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a Network Director, VA Healthcare Network Upstate New York, Albany
b Network Clinical Coordinator for Geriatrics and Extended Care, VA Healthcare Network Upstate New York, Albany
Frederick L. Malphurs, Network Director, VA Healthcare Network Upstate New York, P.O. Box 8980, Albany, NY 12208-0980 E-mail: FRED.MALPHURS{at}MED.VA.GOV.
Decision Editor: John E. Morley, MB, BCh
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Abstract |
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 Top Abstract The Old VHARecent Changes in the...Putting Veterans FirstThe Future of Long-Term...The Nursing ShortageCommunity-Based CareThe New ChallengeResearch and the VHAReferences |
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AT the most recent Institute for Health Care Improvement symposium in San Francisco, Don Berwick gave a keynote address entitled "Magic Spells and Dirty Words." In his speech, he made use of the character Harry Potter, wizard-in-training, as the embodiment of the necessary qualities required by health care systems, as they work to assure the provision of consistent high quality medical care to all Americans. Harry's most distinctive characteristic is that he, from among all wizards, was unafraid to name, and therefore confront, evil. His ability to say, "Voldemort," or "he who should not be named," enabled Harry to develop a plan to deal with the evil in his life. Don proposed we should do no differently. We, like Harry, should be unafraid to uncover our system's evils, its problems, and shortcomings. Thus, despite the incredible successes our system has had in caring for the aged veteran, we need to name what needs to be fixed in our Veterans Health Administration (VHA) health care delivery systems, no matter how foreboding the task may appear or fearsome that fix might be.
Continuing to follow our crystal ball theme, we can invoke another wizard, Merlin. As characterized by Mary Stewart in her book, The Crystal Cave, Merlin lived his life backward. Unlike us mere mortals, Merlin acted in the present, on the basis of what he already knew from having lived in the future. His ability to foretell the future was, in fact, an act of remembering. A lesson for us, I would think. The ability to predict the future is directly related to our ability to remember. To gaze into the crystal ball of long-term care and to predict what the immediate future holds for the VHA, we need to remember, and remember correctly, our VHA past. To act successfully in long-term care over the next 5 years we must remain grounded in the successes of our recently past 5 years.
So, like Merlin, as we attempt to foretell the immediate future, we begin with an act of remembering. The date is March 17, 1995. Try to envision what the VHA was like just a mere 5 years ago. As you try, you will see that it is not so easy to remember, even just 5 short years ago. The vibrant pace of change we experience daily, and the fluid nature of operations required to thrive in the health care world in which we live and operate, make even our relatively recent past seem like ancient history. We have come so far in 5 years. We have a very alive past! The date, March 17, 1995, was chosen because it was truly a defining moment in the VHA. Little about the way the VHA did business remained the same after March 17, 1995, the date the plan to restructure the VHA, "Vision for Change," was published by one of the VHA's own Harry Potters, Ken Kizer.
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The Old VHA |
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TopAbstractThe Old VHARecent Changes in the...Putting Veterans FirstThe Future of Long-Term...The Nursing ShortageCommunity-Based CareThe New ChallengeResearch and the VHAReferences |
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It was in this environment that questions began to be raised nationally about the relevance and structure of the mission of the VHA. Alternatives were proposed, and some proposals included doing away with the VHA.
Clearly, we do not remember the past with an eye toward returning to it. But then, why remember, why begin foretelling with a hearkening back?
To survive into the new millennium, the VHA had to change, and it is perhaps this "change" and action mindset from the VHA's recent past that I want you to hearken back to. The VHA did change over the last 5 years, and changed dramatically and rapidly. Five years ago the VHA changed partly to respond to our aging population. Aged veterans are the VHA's current, and will continue to be our future, population. We know well our aging WWII veteran patients as we care and plan to care for them. What we sometimes lose sight of, however, is the continued aging of our overall veteran population, that is, the aging of veterans in the next 10 and 20 years (Fig. 1).
