Veterans Healthcare Closer to Home

My brief oral presentation at the Veterans Affairs Sub-Committee on Health did not provide an opportunity to relate in some detail the unique model that has developed at Cary Medical Center in Caribou, Maine for the delivery of VA health care services to eligible, rural Veterans.  In my extended remarks that follow I will review the advantages of our current model as well as some of the challenges we face in providing VA care at a non-VA facility. 

It might be wise to consider the current demographics of Veterans living in the United States.  In 2010 there were 21.8 million Veterans living in America.  Nine million of the Veterans are over age 65.  The number of WWII Veterans in 2011 are estimated to be nearly 2.1 million but this number is expected to be cut in half by 2015 and in 15 years will be down to 50,000.  The average age of the WWII Veteran is 86.  Surviving Korean War Veterans are estimated to be between 3 and 5 million with some 3.2 million between 65 and 74 and another 363,000 over age 75.  Surviving Vietnam Veterans number some 7.6 million with an average age of 60 – 65.  Nearly 3.5 million US Veterans have service connected disabilities with some 698,000 at 70% or higher.  

Pertinent to this discussion is that some 3.4 million Veterans or about 41% of the total enrolled in the VA Healthcare System live in rural or highly rural areas of the country.  In recent years the Veterans Administration has been working to improve access to care for rural Veterans and Cary Medical Center has had the privilege to be part of that process.  Cary Medical Center is unique in that the hospital is located in highly rural Northern Maine.  Historically Veterans would have to travel some 500 – 600 miles round trip to access care at Maine’s only VA hospital at Togus, Maine.  Togus is the oldest VA hospital in the United States.

As early as May of 1946 the Department of Maine American Legion was advocating for a Veterans Administration Hospital in Aroostook County sighting the disadvantage suffered by Veterans living in this vast and remote area.  In 1979 the Aroostook County Veterans Medical Facility Research and Development, Inc. (ACVMFRD) was formally incorporated with a single purpose of establishing local healthcare for Veterans living in the County.  Providing access to healthcare for Veterans living in rural areas was not a strong suit for the VA.  During their original efforts to create VA health services the local Veterans group learned that in order to establish a formal Veterans Administration Outpatient Clinic the VA required that some 180,000 Veterans exist within a 60 mile radius.  With less than 100,000 in total population it was clear that Aroostook County would not go the existing route to secure access.  From 1979 to 1987 this small group of Veterans worked with the state’s congressional delegation, the VA, the local hospital, Cary Medical Center and multiple Veterans Service Organizations. 

While Senator George Mitchell initiated the first attempt to create an outpatient VA Clinic in Caribou, Maine based on a new priority of improving VA services to rural Veterans, it would not be until the Director of the VA Hospital at Togus, through his own authority, cleared the way, administratively for a small ‘follow up’ clinic to be opened at Cary Medical Center, a public acute care hospital.  It would become the first such clinic of its kind in the United States.  Senator George Mitchell, Senator Bill Cohen and then Congresswoman Olympia Snowe joined in a united effort to address the issue of rural healthcare for Veterans and helped pass legislation which established a study committee to assess the state of care for rural Veterans and to make recommendations.  The timing was great and as the issue of rural healthcare became more of a priority for the VA, the healthcare services in the new fledgling VA Clinic in Caribou, Maine began to grow.

Over the last 25 years the clinic has seen numerous expansions and now encompasses some 5,000 square feet and serves some 120 veterans per day including more than 5,000 clinical visits annually.   The clinic now has a staff of 21 and provides outreach to satellites in northern and southern parts of Aroostook County.  Primary Care, Mental Health Services, Home Based Care, Tele-Health Services, Health Promotion and Education, and Smoking Cessation are among the offerings at the center.  A number of other CBOCs have now been opened around the State of Maine based on the Caribou model and some 600 clinics are available nationwide.

