mental health services are seen in the following special emphasis programs.

Serious Mental Illness

Preliminary data prepared for the FY 2000 Capacity Report on seriously mentally ill ( SMI) veterans identify $1.9 billion spent treating 290,819 SMI veterans at a cost of $6,551 per veteran. Since 1996, the number of SMI veterans seen has increased by eight percent while the cost has decreased by eight percent, primarily reflecting decreased hospital days of care.

Since 1996, the average length of stay for general inpatient psychiatry decreased from 29.9 to 16.7 days nationally, and the average number of days of hospitalization within 6 months after discharge (reflecting readmissions) dropped from 12.4 to 6.8. The percent of discharged patients receiving outpatient care within 30 days of their discharge has increased from 50 percent in FY 1996 to 60 percent in FY 2000. These indicators suggest more effective hospital treatment and aftercare. A 33 percent decrease in the number of general psychiatric patients hospitalized since FY 1996 was accompanied by a 22 percent increase in general psychiatric patients receiving specialized mental health outpatient care, resulting in a net increase of 22.5 percent of individual veterans treated in specialty mental health. These data suggest an effective move from inpatient to community-based mental health treatment nationwide.

VA has committed itself to expanding state-of-the-art treatments of serious mental illness, using the Assertive Community Treatment ( ACT) model. VA now operates one of the largest networks of ACT-like programs in the country, the Mental Health Intensive Care Management ( MHICM) program. As of June 2001, VA has 54 active MHICM programs with another 10-12 in various stages of development. All VISNs have submitted plans for expansion of MHICM teams, which are under review.

Another aspect of VHA care for the seriously mentally ill is our commitment to using state-of-the-art medications, which result in improved clinical outcomes, decreased incidence of side effects, and increased compliance with prescribed medications. Patient functioning and patient satisfaction are increased. In the last quarter of FY 1999, two-thirds of all new prescriptions were for the new generation of atypical antipsychotic medications such as olanzapine, clozapine, and risperidone.

Homeless Veterans

VA operates the largest national network of homeless outreach programs. VA expects to spend $142.2 million on specialized programs for homeless veterans this year and is projecting a budget of $148.1 million for these programs in FY 2002. In FY 2000, VA initiated outreach contact with 43,082 veterans. VHA Health Care for Homeless Veterans ( HCHV) program incorporates:

• outreach to serve severely mentally ill veterans who are not currently patients at VA health care facilities;

• linkage with services such as VA mental health and medical care programs, contracted residential treatment in community-based halfway houses, and supported housing arrangements in transitional or permanent apartments; and

• treatment and rehabilitation provided directly by program staff.

These activities serve not only to help homeless veterans; they play a role in de-stigmatizing mental illness in the homeless population. Attachment A to this statement further describes VHA homeless programs.

Secretary Principi recently announced his decision to establish a VA Advisory Council on Homelessness Among Veterans with the mission of providing advice and making recommendations on the nature and scope of programs and services within VA. This Committee will greatly assist VA in improving the effectiveness of our programs and will allow a strong voice to be heard within the Department from those who work closely with us in providing service to these veterans.

Post-Traumatic Stress Disorder

VA operates an internationally recognized network of 140 specialized programs for the treatment of PTSD through its medical centers and clinics. In addition, 11 new specialized programs were funded from the Veterans Millennium Health Care and Benefits Act and will become fully operational in FY 2001. In FY 2000, VA Specialized Outpatient PTSD Programs ( SOPPs) saw 53,192 veterans, an increase of 5.4 percent over the previous year. Of these, the number of new veterans seen was 22,607. For SOPPs, the outcome of continuity of care was consistent between FY 1999 and 2000.

Specialized Inpatient and Residential PTSD Programs had 5,106 admissions in FY 2000. Overall inpatient PTSD care is declining while the alternative, residential care, is increasing. Outcomes for Specialized Outpatient PTSD programs (e.g., Continuity of care) and for Specialized Inpatient PTSD Programs (e.g., PTSD symptoms at four months post discharge) have been maintained or improved in FY 2000.

These specialized Mental Health PTSD programs act in collaboration with VHA 206 Readjustment Counseling Service Veterans Outreach Centers. These community-based operations are staffed by a corps of mental health professionals, most of whom have seen active military service, including combat.

Substance Abuse

In FY 2000, 366,429 VA patients had a substance abuse diagnosis. Of these 131,890 were seen in specialized substance abuse treatment programs. The numbers of veterans receiving care for substance abuse disorders as inpatients is decreasing, as part of the shift to outpatient care. Studies show that residential and outpatient substance abuse treatment can be as effective as inpatient services. To accommodate this shift, services are increasingly being developed on a residential and outpatient basis. From FY 1999 to 2000, VA saw a decrease of 7.8 percent in the number of veterans treated in its in-house specialized substance abuse programs. At the same time, a number of networks instituted contracts for residential substance abuse treatment services. Consequently, VA has begun a process to determine where these veterans are now being treated and the adequacy of that treatment.

