VISN 21. Fresno VA Medical Center Reno VA Medical Center Redding VA Outpatient Clinic (Northern California Health Care System) Palo Alto VA

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1 VISN 21. Fresno VA Medical Center Reno VA Medical Center Redding VA Outpatient Clinic (Northern California Health Care System) Palo Alto VA Polytrauma Center

2 VA Central California Health Care System, Fresno, CA The American Legion visit to the VA Central California Health Care System (Fresno) March 23, 2006 Task Force Member: Gerald Schleining Field Service Representatives: Michael M. Smith The Veterans Affairs Central California Health Care System, based in Fresno, is a 157- bed acute care, general medical and surgical center with state of the art primary, secondary and tertiary care in major diagnostic and treatment specializations and two Community Based Outpatient Clinics (CBOCs). It is situated on 18.5 acres and was dedicated in March 1950 to serve the San Joaquin Valley and the rest of central California. Five Primary Care Teams and numerous specialty care clinics, including women s health, provide extensive outpatient services in a managed care environment. A 60-bed Geriatric and Extended Care Unit provides skilled nursing and rehabilitation care. Fiscal Central California s budget for FY 2005 was $113 million, versus $120 million for this year FY 2006, an increase of 6.6%. Management states that it has not had to make any reductions in staffing or levels of services since FY MCCF collections for FY 2005 were $5.7 million, exceeding its goal of $5.5 million. The collection goal for FY 2006 is $5,931,000, which management feels confident it can meet. Management says that Fresno has not had to use capital investment dollars to supplement its medical care budget. Enrollment and Access New walk-in patients are enrolled the same day, with an average wait time of 14 days for the first appointment. About 3% of all Primary Care patients must wait over 30 days for an appointment. Referrals to specialty care clinics are under 30 days, except for gastroenterology, which averages 80 days, reflecting the difficulty of obtaining GI services locally. Management estimates that Fresno has enrolled one quarter of the area s veteran population (30,000 out of 120,000). A lot of veterans are eligible for Tri-Care due to the proximity of Lamore Naval Air Station. According to management, the hospital largely avoids having to divert patients to other hospitals, save for trauma and other specialized requirements not available at VA. CBOCs Fresno currently has two CBOCs: one at Castle Air Force Base (near Merced) with a staff of nine, including a psychologist, and a second in Tulare with approximately nine in the staff, reportedly with room to grow. By 2010, budget permitting, Fresno hopes to have a third CBOC in operation in Oakhurst. Affiliations and Staffing The Central California Health Care System is affiliated with the University of California San Francisco, School of Medicine (for a number of residency programs), and with California State University Fresno, the University of Pacific-Fresno, the UC Berkley, UC Davis, UC Los Angeles, and California State University Bakersfield, as well as a number of community colleges.

3 Fresno has about three or four employees on J-1 visas; all are fulfilling their contractual obligations. The most difficult FTEE to recruit and retain include Pharmacy and Orthopedics, which are presently on contract, as are Dental, GI, Rheumatology, Radiology, Ophthalmology, Optometry, Dermatology, Orthopedic Surgery, Podiatry, Audiology, Urology, Gynecology, Psychiatry, and Internal Medicine. Surprisingly, the center seems to have encountered no major obstacles in hiring and retaining nurses, due in large part, according to management, to Dr. Richardson s aggressive management. At present, Fresno offers recruitment and retention bonuses, relocation expenses, and the Education Debt Reduction Program (for repayment of student loans). There are three employees presently activated in the Guard or Reserves out of 37 presently serving in the military. Physical Plant The main building at Fresno is over 50 years old, creating a host of maintenance concerns: the boilers are approaching the end of their useful life, elevators and switching mechanisms are also beyond their normal life expectancy. The steam lines are also aging and are up for replacement within the next three years. Though Fresno s budget is adequate to meet the current needs of the veterans.[c]hallenges might occur when an unforeseen event happens which requires us to shift funds from one project to another. Examples of this include the repair of the well from which we get our water or of a steam line. But [m]ajor [c]onstruction funding is very competitive and scarce. We submitted a project in FY 04 and FY 05 for major construction dollars to build a 58,000 square foot addition that will address seismic needs as well as increased demand. This undertaking has yet to be funded, and has been resubmitted. However, minor construction funds have been easier to obtain. Fresno has now completed a total gut and remodel of : The Acute Medical/Surgical Ward (2001) Acute, locked Psychiatry Ward (2003) Fourth floor specialty clinics (2005) Also encouraging is management s expectation that a new 12,000 square Mental Health Programs Building will be funded in time to begin construction in It will house chemical dependency, dual diagnosis and homeless programs. It would be impressive if the Medical Center were able to fund its major planned addition and if many of the aging and partially obsolete facilities in the nation s northern tier could afford a facelift. Long Term Care, Mental Health and Homeless Services Management reports no decrease in number of long term care/extended care beds since the Millennium Bill was passed in It remains at 60 operating beds in the Nursing Home Care Unit with 52 presently filled. There are some staffing shortages. There is no dedicated Alzheimer s

