National Office ReportAssociation of VA Audiologists
April 18, 2007
Lucille B. Beck, Ph.D.Chief Consultant, Rehabilitation
Services and Director, Audiology and Speech Pathology Service
2
3
Recognized Benchmark for Quality
RAND study found that VA outperforms all other sectors of American health care across a spectrum of 294 measures of quality in disease prevention and treatment.
A comprehensive Harvard study in Archives of Internal Medicine concluded that federal hospitals, including those run by VA, provide the best care available anywhere for some of the most common life-threatening illnesses such congestive heart failure, heart attack, and pneumonia.
For the 7th straight year, VA received significantly higher marks than the private health care industry on American Customer Satisfaction Index (ACSI).
VA won the prestigious “Innovations in American Government” Award from Harvard University’s Kennedy School of Government for its advanced electronic health records system and performance measurement system.
4
Responding to the Demand…
630 audiologists54 audiologist/speech-language pathologists134 health technicians (assistants)Increase in hearing aid sales (FY96-FY06): 322%
Source: KLF Employee Report (October) and VA Denver Acquisition and Logistics center
5
Audiology Statistics (FY06)
Audiology encounters—928,847─ 920,110 outpatients─ 8,737 inpatients
Number of unique outpatients—464,017(up 2% from FY05)
Number of visits per unique—1.95 (no change from FY05)
Source: National Patient Care Database and VSSC Workload Report
6
Audiology Outpatient VisitsSource: VSSC Workload Report
0100000200000300000400000500000600000700000800000900000
1000000
FY99 FY00 FY01 FY02 FY03 FY04 FY05 FY06
VISITSUNIQUES
7
Top Five Disabilities by Body System (FY05)
MSD 3,002,239 (39.1%)Auditory* 882,413 (10.7%)Skin 799,131 (10.4%)Neurological 521,970 (6.8%)Mental 520,497 (6.8%)
*Includes tinnitus and hearing loss
8
Top 5 Individual Disabilities
Condition # of DisabilitiesHearing Loss 413,989Tinnitus 339,573Musculoskeletal (generalized) 300,098Skin 283,337Musculoskeletal (arthritis) 272,047
9
Auditory Compensation
Condition Number Compensation PaidHearing Loss 130,586 $602,986,029Tinnitus 322,621 $416,452,836Total 453,207 $1,019,438,865
Notes: (1) Does not include 0% SC(2) Total annualized cost of hearing loss and tinnitus. (3) Includes all hearing loss codes (6100-6110, 6250-6258, 6277-6297) and separately for
tinnitus (6260). The table does not include 0% SC as these veterans do not receive compensation. Note: 16,952 veterans (about 5% of total) were rated at 0% for tinnitus, although tinnitus is usually rated at 10%. 283,439 veterans (68% of total) were rated at 0% for hearing loss.
10
Tinnitus Disability Trends
Numbers of Veterans Service Connected for Tinnitus
80,000 86,490 90,556104,630 115,000
132,046144,243
162,409
196,541
242,610
289,159
339,573
395,324
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
450,000
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
Num
ber o
f Vet
eran
s
11
OIF/OEF Demographics
Gulf War Era veterans are the largest pool of veterans second only to the Vietnam Era veterans in number on the VBA roles.
Gulf War Era began on August 2, 1990, and continues to this day.
OIF/OEF, while not an “era” at present began on September 11, 2001.
GWOT includes OIF/OEF and other world-wide deployments.
12
OIF/OEF Service Members
Reserves/Guard 412,400
Active Duty 1,047,000
Total 1,459,400
13
VA Health Care Utilization
• FY 2002 to 2006 (4th Q)• Among all 631,174 separated OIF/OEF Veterans
– 32% (205,097) of total separated veterans have sought VA health care since FY 2002
– 97% (198,379) of 205,097 evaluated OIF/OEF patients have been seen as outpatients only by VA and not hospitalized
– 3% (6,718) of 205,097 evaluated OIF/OEF patients have been hospitalized at least once in a VA health care facility
– 4% of the 5.3 million individual veterans who received VHA health care in any one year (2005 data)
14
Quality…Quality…Quality!
Productivity is not the whole story.Audiologists must provide high-quality, evidence-based care.Professional practice statements define procedures to be performed.Measuring and verifying outcomes are essential to good clinical practice.
15
Practice Statements
• http://www.audiology.org/publications/documents/positions/
• http://www.audiology.org/NR/rdonlyres/0F995137-F66B-4B18-9D7D-A9BEE50EA1C2/0/algorithms.pdf
• http://www.asha.org/NR/rdonlyres/5CC8E228-AF53-40A2-91CE-9D9124FDA8B5/0/18871_1.pdf
16
Productivity
New DSS Rehabilitation Services Report– National encounter and product data drillable to the clinic and
provider level– Outpatient and inpatient data– Basis for productivity and staffing models
Only half of audiology sites reported encounters through QUASAR or Event Capture.Product-level data capture is necessary for national reporting and productivity/staffing modelsStrong association between staff size and the number of encounters (r=.89) but a weak association (r=.18) between staff size and productivity. Larger staff does not necessarily mean higher productivity.
