STATEMENT OF
THE HONORABLE ROBERT H. ROSWELL, M.D.
UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE

March 2, 2004

Mr. Chairman and Members of the Committee:

I am pleased to appear before the Committee to discuss the Department’s ongoing efforts with regard to CARES. 

The CARES process has involved one of the most comprehensive evaluations of the VA health care system ever conducted.  It is a data-driven planning process designed to project future demand for health care services in 2012 and 2022, compare them against the current supply, and identify the capital requirements and the asset realignments VA needs to improve access, quality, and the cost effectiveness of the VA health care system.

Last September, Secretary Principi and I appeared before this Committee to discuss both the CARES process and the VHA draft National CARES Plan.  At that time, the CARES Commission, under the superb leadership of Everett Alvarez and John Vogel, was nearing the end of its site visits and public hearings and was preparing to begin the daunting task of writing its report.  On February 12 of this year, the Commission presented its final report to the Secretary, with findings and recommendations. 

VA is currently reviewing the CARES Commission Report.   However, we must await the Secretary’s final decision on this comprehensive report later this month.  Thus, I will be unable to give you our responses to the Commission’s recommendations today.

Mr. Chairman, we know that many stakeholders have expressed concerns about how VA intends to address the provision of long-term care and mental health services, and the Commission raised questions about our proposal for ‘critical access hospitals’.   I would like to say just a few words on these issues.

Our initial forecasting models did not adequately address the future long-term care needs of veterans.  As a result, the CARES planning model ensured that current long-term care capacity was maintained.  Since release of the draft National Cares Plan we have been working to develop a long term care demand model based on more recent and more complete information, including current national long-term care survey criteria, disability data and reliance factors.  Also, we are reviewing VHA long term care policy in key areas to assure that policy and capital planning will be in synch and that policy supports the vision of providing veterans with the highest quality long term care in the most supportive, least restrictive environment that is compatible with the veteran's medical condition and personal circumstances.    

In regards to Mental Health Programs, VHA is developing a comprehensive mental health strategic plan to transform its mental health programs consistent with the recommendations contained the President’s New Freedom Commission Report on Mental Health.  This plan will recommend fundamental changes in the structure, policy, and culture of our mental health care delivery system.    As part of the plan, VHA is creating a vision for delivery of care to veterans with mental illness and substance abuse within a system that places equal importance and emphasis on mental health and physical health, is integrated, veteran-centered, and based on recovery. 

Developing a mental health demand model that accurately projects the full range of mental health services needed by veterans has been challenging. A revised model that is more detailed and improves on past efforts is currently being developed.  The resulting options for mental health care will ensure that VHA maintains a robust system of coordinated, integrated, “state-of-the-art” care for veterans with mental health care needs.

We have conducted several studies of domiciliary programs over the past year.  These studies highlighted --

• The need for effective coordination with non-VA programs and services to assure that integration is achieved across a continuum of care that is directed to meet the specific needs of individual veterans. 
• That patients need to move to the least restrictive environment consistent with their needs. 
• And that data based population planning is needed to bring about some uniformity of access to this therapeutic residential care continuum including consideration of available State Home Domiciliary programs as well as innovative VA/community partnerships providing Domiciliary services.

Accordingly, I have instructed planners to assure that programs in domiciliary structures are focused on residential rehabilitation and that each patient have a clinical treatment plan.  As each program (e.g. mental health, substance abuse, long term care) defines its discrete capacity for residential rehabilitation, VHA will have a more complete picture of the total capacity requirement for domiciliaries.

Mr. Chairman, we are also reviewing the ‘critical access hospital’ concept that was presented in the draft national plan and are developing a definition of what we now call ‘ rural access hospitals’ and how such facilities should function in our health care delivery system. 

We believe that these facilities may be important in providing access to health care in certain rural markets where access to VA and/or community care is limited.   Such facilities would need to be part of a network of health care that provides an established referral system for tertiary or other specialized care not available at the rural facility. The facility should also be part of a system of primary health care (such as a network of CBOCs).  Such facilities would also need to be a critical component of providing access to timely, appropriate and cost-effective health care for the veteran population served.

Mr. Chairman, should the Secretary approve the final CARES Plan, implementation will take place over a period of many years.   It will be a multifaceted process, depending upon whether implementation of specific initiatives requires additional capital, recurring funding, primarily policy changes, or realignments.  In particular, the complexity of realigning clinical services and campuses necessitates careful planning in order to ensure a seamless transition in services.  In no case will we discontinue services without having alternative sites of care available and operational.  And throughout the implementation process we will keep you and other members of Congress informed and involved and, just as important, we will keep our patients and their families informed and involved. 

This concludes my statement.  I will now be happy to answer any questions that you or other members of the Committee might have.