4 Unit, or dedicated Hospice Unit. Under CARES, Fresno will be eligible for a new clinic addition, though when that will occur, if ever, remains to be seen. Fresno appears to be beefing up its Mental Health services, having recently added a psychologist and social worker to its staff, along with the new two-story mental health clinic, mentioned under Physical Plant above. Management estimates that some 30% of combat returnees suffer from some form of mental health problem, including PTSD. With PTSD, there is emphasis on group treatment and particularly on active involvement in group sessions with spouses and other family members. Management says that in the future it may be developing certain mental health programs specifically targeted to [PTSD patients]. We are screening all OIF/OEF patients for PTSD, depression, alcohol abuse and exposure to infectious diseases, as mandated. We recently were granted funds for one Psychologist position to act as lead for a PTSD Clinical Team. This person will be involved in helping provide direct clinical care and integrating treatment: providing consultation and liaison to general psychiatry units, medical, and surgical units. They will also be responsible for supervising education programs on PTSD and monitoring utilization patterns of patients with PTSD. As a high percentage of OIF/OEF veterans are presenting to the VA with post deployment mental health issues, it will be challenging to meet this need over the long term with current funding levels. [From TAL Questionnaire] Fresno has assigned one psychologist, available in Primary Care most of the week for both referrals and therapy sessions. There is also a licensed clinical social worker available at Primary Care. Also increasingly important is Tele-Mental Health, which operates under IT. Homelessness in Fresno is described as a huge problem, as it is in many parts of California. The facility has no Domiciliary, but does have one (FTEE) Program Coordinator and one (FTEE) Social Worker. There is an ancillary staff consisting of employees, who are part of a community employment program for those 55 and above, and of formerly homeless veterans/clients. Fresno VA provides weekly case management for all veterans in the program at a facility called The McKinley House with 12 (malededicated) beds, which are almost always full. Some 150 veterans are seen per week for needs ranging from information, to intake, to case management. Fresno maintains links with community agencies and has secured a new grant for a program set to open in July that will house 36 (male) patients. Fresno plans to increase its ability to outreach to women veterans in the future, and to develop resources for families as well.

5 VA Sierra Nevada Health Care System (Reno VA Medical Center) The American Legion visit to the Reno VA Medical Cente April 27, 2006 Task Force Member: Gerald Schleining Field Service Representatives: Daryl H. Puryear The Veteran Affairs (VA) Sierra Nevada Health Care System (Sierra Nevada) is a primary and secondary care facility with a large geographical area that includes 21 counties in northern Nevada and northeastern California. Approximately 120,000 veterans reside in this region, with Reno representing the largest urban area. The Reno campus facility, called Ioannis A. Lougaris VA Medical Center, operates 56 hospital beds and 60 transitional care unit beds. VASNCHS provides a broad array of inpatient care and outpatient services in medicine, surgery, neurology, mental health, pharmacy, interventional radiology, alcohol/drug treatment, ophthalmology, audio logy/speech pathology, dental care, and home care. The hospital also offers diagnostic services, including MRI, CT, ultrasound, nuclear medicine, as well as cardiac catheterization services. Extended care provides rehabilitation, skilled care, palliative care, respite care, geriatrics evaluation, transitional care, and long-term care. Tertiary and unique specialty care not available within Sierra Nevada is supported through referrals to community hospitals and VA Medical centers in San Francisco and Palo Alto, California. Fiscal Sierra Nevada budget for FY 2005 was $99.7 million. In FY 2006 it was $107.6 million, representing an increase in funding of about eight percent. The FY 2005 budget allowed Sierra Nevada to maintain FY 2004 levels of services and open enrollment. However, staffing levels were decreased slightly from 775 to 760 FTEE. The impact from the last continuing resolution was the inefficiency of obligating funds on annual contracts on a monthly basis and the difficulty of conducting proper financial planning activity without knowing what the station s budget would be. There were no services eliminated or cut back. The facility had a major budgetary challenge with VA Central Office not realigning funds in timely fashion. There are not any costs going to unused facilities or any equipment dollars used to fund capital improvement projects. The MCCF collection goal for FY 2005 was $11.5 million; $10 million was collected. The collection goal for FY 2006 is set at $9 million; management declares that it will meet this goal. Enrollment and Access During FY 2005, Sierra Nevada provided care to 24,000 unique patients which accounted for approximately 225,000 outpatient visits, while treating more than 2,800 inpatients. Access to outpatient primary and mental health care is also available through community clinics: the VA Sierra Foothills Outpatient clinic in Auburn, CA and the VA Carson Valley Outpatient clinic in Minden, NV. Sierra Nevada provides approximately 2,375 Compensation and Pension examinations per year. It also is covering costs incurred. Additionally, the staff gives Gulf War Registry Exams. Between September 11, 2001 and March 22, 2006, Sierra Nevada has treated 367 OEF/OIF combat veterans. The total unique patient count for FY 2005 was approximately 24,000, so the overall percentage of new veteran patient load is low.

