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IV. Agency Budget Summaries

DEPARTMENT OF VETERANS AFFAIRS


  1. RESOURCE SUMMARY

  2. METHODOLOGY

    • "Treatment Costs" represent the cost for all inpatient and outpatient care of veterans with a primary or associated diagnosis of drug abuse. These figures include the cost of care for these patients in the following: specialized drug abuse treatment programs; specialized substance abuse programs treating veterans with alcohol and/or drug abuse problems; and, all other medical programs (e.g., medicine, surgery, psychiatry, etc.).

    • For specialized drug abuse treatment programs, 100% of the costs are included. However, the majority of patients receiving specialized treatment for drug abuse problems receive their care in substance abuse treatment programs. Substance abuse treatment programs provide services to drug abusers, alcohol abusers and poly-substance abusers. The costs allocated for the treatment of veterans with drug abuse problems in these programs are based upon an analysis of the proportion of drug abuse diagnoses within the total substance abuse population treated in the specialized programs. In determining the treatment costs for drug use disorders in specialized substance abuse treatment programs, 62.9% of the total costs of these programs is allocated.

    • The other related medical costs for drug abuse patients (i.e., costs for care other than specialized drug treatment in dedicated drug or substance abuse programs) is comprised of five general components: 100% of the other related medical costs for patients with a drug diagnosis and treated in a specialized drug program; 100% of the other related medical costs for patients with a primary drug diagnosis and treated in a specialized substance abuse treatment program; 100% of the other related medical costs for patients with a primary drug diagnosis and treated in programs other than specialized drug or substance abuse programs; 50% of the other related medical costs for patients with a second diagnosis (not primary) involving drug abuse and treated in programs other than specialized drug or substance abuse programs; 25% of other related medical costs for patients with an associated (not first or second) drug diagnosis and treated in programs other than specialized drug or substance abuse program.

  3. PROGRAM SUMMARY

    • The Department of Veterans Affairs, through its Veterans Health Administration, operates a network of substance abuse treatment programs located in the Department's medical centers, domiciliaries and outpatient clinics. VA plays a major role in the provision of services to veterans who are "service connected" or indigent. (The term "service connected" refers to injuries sustained while in military service, especially those injuries sustained as a result of military action). All of the drug-related resources support Goal 3 of the National Drug Control Strategy.

    • The investment in health care and specialized treatment of veterans with drug abuse problems identified as funded by the resources in Medical Care helps avoid future health, welfare and crime costs associated with illegal drug use.

    • In coordination with NIDA on how to best employ outreach models, VA has been a participant in the Treatment Improvement Protocol (TIP) initiative developed by the Center for Substance Abuse Treatment of SAMHSA in HHS. A component of this project is the specific development of a TIP relating to case management and the associated facilitation of access to treatment.

    • The dollars expended in research help to acquire new knowledge to improve the prevention, diagnosis and treatment of disease, and acquire new knowledge to improve the effectiveness, efficiency, accessibility and quality of veterans health care.

    • The Department of Veterans Affairs, in keeping with modern medical practice, continues to improve service delivery by expanding primary care and shifting treatment services to lower cost settings when clinically appropriate. Included in this shift to more efficient and cost effective care delivery has been VA's substance abuse treatment system. Initial data suggest these shifts in care delivery may impact budgets in future years. The exact nature of the impact, if any, cannot be determined until additional trend data becomes available.

  4. BUDGET SUMMARY

    1998 Program

    • The 1998 base contains an estimated $1,092.632 million towards this program for medical care. This program consists of $520.571 million for inpatient drug abuse care and treatment, $571.720 million for outpatient treatment and $0.341 million for prevention activities. Evaluation of substance abuse treatment programs will continue in 1999.

    • The 1998 base contains $4.57 million for research and development to be applied towards drug abuse related research.

    Goal 3: Reduce health and social costs to the public of illegal drug use.

    • Strategy: Improve access to diagnostic and treatment services for addicted veterans, thereby relieving suffering and avoiding further social, medical and psychiatric complications.

      • Performance Goal 1: in FY 1998, all newly admitted patients with a primary substance use disorder diagnosis will be tested with the Addiction Severity Index (ASI) instrument. All patients with a primary substance use disorder diagnosis will receive a follow-up ASI at 6-month intervals. At least 50% of the patients whose initial ASI was administered within 14 days of admission to a new episode of care and who have received no treatment in the 30 days prior to admission will show 25% or more improvement in their drug composite score and at least one other composite score. By FY 2003, the proportion of patients who demonstrate improvement will increase to 75%.