Collaboration Key to Success

It would be easy to just assume that providing convenient access to healthcare for Veterans living in rural and highly rural areas of the nation would be a ‘no-brainer’.  Veterans who live in rural communities demonstrated the same level of valor and courage as those living in metropolitan and large urban areas of the country.  However, there were many challenges and these challenges remain.  The VA Clinic in Caribou, Maine is a great laboratory for the ongoing development of rural VA healthcare.  The clinic came about because of a grassroot effort by local Veterans and the relationship that was created between the Veterans groups, a local  hospital, and the Veterans Administration.  The development of the VA clinic was a gradual process.  The clinic started as a follow up clinic for specific patients that had been treated at the VA hospital in Togus.  The VA than established a contract with a local physician and expanded care.  Finally came the establishment of the first VA Community Based Outpatient Clinic staffed by a VA physician and staff.  All along the way there was a communication process that started to open the window for expanded services without creating an adversarial or combative environment between the constituencies.  The VA and its leadership began to hold ‘Town Hall Meetings’ at Cary Medical Center in Caribou.  They listened to the concerns of Veterans and their families.  The VA hospital director would bring key staff specializing in eligibility, benefits, claims processing, women’s health and others to hold one on one sessions for Veterans with specific issues to resolve.  A bond was built that allowed for collaboration to grow.

This dialogue between Veterans, the VA, and the local healthcare providers is absolutely critical to the growth of rural healthcare for Veterans.  There must be an understanding that the kinds and numbers of clinical services available to Veterans in these rural parts of the country depend greatly on the scope of services available in the local healthcare system.  Throughout our experience with Veterans they were keen on preserving the VA healthcare system and wanted to stay connected with it but they also wanted to be able to access more routine care locally.  The credibility of the VA healthcare system and the quality of the system has come a great distance in the past 25 years.  Veterans generally have confidence in VA healthcare and that has been demonstrated by the growing numbers accessing VA care. Recent surveys point out that when asked if they could choose a healthcare provider more Veterans are indicating that they would choose VA care.  In fact based on a CBO Paper, published December, 2007 – The Health System for Veterans – An Interim Report; the VA Healthcare System scores significantly higher than the private sector on multiple measures including Clinical Practice Guidelines and Patient Satisfaction.  The growth of patients seeking care within the VA System has also grown dramatically from 3.6 million to more than 5 million.  The VA system in 2011 treated some 6.1 million Veterans and saw some 80 million outpatient visits.

The entire world changed for Veterans Healthcare when the Veterans Healthcare Eligibility Reform Act was passed in 1996 greatly increasing the numbers of Veterans eligible for VA care.  In the past decade the healthcare budget in the VA has increased from $17 billion to $36 billion  The VA has established a priority system with levels 1 – 8 with level 1 serving those with service connected disabilities and level 8, for which enrollment has been frozen since 2003, for any honorably discharged veteran.

The challenges faced by the growing VA healthcare system are not unlike the traditional American Healthcare system.  Many Veterans like many Americans are aging.  The availability of convenient, local access to healthcare services for this aging population is paramount in providing high quality management of chronic illness which impacts many of the elderly.  Helping individuals to remain in their homes, reducing hospital admissions, preventing pre-mature institutionalization and supporting patients so that they may enjoy a high quality of life during the aging process is also a key goal of both the VA and the private healthcare sector.  The VA has proven itself, in recent years, to be very adept at managing some of the most difficult chronic conditions.  Recent studies point out that patients with the VA Healthcare System receive significantly better care for depression, diabetes, hyperlipidemia, and hypertension.  This has come about primarily because of the expansion of services including more than 882 ambulatory care and community-based outpatient clinics.  Still the problems facing Veterans in rural America remain a major challenge.  How can we use the knowledge and experience gained over the past 25 years to solve these challenges?

The Cary Medical Center Model

We have already discussed the history of the VA clinic at Cary Medical Center in Caribou, Maine.  While there are many aspects of this development that involved pure advocacy of local, dedicated Veterans for their fellow comrades, the integration of the VA clinic in Caribou within the traditional or private healthcare system offers a unique and intriguing perspective as to future approaches to expanding VA Healthcare in rural communities.