6 The time between the veteran s submission of an enrollment application (1010EZ) and his/her receipt of initial healthcare is less than seven days from enrollment to electronic wait list (EWL), less than 30 days from EWL to appointment for service-connected veterans and less than 120 days from EWL to appointment for Non-service connected. Approximately, 2340 veterans waited in excess of 30 days. This number decreased monthly and is now considerably less than previous months. Primary Care staff has realized a need for another provider to assist with recently backlogged patients. The noshow rate is close to ten percent and a multidisciplinary task force has been set up to design a Standard Operating Procedure. Some areas under review include: coding patients, providing information about a cancellation phone number and posters about the effects of no-shows in the care of other veterans. Data for new primary care appointments shows that 94 percent of veterans are scheduled within 30 days of the desired date. Ninety-seven percent of veterans are scheduled for follow-up appointments for established primary care appointments. While these numbers change from day to day, depending on current veteran enrollment, provider changes, and a myriad of other impacts; the staff closely manages these clinics to ensure stability and appropriate access for veterans seeking care. Affiliations and Staffing Major academic affiliations for Sierra Nevada are the University of Nevada School of Medicine in Reno, and the East Bay Surgical Program at the University of California, San Francisco. Approximately 30 medical, surgical, and psychiatry residents rotate annually through Sierra Nevada, as well as approximately 12 pharmacy students through a partnership with the Idaho State University and University of Southern Nevada Schools of Pharmacy. Five additional pharmacy residents rotate through the American Society of Health Systems Pharmacists, but also share affiliation. A number of students, interns, and residents from ancillary services and other academic affiliations also receive training at Sierra Nevada. Staffing remains a concern, due to budget cutbacks. Staffing levels were decreased from 775 to 760 FTEE. Ideally, the facility wants to hire more physicians instead of fee basing so much into the community. The specialties used for Fee/Contract physicians are as follows: Fee-based primary care, dentistry, radiology, neurology, cardiology, psychiatry, pathology, surgery (vascular, gynecology, general), anesthesiology and dermatology. Contracted are: gastroenterology, endocrinology, infectious disease, nephrology, general medicine, hematology and oncology. Three percent of its VERA budget is for Fee Basis services. Even with the Physician s Pay Bill, average specialty care doctors make close to $500,000 per year. The Pay Bill is less than what the facility expected and wished the concept and funding could be stronger. Of special need currently is one neurosurgeon and two gastroenterology specialists. Registered nursing recruitment is going very well, though it has been hard to hire licensed practical nurses (LPNs). There is a program where LPNs can become RNs within one year. Most are finishing that program. Therefore, Sierra Nevada has been hiring more nursing assistants and fewer LPNs.

