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

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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.

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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

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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

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Audiology Outpatient VisitsSource: VSSC Workload Report

0100000200000300000400000500000600000700000800000900000

1000000

FY99 FY00 FY01 FY02 FY03 FY04 FY05 FY06

VISITSUNIQUES

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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

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Top 5 Individual Disabilities

Condition # of DisabilitiesHearing Loss 413,989Tinnitus 339,573Musculoskeletal (generalized) 300,098Skin 283,337Musculoskeletal (arthritis) 272,047

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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.

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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

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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.

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OIF/OEF Service Members

Reserves/Guard 412,400

Active Duty 1,047,000

Total 1,459,400

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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)

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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.

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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

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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.

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Name Change at DDC

Denver Acquisition & Logistics Center

Expanding functions and activities

New name more accurately reflects expanded mission

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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

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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)

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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

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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

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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

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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

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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

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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

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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)

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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)

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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

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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

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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

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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

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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.

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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)

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Polytrauma

• Polytrauma System of Care• OIF/OEF Initiatives• PTSD-Mental health• TBI Screening• Case Management• New Environment of Care

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Culture Change

Applies to all areas of the continuumAge and interestsMilitaryConsumer influenceMarketingBest practice and alternative models

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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

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It Is All About Taking Care of Veterans

“We are dealing with veterans, not procedures; with their problems, not ours.”

General Omar Bradley

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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

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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

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Supplemental Material

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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.

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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.

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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.

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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.

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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.

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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.

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Thanks for Listening!