First, and perhaps most important, the successful implementation of the rural VA outpatient clinic must have near universal support from local Veterans Organizations.  When the small group of Veterans began their advocacy work in the late 1970’s, a visionary Chief Executive Officer at Cary Medical Center, a small centrally located acute care hospital in Aroostook County, Maine offered to help.  The hospital and the Veterans group created a bond of mutual support and respect that still strongly exists today.  Once the Veterans were satisfied that the hospital had the commitment and resources to take on the challenge of an integrated program with the Veterans Administration Medical Regional  Office Center at Togus, Maine, they utilized the expertise of the hospital in advancing the medical, political, and public support that would be required.

The hospital began by approaching the VA about utilizing space to establish a physical presence on the hospital campus.  While initially contracting a member of its own medical staff to the VA for the purpose of seeing a limited number of patients for follow-up after surgical procedures at the VA Hospital, the demand for additional services began to grow.  The VA then moved to recruit a physician from the region to staff the clinic as a Veterans Administration Employee.  Gradually the VA began to expand staff based on volume and the continuing requests of the Veterans advocacy group.

The expansion of the VA clinic came with it a growing relationship between the hospital and the VA. This included the hospital’s understanding of the VA Fee Schedule.  Initially only a limited number of services were available to Veterans outside the VA clinic.  However with the passage of the Veterans Health Care Eligibility Reform Act of 1996, access to more outpatient services was expanded.  There continued to be some hesitancy of the VA to ‘let go’ of traditional care involving Veterans traveling hundreds of miles to the VA hospital for minor outpatient procedures but over time services available locally began to grow. 

The growing integration between the hospital and the VA was a tremendous benefit to area Veterans.  The success of the VA clinic inspired the Veterans advocacy group to explore other important healthcare needs of Veterans living in Aroostook County.  The State of Maine had established the ‘Maine Veterans Home’ program in the 1980’s.  The first home was in Augusta, Maine some 300 miles from Caribou.  Veterans in Aroostook County organized an effort to build a long term care facility.  Working with the State legislature, and the VA, a new home was opened, only the second of its kind in 1990.  There are now five such long term care facilities in Maine as part of the Maine Veterans Homes system.  Then in 2003, a new 30-bed Maine Veterans Home Residential Care facility was opened on the campus of Cary Medical Center.

While the long term care facilities and the VA outpatient clinic are clearly separate, one is directly tied to the VA and the other is a purely State run organization, there are common threads which involve eligibility requirements, reimbursement issues and a connection to the greater Veterans community in Aroostook County.

While the growth of VA health care in Aroostook County presents a very dramatic and unique scenario, the effort to monitor, study, explore and expand services continues to be a top priority for both Veterans and the hospital.  For more than 25 years the hospital has maintained a liaison relationship within the Veterans community.  A member of the hospital’s administrative staff is charged with monitoring the VA health service at the hospital and to assist with any potential issues, and the hospital’s CEO conducts quarterly meetings with key Veterans leadership. These meetings are designed to address a variety of issues including recent national developments in VA healthcare and the needs of the local VA clinic.  These meetings are pivotal to the continued success of the VA clinic and have led to the ongoing expansion of services.

Over the years the clinic has expanded multiple times and current plans are for another expansion.  The key to this growth, again, has been the dialogue, collaboration and partnership among the major players; Veterans groups, the Veterans Administration, and the hospital.  Each expansion has been based on priority need, a well-developed strategy, cost benefit analysis, and the answer to a key question, how the expansion will impact rural Veterans living in Aroostook County.  Over the years the level of mutual trust and respect that has been established have become a way of life here and the rancor and turmoil that characterized so much of the relationship between the VA and the Veterans community of the 1970’s and 80’s has all but disappeared.

Project ARCH – The Next Step

Throughout the years of working with the VA Outpatient Clinic and the development of long term care for Veterans through the Maine Veterans Homes one key priority eluded the Veterans community in Aroostook County, Inpatient and Specialty Care. While Veterans continued to advocate for these services the VA stood firm in protecting the current system of patients being transferred to the VA hospital for any surgical or medical services requiring hospitalization.   The impact of such a reality for Aroostook County Veterans and others living in highly rural areas of the nation should be obvious.

