STATEMENT OF
ROBERT H. SABIN, DIRECTOR
RICHARD L. ROUDEBUSH VETERANS AFFAIRS MEDICAL CENTER
VETERAN INTEGRATED SERVICE NETWORK (VISN) 11
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES

September 5, 2001

Mr. Chairman and members of the Subcommittee, I am pleased to be here today to discuss the progress, challenges, and future direction of health care at the Roudebush VA Medical Center in Indianapolis, Indiana.

The Indianapolis VA Medical Center has been proudly serving Indiana Veterans since 1932. The present medical center, located on the campus of the Indiana University School of Medicine campus, opened in 1952. In 1982, by an Act of Congress, the two-division facility was renamed the Richard L. Roudebush VA Medical Center, after a notable legislator and former Administrator of the then Veterans Administration. The facility has been upgraded numerous times to keep pace with advances in medical care, education and research. Two increments of major construction in the last decade doubled the square footage in the medical center and permitted consolidation of a two-division facility to provide better medical backup and efficiency in the care of veterans. As the Indianapolis Medical Center is VA's tertiary care facility in the state of Indiana, referrals from the Northern Indiana Healthcare System and the Illiana Healthcare System at Danville, Illinois are common and add to the important role of the medical center for veteran specialty medical and surgical care. Furthermore, the medical center accepts referrals from facilities in neighboring VA networks especially in Illinois, Kentucky and Ohio. In addition to providing primary care, specialty care, extended care, and referral services, the medical center also provides an environment that promotes medical education and training, research, and DOD services in support of current and former military service members.

The medical center has a primary service area of 33 Indiana counties containing over 292,000 veterans; 108,000 of whom are over 65 years of age. This facility provides acute inpatient medical, surgical, psychiatric, neurological, and rehabilitation care, as well as both primary and specialized outpatient services. Some noteworthy specialized services include comprehensive cardiac care, a comprehensive surgical program including open-heart and orthopedic surgery, radiation oncology treatment and community-based extended care. Serving over 38,000 patients annually, the medical center has over 350,000 outpatient visits on an annual basis and over 6,000 inpatient episodes of care.

The center is committed to delivering quality care and offers extensive research and training programs. With annual grant support exceeding $7.5 million, Indianapolis VA investigators are conducting scientific research in such areas as cardiology, diabetes, alcoholism, AIDS, Alzheimer's disease, Hepatitis, pulmonary diseases, and cancer. The VA has educational affiliations with the Indiana University Schools of Medicine, Dentistry, Nursing and Allied Health. In addition, there are educational arrangements with six other universities in the states of Indiana and Kentucky. Through these educational programs, the medical center provides clinical and administrative training opportunities for over 1,300 students each year. At any time, one hundred post-graduate physician residents and fellows are pursuing clinical training in the Indianapolis VA medical center and delivering veteran care under the supervision of VA physicians who are concurrently faculty of the Indiana University School of Medicine. This supervised clinical experience for licensed physicians is offered in 22 accredited medical specialties. The Medical Center has nine sharing agreements with the Department of Defense and plays a key role in disaster preparedness as a federal designated coordinating center for the National Disaster Medical System. Further, the Indianapolis VA Medical center provides outpatient diagnosis and treatment to active military service members and their dependents under a TriCare arrangement in cooperation with DOD. Physical examinations are provided to Army Reservists and National Guard troops under a mutually beneficial contract.

The Roudebush VA Medical Center is fully accredited by the Joint Commission on Accreditation of Healthcare Organizations in the Hospital Accreditation, Home Health Care, and Behavioral Health Care Programs. We are also fully accredited by the College of American Pathologists, the Commission on Accreditation of Rehabilitation Facilities, the Nuclear Regulatory Commission and are a certified Comprehensive Cancer Treatment Facility. All recommendations from accreditation surveys have action plans that will ensure the medical center meets all standards associated with quality patient care.

A regularly scheduled Combined Assessment Program (CAP) review by some two-dozen staff of the Office of Inspector General (OIG) was conducted at the Roudebush VA Medical Center in January 2000. The survey found no untoward circumstances significantly effecting management practices of quality of care. The recommendations have been reviewed and acted upon as outlined in the final report.

The medical center has experienced remarkable growth in recent years. Recognizing that the growth in patients served and outpatient visits will be sustained, we have undertaken several activities designed to improve patient waits and delays. More than doubling outpatient visits in the last nine years has caused a strain on the physical plant. We have little more than one exam room per provider. Given the recommended standard of at least two exam rooms per provider, we have almost completed a renovation of existing space that attempts to maximize the utilization of available square footage. While an improvement, this action is still not adequate. Indianapolis has submitted and received approval for the design and construction of additional 10,000 square feet of ambulatory care space. This action will more closely approach the standard of two exam rooms per provider.