7 Long Term Care, Mental Health and Homeless Services The total operating beds within VASNHCS were 122, with 116 operating currently. The average daily count filled is about 91 beds. The nursing home ward is not a locked Alzheimer s unit, and those special need patients are contracted out. Long Term Care services provided are: Geripsychiatric care, respite, skilled rehab, palliative care (hospice) and transitional care. Average daily census measures are being met and the facility has a good fall prevention program. There is a severe lack of options for its Geri-psychiatric patients; the facility does not have enough capacity and options in the community. Staff has difficulties contracting as there is a competition for beds in the community. There have not been any new nursing homes built within the last ten years, with an eight percent patient growth annually. Average discharge time to community is 58 days with the longest time reaching up to six months. There is some state legislative activity and interest in developing a state veterans home in the northern part of the state (Las Vegas only has one), but there are no indications of this materializing in the next year or so. Mental Health Care Services offered are: healthcare to homeless veterans, a vocational rehabilitation program, an addiction and behavioral health program and a continuing and chronic support group care. The facility received a grant for a PTSD psychologist and psychiatrist. Primary care has a psychologist embedded within its outpatient care. If a veteran has a mental health care concern, the psychologist is paged and comes to the veteran, on the spot, for evaluation and referral, if necessary. Some group therapy projects touch on topics such as: anxiety, depression, chronic pain and PTSD. Mental health care services are also provided in the CBOCs. There is a homeless veteran coordinator and a newly funded social worker that will specialize in homeless veteran services and in substance abuse. There is a Sierra Recovery Center that maintains 11 beds for homeless veterans and six other beds are in a group home in South Lake Tahoe. Veteran Service Officer Focus Group This meeting consisted of three State of Nevada office staff of Veterans Services. The group praised the good works of the medical center and there advance clinical access program. One of the concerns, however, was with the Disabled American Veteran van service. Apparently, a couple months prior to the visit they had two fatal accidents. The hospital implemented a focus group to study the routes of the program and cut back two routes. Some patients were concerned that appointment times would not coincide with the days the van came to transport them. Northern California Health Care System The American Legion site visit to Redding Clinic March 20, 2006 Field Service Representative: Michael M. Smith The Redding Clinic, a major facility with an FTEE of about 100, is located 163 miles north of Sacramento, where the main Medical Center for Northern California Health Care

8 is situated. Redding provides a broad range of services including Audiology, Dental, Cardiology (non-invasive), Gastroenterology (including Colonoscopies and Endoscopies), Compensation and Pension Evaluations (through a Nurse Practitioner), Physical Therapy, Occupational Therapy, Social Work, Orthopedic Surgery, Pre- and Post-Operative Surgery, Optometry, Ophthalmology, Podiatry, Urology and Vascular Surgery. For the last five years, Redding has operated a mobile outpatient clinic at six sites, serving over 700 patients. In addition, it operates a daily shuttle service to the main Medical Center at Sacramento, and one to the Martinez facility several times per week. The clinic also instituted some time ago an open access policy to facilitate veterans with urgent needs. The Redding Clinic has a strong relationship with the VA clinic at Chico, which is collocated with the Chico Veterans Center. The Chico Clinic attracts a large number of younger combat vets who are in training at the Fire Department training school, and has experienced a huge increase in Iraqi combat veterans. The clinic is now in the process of adding a dental suite, along with an already established tele-derm facility, which will allow patients to consult with the clinic telephonically from their homes. The Chico Clinic also provides lab work on site, and now has a full-time psychiatrist on its staff. Though the Chico clinic is close to capacity (staff are now on alternate work schedules), the urgent care section has been expanded with increased working hours. There are five mental health providers at Redding, but each job is only one-person deep, requiring a multi-trained staff. About 40-50% of all mental health patients are suffering from PTSD, partly due to a new wave of Vietnam vets. Though, in a sense, Redding and Chico are practicing frontier medicine, according to one manager, veterans expectations are quite high, particularly for veterans from southern California and its large, sophisticated VA medical systems there. This extensive and impressive clinic system, linked by shuttles and served by a range of specialists, with innovative features such as the mobile clinic, high tech advances (telemedicine and a centralized radiologist in Sacramento who can read scans from the clinic immediately through CPRS); all the above significantly improve access and efficiency in this spread out and sparsely populated portion of California s North. Northern California Health Care System The American Legion site Visit to Palo Alto, Polytrauma Clinic March 21, 2006 Task Force Member: Jerry Schleining Field Service Representative: Michael M. Smith