      • External Factors: VA treatment goals are guided by the Office of National Drug Control Policy. To implement this goal VA will develop a "train-the-trainers" program to assure that each VISN has an adequate cohort of clinicians to administer the ASI. Each VISN will select two candidates to attend a training program for trainers. These individuals will then function as training resources for clinical facilities in their VISNs.

    1999 Request

    • The 1999 request is a total of $1,139.074 million, an increase of $41.872 million. The request is composed of $1,134.344 million for medical care and $4.730 million for drug abuse related research. In conjunction with the Department of Health and Human Services (HHS) and the Department of Justice (DOJ), the Department of Veterans Affairs (VA) will make available to communities its expertise in drug treatment theory and program development. The emphasis will be on the establishment of a treatment continuum, the implementation of patient/treatment matching and methods of evaluating treatment outcome. VA will be able to accomplish this within existing resources, primarily through its Center of Excellence in Substance Abuse Treatment and Education (CESATE) and its Program Evaluation and Resource Center (PERC). These two entities already provide these services within VA and will be made available for integration into similar activities within HHS and DOJ.

    Goal 3: Reduce health and social costs to the public of illegal drug use.

    • The 1999 request includes the following Goal 3 enhancements:

      • Increase treatment efficiency and effectiveness. Provide information on successful methods in various programs and the number of referrals that enter treatment. The dollars expended in research help to meet this goal and objective by (1) acquiring new knowledge to improve the prevention, diagnosis and treatment of disease, and (2) to acquiring new knowledge to improve the effectiveness, efficiency, accessibility and quality of veterans health care.

      • Use effective outreach referral and case management efforts to facilitate early access to treatment. In coordination with NIDA on how best to employ outreach models, VA has been and will continue to be a participant in the Treatment Improvement Protocol (TIP) initiative developed by the Center for Substance Abuse Treatment of SAMHSA, HHS. A component of this project is the specific development of a TIP relating to case management and the associated facilitation of access to treatment. Previously issued TIPs have been made available to VA treatment programs, and have been used in VA's continuing education activities. This will continue in the future.

  5. PROGRAM ACCOMPLISHMENTS

    • Specialized substance abuse treatment services are available at 126 VA Medical facilities.

    • VA continues to provide inpatient treatment services to veterans with significant substance abuse and psychosocial problems: 35% are 50 and older, 75% are not married, 36% are members of an ethnic minority, and 33% have service-connected disabilities. Among patients with drug diagnoses treated in specialized inpatient substance abuse units, 63% abuse cocaine, 21% abuse opiods, and 37% have co-existing psychiatric diagnoses.

    • The Program Evaluation and Resource Center (PERC), Palo Alto VAMC, is conducting a major process-outcome evaluation of substance abuse treatment programs. PERC is focusing on substance abuse treatment programs at 13 VAMCs that follow a traditional 12-step and/or a cognitive behavioral treatment approach. These are the two most prevalent treatment orientations in VA programs. Intake and discharge data have been collected on over 3,000 patients; one- and two-year follow-ups are being conducted. Treatment outcome will be assessed in terms of drug and alcohol use, problems related to use, depression, employment and readmission for treatment. The project will also examine the processes underlying the two treatment approaches and whether certain types of patients fare better in each type of treatment.

    • A second outcome-oriented evaluation focuses on the VA's Contract Residential Facilities (CRF) Program that provides residential care which serves as a bridge between inpatient treatment and independent life in the community for selected substance abuse patients. Four-year follow-up findings for patients referred to CRF's in FY97 indicate that those who had longer episodes of residential care were less likely to be readmitted for substance abuse treatment or psychiatric care. A survey of CRFs identified three models of care in such facilities (psychosocial model, supportive rehabilitation model, and intensive treatment model). A prospective follow-up study of patients admitted to CRFs is being conducted to estimate more accurately the effects of such care, to determine the processes that account for those effects, and to identify the characteristics of patients who are the best candidates for placement in different models of CRF care.

    • The Program Evaluation and Resource Center is working with Mental Health and Behavioral Sciences Service to develop a system of indicators to monitor the provision of services to veterans with substance use disorders. The first phase of development will test monitors designed to assess the effectiveness of early intervention as well as monitors measuring access to treatment and continuity of services. Later phases will evaluate treatment outcome using indicators such as changes in substance use, medical and psychiatric status, economic status and social conditions after receipt of services.

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