17
Name Change at DDC
Denver Acquisition & Logistics Center
Expanding functions and activities
New name more accurately reflects expanded mission
18
FY06 Hearing Aid Statistics
310,352 hearing aids issued (-1.6% from FY05)Net sales: $107,048,413 (-2.4% from FY05)Average unit cost: $344.93Batteries: 27,265,017 (+4%)Repairs: 273,203 (no change)Cost of VA contract hearing aids and related services: $125 million
*Does not include off-contract procurementSource: DALC Commodity Sales Report
19
VA Hearing Aid Trends
(FY96-FY06)Source: VA Denver Acquisition & Logistics Center
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
FY96 FY97 FY98 FY99 FY00 FY01 FY02 FY03 FY04 FY05 FY060
20
40
60
80
100
120
140
UNITSSALES (000)
20
FY07 to date (2nd Quarter)
101,785 hearing aids issued (+10% from 2Q FY06)Net sales: $57,322,931 (up 11% from 2Q FY06)Average unit cost: $346.80
21
National Contracts
Digital Hearing Aid Contract─ ITE (60%) and BTE (40%) hearing aids─ New Device Category: Open ear digital BTE (August
2006)─ BTE sales rose from 20% (Base Year) to 40% of VA
sales (Option Year II)New national contracts:─ Cochlear Implants (February 2006)─ Assistive Devices (April 2006)
Contract-mandated education and training
22
New Category Purchases in FY06
Assistive devices:– TV Amplification Systems – FM Systems – Amplified Telephones – TTY/VCO Telephones – Personal Amplifiers – Smoke Detectors – Alarm Clocks – Doorbell Alarms – Accessories
Strong demand: – FM wireless--3,803 devices, net sales: $2.3 million– Other ALD—3,793 devices, net sales: $573,000
Source: Denver Acquisition and Logistics Center
23
Cochlear Implants
Cochlear implants (first year of contract):– 124 implants and 36 speech processors ordered – Net sales to date: $2.9 million– Estimated annual savings: $611,000– All three FDA-approved manufacturers on contract– Average implant price: $22,000– 54 implants and 19 processors FY07 to date (2nd Q)
Source: Denver Acquisition and Logistics Center
24
Hearing Aid Sales Trends
VA sales volume remained stable in FY06 for second straight yearSales peaked in 4th Qtr FY04 stabilized in FY05The Hearing Journal*─ VA sales doubled from 1998 to 2004 and then declined in 2005─ VA market share decreased from 14.9% to 13.2%
Reasons for stabilizing sales trends:─ Sustainable capacity: short wait times, reduced backlogs, continued
veteran satisfaction─ System improvements: 60% increase in audiologist staffing, 720%
increase in use of health technicians, electronic health records (ROES)─ Deferred replacements: focus on re-programming, maintenance, and
repairs
*The Hearing Journal, Vol. 59, No. 12, December 2006
25
Advanced Clinic Access and Best Practices
Major VHA initiativeStrategic Goal: “Health care system without delays”Strategies to improve access, quality, timeliness, efficiency, and satisfaction─ ACA transitioned to Outpatient Systems Re-
design ─ Resource to VISN Clinical Access Teams─ Tips, tutorials, and best practices─ National coaches─ Community of Practice Conference Calls─ Monthly waiting time and “missed opportunity”
statistics
26
Improving Access to Care
Goal: all veterans seen in 30 days.% New Patients seen within 30 days. ─Goal: 89% (June-August average)
% Established Patients seen within 30 days of desired date.─Goal: 92% (June-August average)
Missed opportunities (improving clinic utilization by reducing no shows and cancellations)─Goal: 8% (June-August average)
27
How Are We Doing?
New patients: 76.7% seen within 30 days (only half of sites, and 2 VISNs met the goal)Established patients: 97.2% seen within 30 days (89% of sites, and all but one VISN met the goal)Average wait: 23.5 days (new); 5.8 days (established)Missed opportunities: 8.4% (48% of sites and 52% of VISNs met the goal)
28
Percentage Appoints Seen <31 Days (January)
PERCENT APPTS WITHIN 30 DAYS
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
1 2 3 4 5 6 7 8 9 10 11 12 15 16 17 18 19 20 21 22 23
NEW
EST
29
Missed Opportunities (January)
MISSED OPPORTUNITIES
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
1 2 3 4 5 6 7 8 9 10 11 12 15 16 17 18 19 20 21 22 23
30
Audiology Professional Education
FY08 Traineeships awards:─ 41 Doctoral Externships (12 months)─ 61 Doctoral Clinical Rotations (350 hours)
Competitive site selection using automated standards of excellenceTraining to full scope of practice
31
Quality of Audiology Student Training
Measure Audiology VA-wideOverall (Goal=85)* 92 85Rated Excellent or Very Good 90% 78%Recommend to Others 96% 90%Choose Training Again 96% 87%As good as Other Training 100% 85%
*0-100 scale with 100 being perfect and 70 being passing
One measure of the success of training is whether or not the trainee would consider VA employment.