9 The Palo Alto Polytrauma Center is one of four such centers around the country, and the only one in the western half of the U.S. Its mission is to provide comprehensive inpatient and outpatient rehabilitation services for patients with complex injuries. Intensive case management is an integral component of care. Patients are identified for referral to the Polytauma Program primarily through Military Treatment Facilities, such as Walter Reed or Bethesda. Also service members or veterans are encouraged to contact VA on their own, if they feel they need care or evaluation for any injury, illness or mental health concern. The goals of the Palo Alto Polytrauma Center are sixfold: Provide post-acute medical assessment to patients injured by blast or accident. Provide medical, rehabilitation, and psychological treatment services. Coordinate care as patients move from acute hospitalization to rehabilitation and ultimately back to the home and community. Provide case management and family support through all phases of treatment. Monitor short and long-term outcomes. Pursue research assess treatment effectiveness for TBI, spinal cord disabilities and PTSD. As the name suggests, the polytrauma centers were initiated to treat a spectrum of injuries, since many combat and non-combat traumas involve multiple injuries. Palo Alto has put particular emphasis on Traumatic Brain Injury (TBI), an increasingly common occurrence in combat in the Middle East. Of combat injured evacuated to Walter Reed Army Medical Center, almost one third suffer from TBI, and it is suggested that the actual percentage may be higher for many returning troops who are not even aware that they are suffering from TBI. Another factor confounding effective treatment is determining if PTSD may be exacerbated by undiagnosed TBI. An important feature of Palo Alto s treatment of TBI is its Brain Injury Recovery for Outpatients (BIRO), which provides intensive outpatient treatment for serious brain injury cases. The Defense and Veterans Brain Injury Center at Walter Reed has evaluated and treated over 600 TBI patients from Iraq or Afghanistan between January 1, 2003 and September 29, A little more than half of these have been moderate or severe cases. Palo Alto also features an innovative surgery simulator. Taking its inspiration from the aviation industry s flight simulators, the VA s simulator features a real operating room complete with a full-size plastic dummy that breathes, opens and closes its eyes, receives medication, and quite frequently suffers cardiac arrest, convulsions and many other lifethreatening events that most surgeons do not, thankfully, experience very often, thereby allowing surgeons to hone their skills in practice in preparation for when the real emergencies occur.

10 VISN 22. VA Southern Healthcare System (Las Vegas VA Medical Center)

11 VA Southern Healthcare System (Las Vegas VA Medical Center) The American Legion visit to the Las Vegas VA Medical Center April 26, 2006 Task Force Member: Gerald Schleining Field Service Representatives: Jacob Gadd VA Southern Nevada Healthcare System (Las Vegas) provides outpatient and inpatient medical services to veterans residing in Southern Nevada. The system includes Clark, Lincoln, and Nye counties in Nevada, Iron and Washington counties in Utah; Mojave, Yavapai, and Maricopa. Las Vegas covers the metropolitan Las Vegas area and Pahrump Nevada. Due to structural deficiencies at the Addeliar D. Guy III, Ambulatory Care Center, ambulatory care operations were relocated to ten separate leased sites of care in Primary and specialty care services are now provided through the Central clinic, East Clinic, North Clinic, Northwest Clinic, Southeast Clinic, Southwest Clinic, and the West Clinic. Business, Logistic, and Administrative services are located at: Central Clinic, Business Center, Data Center, and Warehouse and Transport Center. Mental Health services are provided at the North Clinic. Mental Health services, Homeless Outreach and Psychiatric Day treatment are offered through the Arville House and Readjustment counseling at the Vet Center. The healthcare system established Community Based Outpatient Clinics (CBOCs) in Henderson and Pahrump, Nevada that provide both primary care and mental health services. Pahrump is approximately 64 miles from the Las Vegas VA Clinic. Las Vegas has a DoD joint venture with the 99 th Medical Group, at the Mike O Callaghan Federal Hospital. VA has a total of 52 inpatient-operating beds that include surgery, psychiatry, and jointly staffed VA/DoD intensive care unit. Activated in 1994, Mike O Callaghan Federal Hospital was the first DOD/VA joint venture and is recognized as a national best practice. Fiscal Las Vegas s budget for FY 2005 was $145 million. In FY 2006 it is $158 million, representing an increase in funding of about 8.9%. The MCCF collection goal for FY 2005 was $10,165,145; $12,578,057 was collected. The collection goal for FY 2006 is set at $12,387,461; management feels that it will meet the goal. The budget at Las Vegas is different from any other VA; the healthcare system does not own any property. All the properties are leased, resulting in less money and more infrastructures. Las Vegas did have to use capital investment dollars to supplement its medical care budget. However, because of its recent relocation to leased facilities, this was not a major impact on the organization. Major budgetary challenges include funding for the new medical center complex, (include activation and staffing) and relying on community resources for specialty care and a short-term vulnerability with growth, while waiting for the new hospital to be built. Enrollment and Access The time from veteran s submission of an enrollment application (1010 EZ) and receipt of initial healthcare depends on how the veteran