Patients who require hospitalization are often the most medically burdened elderly and may find it difficult to travel the hundreds of miles required to receive the services.  In rural Northern Maine we have no Interstate system and our roads our icy and snow covered for many months every year.  Many of the Veterans in need of this care are low income and while the VA does reimburse travel for the Veteran, family members and others who may be key support to the Veteran are often unable to make the long trip to the only VA hospital in Maine.  The support of family and friends has been demonstrated to be a key element in the ultimate and early recovery of patients.

Over the years the issue of inpatient hospital care has been discussed and in fact, the CARES project revealed a serious need to address hospitalizations for Veterans in rural communities.  The project actually designated specific areas, including Northern Maine, as a priority location for inpatient beds.  Funding to execute the findings never materialized. The establishment of Project ARCH, Access Received Closer to Home, has finally made this piece of the care continuum available to Veterans living in five areas of the nation as a pilot or demonstration project.   Fortunately Aroostook County was one of these selected areas and Cary Medical Center was the hospital selected to contract with the Veterans Administration to provide a select number of specialty services including hospital care for eligible Veterans.

Once again this project benefits greatly from the long history that Cary Medical Center has with the Veterans Administration and the Veterans community.  The VA already has primary care and other related services on the hospital campus.  The level of satisfaction with hospital care experienced by Veterans and the hospital’s ongoing support and advocacy for Veterans healthcare also played a key role in attracting Veterans to Project ARCH project.   The compassion and quality of care provided by the VA outpatient clinic itself was another key driver for the initial and remarkable success of the project.

A key question with Project ARCH was whether or not the community hospital could meet the stringent demands for quality and customer satisfaction required by the VA.  In the CBO Interim Report – The Health Care System for Veterans sighted earlier addressed the improving quality of care in the VA system.  The VA has adopted the Institute of Medicine (IOM) definition of quality:  “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”.   The IOM also noted that health care should be Safe, Effective, Patient-Centered, Timely, Efficient and Equitable.  The VA tracks many aspects of its health care along the dimensions highlighted by the IOM.  Based on established Clinical Care Guidelines and other measures the quality of care in the VA has significantly improved since the organization   experienced reengineering from 1994 – 2000.

Early indicators are that Cary Medical Center is not only capable of meeting these quality expectations but has exceeded them both in specific measures of clinical quality and patient satisfaction.  The hospital has worked closely with its VA contracting office and has established a team of key stakeholders in the care delivery process including clinical personnel, case management staff, administration, finance and other aspects of the project.  While the project is just now completing its first year of operations nearly 1,000 clinical encounters including a number of surgical procedures and hospital stays have been completed. We are now in the process of assessing the outcomes and opportunities for improvement.   The vigilance of the VA in monitoring quality and patient satisfaction for Veterans eligible for healthcare close to home is admirable. 

While we wait for the specific and detailed data on the first year experience with

Project ARCH it is appropriate to pause and consider where we have come.  From our earlier discussions on the long history of the development of the first VA Community Based Outpatient Clinic (CBOC) in a rural hospital in the United States to the reality of providing overnight hospitalization and specialty services to eligible Veterans closer to their homes much has been accomplished. The Veterans Health Care Eligibility Reform Act of 1996 made it clear that our nation wanted to do more for those men and women who gave so much in service to our country.  We have also discussed the aging of our Veterans population and the declining WW II survivors.  Our Korea and Vietnam Veterans are also aging and the implications for their medical needs and those that will come after from experience in Iraq and Afghanistan are daunting.  Visionary ideas like Project ARCH will go a great distance in advancing access to care for rural Veterans. 

While we applaud the VA for its consideration of our nation’s Veterans and the advancement of both access and quality of care, there are some issues that we face here in Maine that are of particular concern.  The VA has a reimbursement program based on the Medicare Fee Schedule.  Unfortunately the State of Maine is among the lowest, in the nation, in the level of Medicare reimbursement. While the complicated implications of this payment system are much too voluminous for discussion here such reimbursement unfairly impacts Cary Medical Center as we provide care to Veterans through the VA system.  Payment for the same service here at Cary Medical Center such as a total joint replacement is far lower than the same procedure performed in other states.  We continue to work with our congressional delegation, including Congressman Mike Michaud to gain a more equitable Medicare reimbursement rate which would, in turn, support improved reimbursement for healthcare services we provide to Veterans.  