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Recent Changes in the VHA |
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TopAbstractThe Old VHARecent Changes in the...Putting Veterans FirstThe Future of Long-Term...The Nursing ShortageCommunity-Based CareThe New ChallengeResearch and the VHAReferences |
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First, the path to change was crafted. The "Vision for Change" was a template to reward new attitudes and behaviors—attitudes and behaviors that would literally transform the entire VHA organizational culture to create a more efficient and patient-centered health care system. What was it about the "Vision" that was so powerful that it could take an organization such as ours, an organization many thought was incapable of change, and transform it in 5 short years into a world-class system? A health system that none of us (without the advantage of current hindsight) could have predicted would come about? Where did the impetus and the power to change come from? Truly, the answer is simple.
The impetus for change was the veterans themselves. The VHA changed because the veterans needed us to. Sound too simple? Too simple to produce the extraordinary changes the VHA has undergone?
In Veterans Integrated Health Network (VISN) 2, we recently gave the Executive Leadership Council a copy of the book, Edge Ware (3), subtitled "insights from complexity science for health care leaders." According to the authors, one of the paradoxes of complexity is that simple patterns of interaction can create huge numbers of potential outcomes. The paradox is that simplicity leads to complexity.
Again, where did the impetus and the power come from over the last 5 years to produce complex and massive structural reorganization? The answer is simple. Distilled to its essence, the "Vision" contained a simple premise: "put veterans first." You might say it was the VHA's incantation, our magic spell. We may not remember what is contained in the entire publication of the "Vision for Change," but we all do remember its core: "put veterans first." This is what we remember. And this premise, this incantation, is what we should use to foretell the future of long-term care in the VHA.
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Putting Veterans First |
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TopAbstractThe Old VHARecent Changes in the...Putting Veterans FirstThe Future of Long-Term...The Nursing ShortageCommunity-Based CareThe New ChallengeResearch and the VHAReferences |
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A short list of organizational accomplishments over the last 5 years illustrates how the VHA has been impelled to change by taking our words "putting veterans first" seriously:
Remarkable changes have occurred in just over 5 years. But we are not here to revel in past success or dwell in the past. Rather our project is to foretell the future of long-term care. Our past lives, and because of that, today there is a new VHA. The changes and the work the VHA has done as a national health care system over the last 5 years position it well for the upcoming years. However, the challenges that face the VHA, and the changes we need to continue to make as a health care delivery system over the next 5 years, will be just as dramatic as the last 5.
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The Future of Long-Term Care at the VHA |
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TopAbstractThe Old VHARecent Changes in the...Putting Veterans FirstThe Future of Long-Term...The Nursing ShortageCommunity-Based CareThe New ChallengeResearch and the VHAReferences |
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Repeating the essence of change for the VHA, we again incant, "putting veterans first"—the simple premise that remains. Over the next 5 years in long-term care we will continue to be guided by this simple and straightforward premise. It has already been proclaimed in the Long Term Care at the Cross Roads report (4) that "Long Term Care is defined by patient needs and not by programs." I propose that persistent faithful adherence to this premise will continue to yield equally complex outcomes for long-term care in VHA. When in doubt, or overwhelmed by the changes we know need to be brought about, we are going to have to repeat this phrase often to ourselves, and to all who will listen: "Long Term Care is defined by patient needs and not by programs."
Let us see where adherence to this mission statement—our chant, the magic words, which for wizards only work if you have the right thoughts in your head—takes us.
Long-term care is defined by patient needs.