12 applies. If a veteran applies in person, initial healthcare is available the same day--if eligible. Las Vegas has implemented Advance Clinical Access guidelines that allow for veterans to be seen from one to three days. During FY 2005, there were no veterans who had an initial appointment scheduled beyond 30 days unless it was at the veteran s request. In FY05, there were 40,419 unique patients entered into the system, with total count of 51,033. There are approximately 700 combat veterans, which is about two percent of Las Vegas total workload. The facility provides expedient care for those returning veterans, and they are fast-tracked into the system with walk-in, same-day appointments. There are mental health staff members who provide briefings at Guard and Reserve units for newly returning combat veterans. The facilities attend Transition Assistance Program (TAP) briefings held at Nellis Air Force Base twice a month and provide information regarding VA healthcare benefits. They also recently participated with the Nevada Guard and conducted Post Deployment Health Reassessments. Individuals were referred for care within the VA health care system. Las Vegas has an OEF/OIF case manager who makes contact with all identified OEF/OIF veterans offering them the opportunity to meet with her regarding health care benefits and other programs both VA and non-va that may be of assistance. Planning Initiative Las Vegas has received approval for a comprehensive medical center complex that includes an outpatient clinic, inpatient hospital, and nursing home care unit. The 750,000 square foot facility will accommodate 90 inpatient beds and 120 bed extended and skilled care nursing home care unit. The application was supported by CARES data that identified future workload gaps based on Las Vegas workload trends through FY 2022 especially in request to the dynamic population growth in Southern Nevada. A comprehensive medical center complex would resolve many of the issues for veteran health care in Southern Nevada. Fifty percent of primary care workload will remain in CBOCs. The medical center will provide a One-Stop Shopping approach for veterans whose healthcare needs cross the continuum of services including primary care, specialty care, surgery, mental health, rehabilitation, geriatrics and extended care. Affiliations and Staffing Las Vegas shares affiliations with the University of Nevada, Reno, School of Medicine; University of Nevada, Reno, Department of Nutrition; University of Nevada, Las Vegas, School of Psychology; University of Nevada, Las Vegas School of Nursing; Touro University School of Medicine; Community College of Southern Nevada; Nevada State College, Department of Nursing; Southern California College of Optometry; Illinois College of Optometry; Idaho State University College of Pharmacy and Creighton University School of Pharmacy and Health Professions. There is difficulty in recruiting specialty doctors. There are a few physicians on staff with J-1 Visa status. Those specialty areas are in Cardiology, Gastroenterology, Neurology, Radiology and Ophthalmology. Due to the lack of specialty doctors, Las Vegas fee bases approximately 20 percent of its budget to the community. Relocation bonuses are one incentive offered to pharmacists and scarce medical providers. Senior management believes the impact of the Physicians Pay Bill will result in salary increases

13 and thereby, offset dependency on community resources. The Pay Bill will increase ability to recruit specialty providers. VA/DOD Joint Venture The Mike O Callaghan Federal Hospital (MOFH) was the first facility funded, planned, and built as an operational joint venture. VA and the Air Force purchase services from each based on agreed reimbursement methodology. This includes 52 inpatient medicine, psychiatric, and surgical beds. Las Vegas has also been funded with $3.9 million for the Mike O Callaghan Federal Hospital Tower Project that will double the capacity of the Emergency Room, create six step-down beds adjacent to the Intensive Care Unit, and provide a locked recreation area for the VA locked psychiatric unit. Construction has been completed and it is anticipated that activation will occur in the near future. Current issues recognized by senior leadership on VA/DOD sharing include: differing missions and differing patient needs, dual computer systems (DOD does not use the VA computerized medical record), difficult processes for obtaining VA and AF approvals at the national level, limited access to the Mike O Callaghan Federal Hospital during levels of military security and lack of effective mechanisms to calculate an equitable financial reimbursement. Mental Health and Homeless Services Mental health outpatient clinics piloted Advanced Clinical Access, allowing veterans to be seen in a timelier manner. Veterans can schedule same day appointments in Mental Health on the day they need treatment. The Arville house, a 20-bed inpatient program, helps veterans that need psychiatric day treatment. The goal of this program is to promote independent community living through experiential learning in a psychosocial setting. There is an addictive disorders treatment program providing diagnostic, therapeutic and support services to veterans with alcohol, drug and/or gambling related problems. The Post Traumatic Stress Disorder (PTSD) Clinical Team presented information regarding its treatment program to the National Guard twice last year. Unit members were provided signs and symptoms of stress related disorders, and information on how to connect with the healthcare system. PTSD Program continues to offer an OEF/OIF Returning Home Program, with plans to pilot a Booster Group in the near future. This group will provide veterans completing various PTSD program components the opportunity to address implementation issues of concepts presented in formal treatment. Of 177 veterans seen in the VA, 125 were for the PTSD Clinical Team. The PTSD program lasts 32 weeks, however, there is an abbreviated 13-week version that offers more individual time. Currently, there are 93 transitional beds for Homeless Veterans. An expansion will be taking place through June and July to open and house an additional 75 veterans. The CBOC participates in two homeless stand-downs annually.