At the same time and perhaps counter intuitive in light of the current reimbursement structure, Veterans who have experienced care at the local level from Cary Medical Center are clamoring for more access.  The ability to still feel connected to the VA through accessing primary care at the VA Community Based Outpatient Clinic and at the same time obtain specialty care, and, if needed hospital care close to their homes has been a very positive experience for Veterans.  It is our hope that the Veterans Administration will, over time, consider adding more specialty care options for eligible Veterans in Project ARCH such as Ophthalmology. The idea of expanding specialty care in rural communities to meet an expanding market share of eligible VA patients has a number of positive implications for not only the Veterans who will be served but for the entire local community.

Often times specialty services are not available in a rural community due to the number of patients needed to support such services.  While access to primary care has dramatically improved in Caribou, Maine thanks to the expansion of our Federally Qualified Health Center, Pines Health Services, additional medical specialists are needed.  Thanks to the growth in volume presented by Project ARCH we have already been able to expand services in Cardiology Pulmonology, Neurology, General Surgery and Orthopedic Surgery.  Such development speaks well for the future of the hospital and the quality and availability of specialty care for the communities we serve including a growing number of Veterans.

Another challenging issue for providing VA healthcare in non-VA facilities has to do with measures of access.  Within the current ARCH contract the VA has included strict access guidelines.  The contract calls for Veterans to be scheduled with a specialty medical provider within 14 days of authorization.  This has been a difficult task for our local hospital as we try and build the Veterans patients into the routine schedule of very limited specialists, often a single specialist deep.  Recent figures sighted by the VA IG suggested many VA patients were not receiving appointments within 30-days within the VA healthcare system itself.  Still, creative solutions are being developed to cope with this issue including additional recruitment of specialists, ‘set-aside’ days where the specialists schedule only VA patients or ‘catch-up’ days that may be held on a Saturday or other non-traditional access times. 

The beauty to the seamless integration of the private sector healthcare system at the local community hospital level and the VA primary care clinic is that as these issues surface and mutual team, committed to improving the delivery of care to the Veteran, comes together and creative solutions are identified, tested, modified and implemented on an ongoing basis.  This process has helped to create what we believe is a potential national model for community based Veterans healthcare.

A Focus on Prevention and Patient Education

We have established the many benefits of bringing health care closer to home for patients within the Veterans Administration Healthcare System.  We have also demonstrated that through closer partnership and with mutual trust and respect a strong collaborative approach can be developed assuring the provision of quality care and high customer satisfaction.  But one key advantage that we believe can have significant implications in the future is the growth of patient education and prevention. This is one area that has only begun to evolve.  The partnership that exists between the community hospital and the VA outpatient clinic holds great promise in the collaborative approach to educating patients about chronic disease, preventing Type 2 diabetes, reducing the risk for heart disease and stroke and many other preventable health conditions.  The resources of the local VA clinic may be limited for such general community work but partnering with the hospital and its strong outreach programs could lead to a healthier more personally accountable general population as well as a healthier Veterans Community. 

Conclusion

It is our hope that we have been able to present a strong case in support of Project ARCH and the continuing willingness of the VA to work with rural communities in establishing more locally available healthcare for our nations deserving Veterans. Once again we applaud the VA for its continuing advancements in technology, patient safety and overall quality of care.  It is our belief that the continuing dialogue between the VA and the private healthcare sector in rural areas of the country will lead to an ever increasing partnership and improving health status for the communities in rural America. 

Cary Medical Center particularly salutes the Veterans Administration Regional Medical Office Center at Togus, Maine for their visionary and remarkable outreach in advancing the care of Veterans in rural Maine.  We stand ready to offer any assistance we can in advancing such efforts and we pay tribute to the Veterans, many of whom have now passed, for their tireless efforts on behalf of their Veteran brothers and sisters to establish Veterans healthcare close to home.  While all of us can hope for an end for the wasteful violence and tragedy of War we recognize the many perilous and dark forces that challenge freedom on nearly a daily basis.  Those men and women who put themselves in harm’s way offering the greatest sacrifice deserve our best efforts in guaranteeing that they will be well cared for when they return home to a grateful nation.