─ Before training—54% would consider VA employment─ After training—88% would consider VA employment
VA-wide, 33% would consider VA employment before training. After training, 66% would consider VA employment.
Source: 2006 Learner perception Survey, Office of Academic Affiliations
32
Improved Information Technology
Audiometer Interface Project:– Survey of all equipment used in VA– Automated collection of audiometric data
• Top 3 manufacturer interfaces have been tested successfully.
• Interfaces will send audiometric data (pure tone thresholds and speech recognition scores) into a national database.
• Audiograms available in electronic health record and ROES.
33
Cochlear Implant Initiatives
10 designated centers, 8 developing centers, and 4 DoD centersClinical practice recommendations─ Addresses medical criteria, site criteria (teams,
experience), eligibility, and logistics Joint collaboration between VA and DoDCochlear Implant RegistryNational contracting at DALCCI Advisory Board (CIAB)
34
Polytrauma
• Polytrauma System of Care• OIF/OEF Initiatives• PTSD-Mental health• TBI Screening• Case Management• New Environment of Care
35
Culture Change
Applies to all areas of the continuumAge and interestsMilitaryConsumer influenceMarketingBest practice and alternative models
36
Congress and the Media
• We are in the spotlight, sometimes positively, sometimes not
• Families have instant access• Expectations are high• Congressional inquiries are part of the job• Our Leadership in VA knows we are doing a
good job
37
It Is All About Taking Care of Veterans
“We are dealing with veterans, not procedures; with their problems, not ours.”
General Omar Bradley
38
Challenges
High risk of noise-induced hearing loss─ Over 750,000 veterans with hearing loss and tinnitus
disability─ Hearing loss is most common service-related injury
Increased awareness of hearing loss and tinnitusAging of the veteran population ─ Increased co-morbidities
Aging of the workforce─ One-third of work force eligible for retirement─ Mentoring new leaders
Technology Development─ Treatment technologies─ Information technology─ Staff education and training
39
The Future
Focus on patient-centered care and involvement in care decisionsFocus on outcomes and auditory rehabilitationSystems Improvement:– Workflow analysis– Time savings converted to increased direct patient care– Automation opportunities (ear impression scanning)
Improved information systems– Transition from 128 individual all-electronic medical center-based
systems → national, all-electronic health record (Health Data Repository)
Mentoring and staff educationTechnology summit
40
Supplemental Material
41
Strategic Plan
1. Continue development and validation of productivity models in collaboration with the physician productivity group.– 1-1 Assess and validate test data via DSS and other
modeling processes.– 1-2 Review varied models for measuring productivity
for ease of implementation.– 1-3 Recommend a model to the Field Advisory Council
for use in the field.
42
Strategic Plan
2. Implement the IOI-HA Outcome measure for hearing aid services.– 2-1 Develop format to collect sample data from test
sites within the field.– 2-2 Validate the data collected to assure it provides an
appropriate outcome measure– 2-3 Assess potential of integrating measure with ROES
hearing aid issuing process.– 2-4 Recommend a collection model and methodology
to the Field Advisory Council for use in the field.
43
Strategic Plan
3. Continue focus on Advanced Clinic Access (Outpatient Systems Re-design)– 3-1 Develop and provide a "Right Practices" module
for use in the field.– 3-2 Develop Health Technician standards of practice
and training– 3-3 For sites having trouble meeting ACA guidelines,
assess effectiveness of current ACA principles in achieving the expected goals.
44
Strategic Plan
4. IT Road Map Implementation– 4.1 Prepare for roll out of audiometer and CPRS
patient data interface in march 2007– 4.2 Prepare and gain support for a New Service
Request for development of CPRS-ROES based Hearing aid interface and Impedance equipment interface.
– 4. 3 Prepare and gain support for a New Service Request for major modification of QUASAR into a workload and productivity GUI management tool.
45
Strategic Plan
5. Identify key Mentoring and Communication Program Modules in a joint goal with Speech Pathology.– 5.1 Pilot two modules and methods for mentoring and succession
planning.
OR– 5.1 Conduct a needs assessment of new Service Chiefs.– 5.2 Develop a mentoring program to link new Service Chiefs with
seasoned Chiefs.– 5.3 Update Audiology/Speech Pathology website to ensure
content reflects needs of new Chiefs.
46
Strategic Plan
6. Review effectiveness of Audiology intern inter- program socialization consistent with processes from the Office of Academic Affairs– 6.1 Appoint a task force to be responsible for reviewing
trainee socialization.– 6.2 Field Advisory Council to charter the taskforce with
expectations and time lines.– 6.3 Task force to recommend strategies and
collaborative efforts to assure and monitor effective socialization of Audiology trainees.
47
Thanks for Listening!