14 VISN 23. Minneapolis VA Polytrauma Center

15 Minneapolis VA Medical Center The American Legion visit to Minneapolis VA Medical Center March 23, 2006 Task Force Member: Tom Mullon Field Service Representative: Joseph L. Wilson The Minneapolis VA Medical Center (Minneapolis) is a tertiary care facility classified as a Clinical Referral Level I Facility for the VA Midwest Health Care Network, Veterans Integrated Service Network (VISN) 23. Minneapolis is also one of four facilities chosen in January 2005 to construct and maintain a Polytrauma Center. Fiscal The Minneapolis VA Medical Center s FY 2005 budget was $351.6 million and the budget for FY 2006 is $357.9 million, a 1.79 percent increase. MCCF collections for FY 2005 were $34,689,885 million of a $38,992,835 million goal, a 12.4 percent increase, which is third amongst VA centers nationwide. Minneapolis MCCF collection goal for FY 2006 is $38,992,835 million. Minneapolis reports funding for fiscal year 2006 s preliminary operating status projections are $368.4 million. Expenses are estimated to be $378.1 million, a $3.2 million deficit between the aforementioned. For FY 2006, Minneapolis has scheduled to implement seven planning initiatives to support the goals of VISN 23. The initiatives are as follows: implementation of Advanced Clinic Access (ACA) throughout the VAMC; submission of revised business plan for the CBOC in Western Wisconsin; implementation of enhanced use projects for the credit union and transitional veteran housing; establishment of a workload dashboard; completion of the Combined Assessment Program by the Inspector General Survey; establish a new center to accommodate veterans with polytrauma; continue construction of the Spinal Cord Injury (SCI) Center. Enrollment and Access The Minneapolis VA Medical Center provides comprehensive health care services to over 71,000 patients, of which 20,000 come for specialty care. Approximately 50,000 have primary care at Minneapolis. During fiscal year 2005, these services were provided to veterans residing in 50 states, including the District of Columbia, Puerto Rico, the Philippines, and the Virgin Islands. By October 2005, approximately 50,000 veterans had an actual primary care provider at Minneapolis. This represents 67 percent of all veterans treated at the facility. The Primary Care Patient Service Line offers a broad range of treatment modalities, with an emphasis on health care prevention. When the veteran submits an enrollment application, Minneapolis reports it takes three days, on average, to process. Management reported there is no tracking system for wait times of patients referred by Primary Care Providers. It tracks all patients, regardless of where the referral comes from, but only for specified clinics. Minneapolis is also involved in outreach to 3,800 returning combat veterans by sending packet with enrollment and benefits information. The number of OIF/OEF veterans

16 treated since the beginning of the Iraqi conflict is The accumulative number of OIF/OEF veterans enrolled but not receiving care is1307. Minneapolis does not actually track, but instead measures by the percentage of appointments scheduled within 30 days of the desired date. The current data listed for established patients in FY 2005 is as follows: Audiology at a percentage of 81; Cardiac and Primary Care at a percentage of 98; Eye at a percentage of 93; Gastroenterology at a percentage of 96; Mental Health and Urology at a percentage of 99; and Orthopedics at a percentage of 87. Community Based Outpatient Clinics (CBOCs) The Minneapolis facility has CBOCs in Superior and Chippewa Falls, Wisconsin; Hibbing, St. James, Maplewood, and Rochester, Minnesota. The current enrollment amongst all area CBOCs is 17,000. Minneapolis reports they have very few volunteers at their CBOCs, but the process is in place to expand those numbers if the clinic expresses additional needs. The volunteers at the CBOCs are supervised by VA employees at the respective CBOCs and are tracked as part of the Minneapolis VAMC Voluntary Service Program. Minneapolis also reports that a proposal for a new CBOC in Northwestern Wisconsin is being considered but is on hold, pending further VA Central Office guidance. Affiliations and Staffing The Minneapolis VA Medical Center is actively affiliated with the University of Minnesota Medical and Dental Schools. There are over 733 University residents, interns, and students trained at Minneapolis each year. The facility has formal affiliation agreements with 63 schools to provide allied health training in 36 programs. Minneapolis has its own accredited hospital based training programs for radiology technicians and dental residents. It also currently has 200-plus physicians with credentials from neighboring universities. Minneapolis personnel statistics, as of October 2005, included 3040 total employees (not FTEE). The composition was: 205 physicians, 748 registered nurses, 265 licensed practical nurses and nursing assistants, and 1,822 others. The total FTEE for FY 2005 was 2, The facility reports there have been a great number of turnovers of nursing assistants. It has accomplished the task of meeting the salary requirements for the nursing staff. However, Management does report it has no problem retaining Certified Registered Nurse Anesthetists (CRNA). Due to the rise of competitive salaries in the private sector, Minneapolis plans to meet with its physicians to set an appropriate salary, which should be fully implemented by April Minneapolis has devised various hiring incentives to attract and obtain potential and actual employees. This includes offering a retirement plan with a 401k type of tax deferred investment account. In addition to this plan, the investment agency will contribute one percent of salary automatically and dollar for dollar match on the first three percent of the employee contribution, as well as, dollar for every two dollars match on the second two percent of employee contribution. The total match from the agency is five percent. There are also appropriate recruitment and relocation bonus payments offered, upon approval of the VA.