The VHA has estimated that the number of veterans needing long-term nursing home care on any given day will increase by approximately 10,000 over the next few years, reaching almost 180,000 nationwide by 2005. The Millennium Health Care and Benefits Act (Public Law 106-117) addresses this need for us: the "VHA will retain its core long term care services while improving access and efficiency of operations." The VHA operates on the basis of our fiscal year 1998 baseline for staffing and level of in-house extended care services. The VHA has a baseline, a minimum floor, for operations for our nursing homes. The VHA knows clearly what the will of Congress is, as embodied by law. The challenge as an agency will be to maintain and use these nursing home beds effectively. And the VHA is doing just that. Over the last 5 years we have dramatically decreased the length of stay in our nursing homes, while, within the same time period, treating ever so many veterans with those same nursing home resources (Fig. 2). These nursing home resources need to be available at the right time for our veterans' health care needs, which is often in the end stages of illness.
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Veterans' needs come before programs. Even if VERA changes along these lines are not made within the next couple of years, it would be good managerial practice to pull Case Mix Indexes of MDS data in all VHA nursing homes and use this information to inform resource deployment at the network level.
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The Nursing Shortage |
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TopAbstractThe Old VHARecent Changes in the...Putting Veterans FirstThe Future of Long-Term...The Nursing ShortageCommunity-Based CareThe New ChallengeResearch and the VHAReferences |
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The Outlook for Nursing in America
In response to this situation we need comprehensive national and network approaches in the VHA to recruitment and retention of staff. Included in this comprehensive approach should be proposed legislative changes. Congress has legislated its will in the Millennium Health Care and Benefits Act, and over the next 5 years we need to educate Congress on the changes and support levels required to meet the intent of this legislation.
Some changes that may be necessary and are practical include:
Some initiatives and proposed legislative changes are self-explanatory:
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Community-Based Care |
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TopAbstractThe Old VHARecent Changes in the...Putting Veterans FirstThe Future of Long-Term...The Nursing ShortageCommunity-Based CareThe New ChallengeResearch and the VHAReferences |
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The decision makers at the VISN level would be wise to attend to their deployment of VISN resources to meet the long-term care needs of their enrolled veterans and the potential growth in their market share of this population. This is especially relevant given that current reimbursement methodologies (VERA) align fiscal incentives with patient needs, the regulations codified in the Millennium Health Care and Benefits Act and estimated in the projected demand for services generated by the long-term care model.
To underscore the importance of this point, in Network 2, on average, over the last 3 years, at least 40% of our total network revenue is generated through the VERA-designated special care (complex care) patients. There is a direct correlation between the fiscal health of a network and the number of complex care patients it serves. Our primary care population and services to basic care patients are essentially underwritten through the services we offer to special care patients at the complex rate. In every case nationally where networks have experienced a decrease in the number of their complex care patients or curtailed resources for long-term care services, these networks have suffered overall negative financial consequences.
Additionally, while networks are not reimbursed for Priority 7 basic care patients, our experience in Network 2 often shows that veterans who initially come to us as Priority 7 patients rapidly migrate down to priority categories 4 and 5. This frequently occurs as a result of patients using their money to pay for management of their chronic care illnesses.
Another recent trend that bears monitoring is the dramatic increase in cost of pharmaceuticals. In fact, it has been stated (by Dr. Judy Feldman, Network 3, at a recent Management Advisory Council meeting) that in some instances costs for medications are, or soon will be, outpacing outlays for acute illness treatment. While this is good news for patients, in that they potentially avoid an acute admission, it is a factor that the VA cannot afford to overlook or avoid managing if it is to remain successful in delivering quality care to our aging veterans.
In the future, long-term care planning at the network levels, more than ever, will need to draw upon the expertise of geriatrics and extended care (GEC) to translate network policy and resource alignment in a way that puts "patients' long-term care needs first." Such planning input is good for the aging veteran and is good for the VHA networks. GEC and network goals are allied, and VHA provides financial incentives to support this alignment through VERA-modeled resource distribution. Capitalizing on the VHA's resource models taps into the agency's goal of promoting development of the health care system for our aging veteran population.
With the passage of the Millennium Health Care and Benefits Act, long-term care is no longer seen as an add on. Our patients' needs for long-term care have been placed solidly within the core of VHA service delivery to our enrolled veterans. As demand for long-term care service grows over the next 5 years, the VHA will be challenged administratively to meet these demands within resource constraints.