System revisions have also been undertaken to improve the clinic waiting times. The Roudebush VA Medical Center is unique in the VA in initiating implementation of a commercial off-the-shelf software package for the scheduling of outpatient clinic appointments. Staff members have developed an interface with existing VA software to produce early results of a 30% reduction in clinic waiting times. As implementation is rolled out to all clinics, similar results are expected. Furthermore, the medical center is in the process of implementing the open access model of care as developed by the Institute for Healthcare Improvement. This model enhances continuity of care by permitting patients to see their primary care provider, even on an urgent basis. This improves care and reduces clinic waiting times. Further work is needed in many clinic areas and is an ongoing process.

The Roudebush VA Medical Center contracts with private providers for the operation of two community based outpatient clinics (CBOCs). The CBOC located in Terre Haute, Indiana is the more mature operation and has over 5,000 veterans enrolled for care and has served over 4,000 on an annual basis. The CBOC in Bloomington, Indiana has been open slightly more than one year and serves almost 2,000 veterans. Both CBOCs are monitored for compliance with contract provisions that include electronic medical records, access, patient satisfaction, and quality of care monitors.

The Indianapolis VA Medical Center has been a leader in the area of medical care cost recovery (MCCR) collections of co-payments and third party insurance coverage. Over $11 million in collections is expected this fiscal year. This represents 6.6% of our annual operating budget. Indianapolis ranks 10th VA-wide in terms of total dollars collected. The efficiency of the billing and collection process is noteworthy when monitored by both VA and private-sector performance measures. The MCCR staff collects on average $650,000 per FTE. Furthermore, the medical center has reached an agreement with Anthem Blue Cross Blue Shield of Indiana, which will yield higher collections as well as reimbursement for back claims.

The Roudebush VA Medical Center enjoys a cooperative relationship with the VA Regional Office, Veterans Benefits Administration, located in downtown Indianapolis. The medical center receives about 260 veterans' compensation and pension (C&P) exam requests each month. More than 99% of the transmissions between Regional Office and the medical center are completed electronically. Completed C&P exam reports are stored in the electronic medical record and are available not only to Regional Office staff, but also to clinicians providing ongoing healthcare to the veteran. While the Compensation and Pension ( C&P) examination turnaround time exceeded 45 days in recent months, we have isolated the problem. Approximately 25% of all exam requests include an audiology exam. While current waiting times for veterans needing an appointment in audiology clinic have decreased 50% in this fiscal year, veterans requiring a C&P audiology exam are scheduled 120 days in the future. This aspect of the evaluation will be improved through our new scheduling system in combination with contracted services. Our turn around time for all other exams is 31 days.

The Roudebush VA Medical Center provides veteran health care across the continuum. From preventive to acute to chronic care, the medical center utilizes modern technology, compassionate, qualified staff, and a variety of healthcare venues to ensure that patient healthcare needs can be met. Provision of community based extended care has undergone change over the past few years. While we continue to use community nursing homes to provide institutional care for veterans near their homes, the Indianapolis VA Medical Center has developed the network's largest and most active home care program. We typically provide VA-paid care for more than 200 veterans in their homes at any given time, and we have realized a 66 percent reduction in institutional bed days of care for patients enrolled in our traditional homecare visit program. In addition, we are pursuing the use of telemedicine technology to maintain more available monitoring and communication with veterans and their families who prefer home care and for whom it is clinically appropriate.

Currently, the medical center uses a multi-disciplinary clinical team in the extended care screening process. The team receives referrals from medical center providers and uses clinical and social indicators to determine the most appropriate location and type of care. The screening committee considers inpatient status here and elsewhere. Veterans seen only in the outpatient venue are also considered for placement and may be enrolled in our extensive home care operation.

The Indianapolis Medical Center provides acute and ongoing mental health treatment to veterans in a variety of settings. We will implement mental health service in both of our community-based outpatient clinics by the end of this fiscal year utilizing a psychiatric clinical nurse specialist. As an alternative to repeat hospitalizations, Indianapolis established a contract Psychiatric Residential Rehabilitation Treatment Program (PRRTP) last year. In the first nine months of operation, 29 patients were admitted to the PRRTP. We have applied for CARF accreditation for the Homeless Team and Vocational Rehabilitation by the end of 2001. Our Homeless Team and Vocational Rehabilitation staff is co-located with a community partner increasing access and support to mentally ill veterans. Psychiatry service participates in the city's PAIR Project (Psychiatric Assertive Identification and Referral Project). PAIR works to identify people in jail (prior to trial) with a psychiatric disorder, and get them into appropriate treatment.

I will be pleased to more fully develop information and programs cited in this statement or to address other matters of interest to the Sub-committee.