Public Law 104-262, the "Veterans Eligibility Reform Act of 1996," requires VA to maintain its capacity to meet the specialized treatment and rehabilitative needs of certain disabled veterans whose needs can be uniquely met by VA. Mental health encompasses two of the designated populations: severely, chronically mentally ill ( SMI) veterans and veterans suffering from post-traumatic stress disorder ( PTSD). As part of its monitoring of the capacity of SMI programs, VA tracks its capacity for treating homeless mentally ill veterans and veterans with substance abuse disorders.

From FY 1996 to FY 2000, VA has maintained or increased capacity to treat veterans in both the SMI and PTSD categories in terms of patients served. Although overall capacity has increased, there has been a decrease in the number of veterans with substance abuse served in specialized programs by the system as a whole, from 107,074 in FY 1996 to 94,603 in FY 2000. In addition to this apparent loss of treatment capacity for substance abuse, there are also system-wide variations in the capacity to provide specialized treatment services to veterans for the other categories as well as in substance abuse. VHA is currently conducting a detailed review of specialized mental health treatment programs, to determine if the apparent loss of substance abuse treatment capacity is due to counting errors or to actual loss of services. This review will also address the quality of care provided to patients with the target diagnoses (e.g., PTSD, Substance Abuse Disorders) both within specialized VHA treatment programs and outside of these programs. We expect the results of this review to be reported in April 2002.

Program Monitoring

To track its progress and enhance its performance in mental health services, VA has one of the most sophisticated mental health performance monitoring systems in the nation. To monitor the care provided to over 670,000 veterans per year, VA uses measures of performance, quality, satisfaction, cost, and outcomes. The results published annually in VHA National Mental Health Performance Monitoring System report indicate that care is improving. Lengths of inpatient stay are decreasing as are readmission rates and days hospitalized after discharge. Outpatient visits after discharge are increasing, as is continuity of outpatient care. However, development work is continuing to improve the outcome measures for mental health care.

The Seriously Mentally Ill Treatment Research and Evaluation Center (SMITREC) has created a Psychosis Registry, a listing of all veterans hospitalized for a psychotic disorder since 1988. This registry tracks the health care utilization and outcomes of these veterans over time. Over 70 percent of these veterans are still in VA care.

To support its mental health programs and to ensure acquisition of the most current knowledge and dissemination of best practices, VA has undertaken a number of activities. These include development of practice guidelines, educational programs, and partnering with other organizations involved in mental health services.

VHA has also published up-to-date, evidence-based practice guidelines for major depressive disorders, psychoses, PTSD, and substance use disorders. The International Society for Traumatic Stress Studies used VHA PTSD guidelines as a start for their guideline development. Recently, the major depression guidelines have been revised in collaboration with the Department of Defense ( FY 2001). A new "stand-alone" Substance Abuse guideline created with DOD is in final stages of development, and the Psychoses Guidelines are also being updated. Automated clinical reminders are in development to assist clinicians in following the practice guidelines and document and track compliance and outcomes.

As was previously announced, VHA will soon begin a new quality improvement program - the National Mental Health Improvement Program (NMHIP). This program will be modeled after a number of VHA well-established, data-driven improvement programs, such as the Continuous Improvement in Cardiac Surgery Program (CICSP), the National Surgical Quality Improvement Program (NSQIP), the VA Diabetes Program, the Pharmacy Benefits Management Program (PBM), and the Spinal Cord Injury/Dysfunction National Program. The NMHIP will use validated data collection, expert analysis, and active intervention by an oversight team to continuously improve the access, outcomes, and function of patients in need of our mental health programs. It will draw upon existing resources in VHA's Health Services Research and Development Service, including existing initiatives in the Quality Enhancement Research Initiative (QUERI), the Northeast Program Evaluation Center (NEPEC), and the Mental Illness Research, Education and Clinical Centers (MIRECCs).

VA has been a leader in the training of health care professionals since the end of World War II. More than 1,300 trainees in psychiatry, psychology, social work, and nursing receive all or part of their clinical education in VA each year. Recently, VA has developed an innovative Psychiatry Resident Primary Care Education program with involvement of over thirty facilities and their affiliates, representing approximately 11 percent of VHA more than 700 psychiatry residents who receive training in VA facilities each year. In addition, 100 psychology and psychiatry trainees are involved in the highly successful Primary Care Education ( PRIME) initiative, which provides mental health training within a primary care setting. This type of activity is changing how VA is training mental health providers and preparing them to meet the primary care needs of mentally ill patients. It serves and improves the mental health of veterans seen in medical and geriatric primary care in both VA and the nation.