In this regard, GEC is called upon to manage our extended care services efficiently and effectively. The home-based primary care programs offer lower cost alternatives to facility-based nursing home units. Effective administrative oversight and management of the entire continuum of extended care support the long-term care patient in the appropriate setting for his or her care needs. Facility-based resources are only one part of the continuum. They are best kept available for only those who require them and only when they require them. The VHA has been able to offer more extended care services to more veterans and forestall or avoid institutional care by dramatic expansion of home care programs. Services offered in the home support veterans where they, and their families, want them to be treated for as long as it is appropriate. In these home and community settings I foresee that over the next 5 years the VHA will not only maintain, but also increase, already established home-based services for patients with chronic illnesses. The VHA will not only open up these home and community programs to even more veterans (this in itself is an administrative and financial challenge), but in fact will have to extend home care services further than are currently provided.
One of the demonstration projects that illustrates this expansion is the offering of palliative and end-of-life care offered in the home. The AHEAD project (advances in home-based end-of-life care to Alzheimer's patients with dementing disorders), a rapid cycle breakthrough series, offers the promise of rapidly transforming service delivery patterns to the terminally ill in their homes (another example of long-term care defined by patient need). This model is significant in that it modifies the capacity of the HBPC program to further adapt to the changing needs of our aging, chronically ill veterans. In a network such as Network 2, having a GEC line across all facilities contributes to the rapid deployment of this type of initiative.
The demographic imperative cited in the Federal Advisory Committee Report is real. The WWII veterans may be dying at the rate of 1,000 per day, but, increasingly, WWII veterans represent a proportionally larger percentage of those who use the VHA health care system. It is not just the volume of aging veterans that is the challenge in the near future. As veterans age they become heavier users of health care resources. So it is literal numbers coupled with increased use patterns that are the challenge.
Additionally, and perhaps most significantly, it is also the nature of their illnesses. Progressively, the VHA is more and more often presented with the chronic condition of the patient as well, for as our veterans age, they will age with concomitant chronic illnesses.
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The New Challenge |
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TopAbstractThe Old VHARecent Changes in the...Putting Veterans FirstThe Future of Long-Term...The Nursing ShortageCommunity-Based CareThe New ChallengeResearch and the VHAReferences |
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So, what is the nature of this challenge?
The VHA has organized itself and the medical care delivery system for episodic outpatient treatment and cure, and if not cure, then management of acute illness in one of our hospitals or in a subspecialty treatment center. But increasingly the patients present with chronic illnesses. If the challenge of putting their needs first is taken seriously, the VHA primary care system will have to be overhauled in the next 5 years.
Let us examine this challenge more carefully.
In the course of the previous 5 years, there has been a paradigm shift. The VHA has changed from hospital-based care to primary care. In order to provide for the long-term care needs of veterans, the VHA must change further, and this change will also require a paradigm shift. Changes in primary care are necessary because of the very nature of chronic illness itself. Chronic illness is lived 24 hours a day. It is not amenable to cure. As our veterans adapt to the chronic conditions, typically their entire life is affected, as well as that of their families. These full spectrum changes are at the heart of chronic care management. How will the VHA address these needs in a primary care setting?
At present, the VHA is configured as a primary health care delivery system. Primary care is very good at medical symptom management and treatment. What the VHA is not so good at is total care management of chronic conditions. It bears repeating. Perhaps this change in primary care delivery to accommodate total care management of persons with a chronic illness is the most significant change I foresee for the VHA over the next 5 years.
What is involved, then, in the paradigm shift to integrating chronic care management into the VHA primary care service delivery patterns?
