January 19, 2016


Hill Country Veterans Council Meeting
January 19, 2016
Kerrville VA Medical Center

HCVC Officers: President Vicki Marsh, VP Dave Rittenhouse
HCVC Members: Byron Warren, Dennis Birchall, Bill Cantrell, Gary Noller
KVA: Dr. Jennifer McElroy, Dr. Veronica McClean (Primary Care Mental Health Integration), Kim Wilson, Dr. Aven Senter, Dr. Raymond Castello
Guests: Nick Oprea
A presentation was provided by Dr. McClean on Primary Care Mental Health (PCMHI):


The PACT’s (Patient Aligned Care Teams) work directly with Patient Centered Medical Home, referring all patients either by patient request of Primary Care Physician identification.

The PCMHI PC Team concept consists of “Teamlets”: PCP, RN, LVN, clerical staff person
An extended team exists to provide additional support: Psychologists, Clinical Pharmacists, Dietician, SW's, Mid-Level Providers (NP, PA).
Typical Mental Disorder Sources include PTSD, Agent Orange, and everyday stress.

A Population Based Integrated Mental Health Care concept helps to achieve maximum effect on the served population.

There are two basic Models of care used throughout the VA system, plus a Blended version:
Co-Located Collaborative Care Model
Care Management Model
Three Levels of Care are provided:
Primary Care - Screening for MH issues
PC-MHI - Integrated Care
Specialty MH - Secondary and Tertiary Care
Main Line Care includes:
Chronic Disease Management
Comorbidities (secondary or tertiary illness) treatment, especially patient non-compliance with treatment (ex. Not taking medication) and adjustment disorders.
Psychosocial/Behavioral Issues
Depressive and Anxiety Disorders
Alcohol Misuse and Abuse
PTSD and Adjustment Issues
Insomnia, chronic pain, Panic Attacks, unexplained somatic symptoms, smoking, stress
Specialty MH Programs include:
PTSD Oriented Programs
Residential Treatment Programs
Intensive Outpatient Programs
Opiate Substitution Programs
Homeless Programs
Serious Mental Illness (STARR, Stepping Stones)
Supported and Therapeutic Employment
Mental Health Intensive Case Management (MHICM) - go into Veterans' homes
Long Term and Specialized Psychotherapy
Screening is done to categorize PCMHI into both low risk and high risk categories requiring differing levels of treatment.

One concept includes Shared Group Medical Appointments for Chronic Disease Management and DIGMA's (Drop In Group Medical Appointments).
Telephone based care is provided at KVA by Kim Wilson for appropriate patients.

There is no walk-in clinic; all referrals must come from the patient’s PACT.

Benefits of the PCMHI to Veterans include:
Improved access
Reduced wait times
Enhanced treatment engagement and adherence
MH capability has grown significantly since 2004 and it is considered to be reasonably well resourced in the STVHCS.

Civilian Care cooperation includes working closely with Veteran Treatment Centers (clinic) which include family oriented care.
Vicki expressed concern that Veterans and the community are not well enough informed on MH resources and how they are deployed.

There is a PCMHI meeting planned in February for the PACT's at KVA.

There is need to have Mental Health Summits well-advertised in advance.

The HCVC has offered to put key information on its website.

Telehealth contract arrangements exist with the Junction and Del Rio clinics. To provide this and other telehealth MH services, 2 STVHCS psychologists are full time telehealth.
There is also home based MH care for those who are home bound.

HIPPA concerns must be properly addressed. For non-emergency cases, the Veteran is asked for permission to access appropriate contacts. In the event of emergent situations, there may be a need to waive some aspects of HIPPA, which is allowed by law.

Old Business
Status of Fills

The ROI Clerk position has been filled. The may be a new phone number; not yet resolved.
STVHCS has completed Admin Officer interviews for KVA and final selection is in progress.
Green and Blue team doctor selections are on track.

The psychologist for GEM, Dr. Mark Floyd, has a March 24 start; he will transition to full time.
When patients are moved among PACTs once these fills are accomplished, they will be informed

Vacant custodial positions: 10 total custodial + laundry has 6 vacancies.

The new Dental Hygienist is now at Data Point for in processing.

KVA will be hiring an additional hygienist and additional dental assistant.

There is a new Psychiatrist lined up to start in July; in interim KVA is using telehealth.

The Secretary replacement (for Linda Watts) is pending an overdue update in position description.

KVA has identified a convenient location for displaying hiring postings.
Relative to posting jobs in KDT, the new HR chief is analyzing this for effectiveness and efficiency. As the VA budget is not yet released, but only a continuing authorization, there is in any case no funding at the moment.
Usajobs.gov now has KVA job postings.

There is a need for local advertising, which may most effectively further refer to usajobs.gov.

Veteran Emergency Care at PRMC: Due to the continuing issues with resolving outstanding payments from VA, PRMC has decided to start billing directly to patients. Jennifer has been meeting with PRMC to try to resolve the issues, which appear to originate from both parties. She is trying to set up a face to face meeting.

Jennifer does not know exactly when she leaves, but will attend at least one more HCVC meeting.

Choice Program:
Providers are increasing, there is now a surgery center included.
23,000 Veterans are eligible in STVHCS; about 2,500 have used Choice according to Tri-West
The "30 day" period is becoming problematic; there are a number of reasons why there might be more than a 30-day waiting period to include the Patient can change their appointment date.
Some Veterans Frustrations include:
Community wait standards might be much longer than 30 days.
Choice is not used for second opinions.
VA is working on a more consolidated “VA Care in the Community” concept for all non-VA Care plus Choice. However, the two programs remain separately funded.
The chart for Non-VA Emergency Care eligibility has been updated though the content remains the same.

The KVA telephone tree has problems and Jennifer is addressing this.
The request for a Full Time Wound Clinic has been investigated and there is not sufficient demand. Veterans currently have 5-day access to wound care.
Jennifer is unaware of a VA maggot policy (for removal of dead tissue).
Jennifer is unaware of VA re-writing RX's from outside providers. There may be varying medical opinions which can result in PACT not prescribing something a community provider prescribed.

Why do check in kiosks not work? A problem with the software has been identified. Houston has not removed their kiosks (as had been reported) but has relocated some to better locations.
KVA does not normally transport veterans from Freedom's Path. However, KVA has been working with Freedom's Path on their organizing a golf cart run by volunteers.

My Healthevet is now administered by Craig Rickaway.
The Museum will likely be provided with its own building; one of the old houses on the KVA campus.




Comments to us or the V. A. would be greatly appreciated.