VHA educational efforts involve both traditional programs and innovative distance learning techniques. Face-to-face workshops serve a useful purpose for certain kinds of demonstrations (e.g., Prevention and Management of Disturbed Behavior Training) and for networking (e.g., the 2001 "Impact of Mental Health on Medical Illness in the Primary Care Setting and the Aging Veteran" MIRECC/ GRECC conference). Distance learning such as satellite broadcasts, Internet training, and teleconferencing, offer accessible, cost-effective training.

VHA National Center for PTSD, established in 1989, is a leader in research on PTSD. Its work spans the neurobiological, psychological and physiological aspects of this disorder. Women's sexual trauma and mental health aspects of disaster management are also addressed by the National Center, which has become an international resource on psychological trauma issues.

VHA Mental Illness Research, Education and Clinical Centers ( MIRECCs), which began in October 1997, bring together research, education, and clinical care to provide advanced scientific knowledge on evaluation and treatment of mental illness. The MIRECCs demonstrate that the coordination of research with training health care professionals in an environment that provides care and values results in improved models of clinical services for individuals suffering from mental illness. Furthermore, they generate new knowledge about the causes and treatments of mental disorders. VA currently has eight MIRECCs located across the country, from New England to Southern California.

Mental health currently has three projects in the VHA QUERI program. These include the Substance Abuse QUERI project, associated with the PERC, the Major Depression QUERI associated with the VISN 16 MIRECC, and the Schizophrenia QUERI associated with the VISN 22 MIRECC. The goal of QUERI is to promote the translation of research findings into practice and observe their impact on quality of care.

VHA has established an interagency Memorandum of Agreement ( MOA) with the Substance Abuse and Mental Health Services Administration ( SAMHSA) and Bureau of Primary Health Care (BPHC) of the Health Resources and Services Administration (HRSA). This MOA will support a cross-cutting initiative to determine if there are statistically significant differences over a full range of access, clinical, functional, and cost variables between primary care clinics that refer elderly patients to specialty mental health or substance abuse services ( MH/SA) outside the primary care setting and those that provide such services in a integrated fashion within the primary care setting. It will also address improving the knowledge base of primary health care providers to recognize MH/SA problems in older adults.

VA is also a partner with the National Institutes of Mental Health and the Department of Defense ( DOD) in the National Collaborative Study of Early psychosis and Suicide ( NCSEPs). This ongoing project is designed to better understand the clinical and administrative issues of service members who suffer from psychotic disorders during military service, their course of care, and the transition from DOD to VA care in such a manner that continuity of care is maintained.

In FY 2000, VA Research Service funded 397 mental health projects at a cost of $53,884,518. Attachment B, "Research Highlights," provides further information about selected research projects.

VA Mental Health programs provide a comprehensive array of clinical, educational and research activities to serve America's veterans. Our clinical programs are designed to provide the highest quality, most cost-efficient care, across a continuum of care designed to meet the complex and changing needs of our patients. Our educational programs train a significant proportion of our nation's future mental health care providers and ensure that our employees remain on the cutting edge of knowledge about the best clinical practices using traditional as well as innovative educational approaches. Our mental health research programs encompass both basic science as well as the essential translation of scientific findings into clinical practice. The Mental Illness Research Education and Clinical Centers ( MIRECCs) are excellent examples of the creative fusion of all three of these tasks. Perhaps the most exciting aspect of VHA mental health programs as we look to the future lies with the National Mental Health Improvement Program ( NMHIP). Dedicated to the development of performance and outcome measures and their implementation through research, education, and monitoring, NMHIP will ensure that VA becomes a national leader in the development of evidence-based care for the continuing benefit of our veteran patients. Our mental health care system is strong and effective, but no system is perfect. The NMHIP concept symbolizes VHA ongoing commitment to continuing improvement in the delivery of comprehensive, high quality clinical services to those veterans who need our care.

Mr. Chairman, while we truly believe that VA Mental Health Services remain strong and effective, no system is without problems. It is imperative that access to mental health services and best clinical practices be provided in a uniform manner across the VA health care system. To the extent that there are unacceptable levels of variance in these parameters, corrections must and will be made. If additional resources are required to provide needed care, whether by virtue of shifts of populations or unmet care needs, then a plan to provide these resources will be developed. We have a lot of questions to answer. For example: Have we gone too far in reducing inpatient care services for these patients who need them or neglected to establish sufficient residential care for patients who need that level of care? Where do we need to place more opiate substitution services? What kind of mental health capacities do even the smallest of CBOCs need, and what is the best and most effective way to provide them? We will answer these and other questions. Although we anticipate that much of the data gathering, practice monitoring, and staff education that will be involved in making these changes will be enhanced by technology, we must assure that clinicians, at the point of service, have adequate and timely access to these technologies so they can actually use them to benefit patients. This may require allocating additional resources within VHA for this purpose. It should be noted, however, that technology issues impact not only mental health care, but all VA health care.

Mr. Chairman, I will now be happy to answer any questions that you or other members of the Subcommittee may have.