We, in the VHA, have built a fine primary care infrastructure, and as the VHA changes to respond to the needs of our long-term care patients, it is not going to discard this key component of the health care delivery system. In fact, the VHA cannot forget that our veterans with chronic illnesses are not the only veterans our system is responsible for treating. The challenge to the VHA is to continue excellent primary care service delivery for our general veteran population while modifying it to accommodate changes in the way care is managed for veterans with chronic illnesses. This is a paradigm shift. The shift is not unlike the one that occurred when we moved from single function Swiss movement wrist watches that just told time to multifunctional digital gadgets that tell us time in multiple time zones, the pace we are keeping for our power walks, ambient temperature, altitude, and so on. The shift is from a single function to an increase in multifunction capacity.
Over the last 5 years the VHA has had a good organizational experience of a paradigm switch from hospital-based care to primary care, and in the process it has not done away with hospitals. Yet, the VHA does not use its hospitals in the same manner as it did 5 years ago, either. As the VHA changes over the next 5 years, it will retain primary care but it, too, will not be used in the same way 5 years from now as it is today.
The paradigm shift the VHA now faces is for primary care to accommodate the integration of chronic or long-term care management into a primary care setting.
How will this happen? What will integrated primary care look like in 5 years? Some of the elements of the needed changes in primary care service are available in the literature. One such model is from Dr. Edward Wagner of the Chronic Care Institute. His work, funded by Robert Wood Johnson, offers a demonstration of an integrated chronic care model that differs from classic primary care.
The goals of primary care treatment for the chronically ill become management of conditions rather than effecting cures. Roles will change. The providers will not be thought of as the "primary care providers." The chronically ill veterans and their families will be the primary care providers. To work with these "providers" we have to spend time with them. And we have to spend time with them over time. But how do we get to know more thoroughly our aging veterans and their families, and the changes they are going through, with the current system of 15- to 20-minute primary care sessions?
One of the first things the VHA needs to do is to make family members feel comfortable and part of the health care team. The staff will have to learn how to encourage patients and their families to be engaged actively with the self-management of their conditions rather than place unrealistic reliance on our health care providers. One of the promising methods to "expanding the 15-minute visit" is demonstrated by Dr. Wagner with the use of the "group visit." By scheduling groups of patients, and at times their families, to meet with a provider, chronic illness management, progression of illness monitoring, and intervention strategies can be done for a group of patients rather than individuals. Veterans may actually spend more time with providers in a group visit than they currently do in an individual one, and they would additionally benefit from mutual support of veterans with common problems. Providers would have more time to see more patients and would be able to maximize their use of time.
Chronic care treatment is ongoing, rather than episodic, and changes the type and frequency and the very nature of the treatment relationship. Doctors and midlevel care providers would be able to do it all, and the primary care visit would not be the only place where care happens. We will need to expand the care contacts outside of outpatient visits. Telecare, ongoing case management, incorporation of community agency interventions, and so on, all planned along the progression of chronic illness, will need to be incorporated into a primary care plan. The computerized medical record and integrated databases will assist the VHA as we move to integrate care delivered to veterans from multiple sources, at multiple sites, into one integrated, coordinated plan of chronic care management. Templates within the medical record will have to be changed by soliciting input from our practitioners about vital comparative medical information that they need to effectively track changes in conditions over time and to inform their recommendations for treatment and interventions.
Network 2 within the VHA has touched on some of this future. We are participating in the National Chronic Care Consortium's Chronic Care Network for Alzheimer's disease (CCN/AD) national demonstration project. For this project, we are working within the rigors of a defined research protocol to attempt a systems change, and our structure in Network 2 has contributed to rapid deployment of these changes. We are working out procedures for early identification of patients with high risk chronic conditions and patients with dementia, and we are doing this in the primary care setting. Identification is followed by established testing protocols and referral procedures to activate dementia care managers, all within the primary care setting. Our care managers then maintain ongoing relationships with the patients suffering from dementia and their families. They become key players in gathering critical information in the evolving story of the dementia as it plays out in these patients' lives.
The dementia care managers provide routine reports to primary care providers on the status of the entire situation in the family, their ability to manage the patient, as well as changes in the patient's functioning. Experience has shown that, without a total picture of the financial, emotional, physical, social, and community supports that are at play, and, additionally, how the family and patient are or are not managing the chronic illness, the primary care provider is, in fact, marginalized.
Another benefit of this CCN/AD project has been the partnership VISN 2 has had with both local chapters and the National Alzheimer's Association. We have learned that despite the vast array of long-term care services in the VHA continuum, as the VHA tries to assist patients in managing their chronic illnesses, there will never be enough resources or programs. The all-encompassing 24-hours-a-day nature of chronic illness is too much for any one system, even one as large as the VHA. To be truly successful at providing long-term care as defined by patient needs, the VHA needs to successfully partner with community agencies. And it needs to partner to the degree where these agencies are integrated into primary care planning. There is a need to incorporate into the overall care management plans what the community knows about VHA patients and families and what they are doing for and with them.
Management of chronic care pushes the edges of all the VHA partnering relationships. But growth is always at the edges! In fact, the VHA is on the frontier, pushing the envelope. The VHA will need to change its relationships with most of the community and allied partners in the delivery of coordinated chronic care, not just with Alzheimer's Association chapters. In some cases, as in the case of the state veterans' home partners, expanding the partnerships may mean revisiting the regulations that define and bind these interactions. For some of the community agency partners it may mean increased sharing agreements.
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Research and the VHA |
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TopAbstractThe Old VHARecent Changes in the...Putting Veterans FirstThe Future of Long-Term...The Nursing ShortageCommunity-Based CareThe New ChallengeResearch and the VHAReferences |
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So where will the VHA go in the future in the areas of research and education? The new VHA special fellowships in geriatrics are already laying the groundwork for the development of the next generation of academic geriatricians. With 21 GRECCs now spread throughout the United States, one may expect to see further excellent basic and clinical research in aging emanating from the VHA. The GRECCs will continue to provide high quality innovative educational programs for both the VHA and other health professionals. The GRECCs are also in a unique position to play a leadership role as the VHA develops its system-wide community integrated care system for the aging veteran population.
Summary
In summary, I foresee over the next 5 years nothing less than a radical paradigm shift that changes the roles, responsibilities, and practice patterns of primary care. I also foresee the VHA leading the way in this transformation. Our population of elderly patients is aging perhaps 15 to 20 years ahead of the rest of American society. The successful changes the VHA makes will impact health care delivery for the nation.
Over the next 5 years I foresee changes in the type of information, resources, and staff the VHA shares with its community partners. People will be reporting and coordinating with treatment teams in ways currently not seen. Care management will not be seen as located in any one place at any one time; it will be offered continuously with supports brokered and arranged with a myriad of partners. The future of the VHA will not be as sole provider of care but as a solidly aligned partner with multiple providers involved in the care management of chronic illness.
There is no magic to effect changes that need to be made in long-term care. Change will come about with or without active involvement of the VHA. But the VHA can bring about the future if we choose to. The magic, if there is any, is in our repetition of the VHA incantation and our continued faithful adherence to the premise of "putting veterans first."
Received April 18, 2001
Accepted May 3, 2001
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References |
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TopAbstractThe Old VHARecent Changes in the...Putting Veterans FirstThe Future of Long-Term...The Nursing ShortageCommunity-Based CareThe New ChallengeResearch and the VHAReferences |
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  J. E. Morley, J. H. Flaherty, and D. R. Thomas Editorial: Geriatricians, Continuous Quality Improvement, and Improved Care for Older Persons J. Gerontol. A Biol. Sci. Med. Sci., September 1, 2003; 58(9): M809 - 812. [Full Text] [PDF]
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D. Tsilimingras, A. K. Rosen, and D. R. Berlowitz Review Article: Patient Safety in Geriatrics: A Call for Action J. Gerontol. A Biol. Sci. Med. Sci., September 1, 2003; 58(9): M813 - 819. [Abstract] [Full Text] [PDF]
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