17 Minneapolis also emphasized the need for extra staffing for its Polytrauma Center, which is one of the major four Polytrauma Centers throughout the VA nationwide. Management states it is dedicated to accommodating employees who are serving in the National Guard or Reserves. Of the 129 employees who are serving in the National Guard or Reserves, 2 have been activated. While activated, these respective employees may be paid any accrued military leave or annual leave. Usually, they elect to use their military leave and retain the annual leave balance for their return. To compensate for lost productions of activated employees, the facility has implemented temporary promotions with the anticipation that all persons will return to their old jobs. It has also appointed replacement staff on a temporary basis. Physical Plant The Minneapolis facility received $40 million to update key equipment, to include their MRI unit. They report there has been a transition to convert facilities used for inpatient care to facilities for outpatient care. The credit union has expanded and now includes a branch behind the Fisher House. Finally, Minneapolis states that the only major or minor construction project it has in FY2006 is the Spinal Cord Injury Center (SCI). It appears that the project is currently within construction budget, however, it is not known if personnel and actuation funds will be sufficient. Long Term Care, Mental Health and Homeless Services Minneapolis VAMC was chosen in January of 2005 to erect and maintain a Polytrauma Center to support the veteran and his/her family. The creation of Public Law has provided and earmarked 20 million dollars, which was dispersed across the VA, to assist the Polytrauma Centers. Since it s beginning, the Minneapolis based Polytrauma Center has received recognition from the Commission on Accreditation of Rehabilitation Facilities (CARF). The Minneapolis VAMC reports that it makes attempts to continue to improve the rehabilitation of the veteran, by adopting such care as housing a uniformed military liaison within the unit. The liaison assists with access to the patient s records. Minneapolis is also equipped with Telehealth Communications to contact families and others at Walter Reed and Bethesda prior to the veteran coming to the Polytrauma Center. By partnering with the community (police, mayor, fire department, etc), VA has provided mental health information, problem-solving strategies and resources to these community partners who are interested in supporting the returning combat veterans. In other efforts to outreach to veterans, despite the administrative hold on the hiring of a social worker in Duluth, Minneapolis has provided two nurses who served over a year in Iraq to work with OEF/OIF veterans. They are constantly assigning these nurses elsewhere due to staff shortages. Minneapolis continues to provide priority care for transitioning OIF/OEF veterans by ensuring that those with urgent medical needs are seen in urgent care within one to two business days. They also have urgent care mental health available and are able to see patients on an urgent basis immediately. Patients who are identified as OIF/OEF veterans, are seen within 30 days. If the appointment can wait, consults are sent to

18 primary care and mental health. The Mental Health Department (MHC) stated it has applied for programs that were approved, but because of a deficit posture, the funds never reached the Mental Health Clinic. The number of Post Traumatic Stress Disorder (PTSD) patients in FY2005 has increased ten to eleven percent. The increase for FY2006 is currently at eight percent. The total number of uniques seen during 2005 was 12,000. Minneapolis stressed the need for a fulltime Mental Health employee, due to the increased number of claimants. Through Minneapolis studies it found that most patients seen at area CBOC s want to be served in their areas. Management states that the Telemedicine program is effective, however, it has a shortage of lines. To alleviate this problem, it has stressed the need for more equipment to accommodate the veteran. Minneapolis has a Day Hospital that accommodates and treats patients with psychiatric disorders, addiction disorders, and homelessness issues. Patient, Family and Employee Surveys There were a total of eight veterans interviewed at the Minneapolis VAMC, to include, five outpatients and four inpatients. They all live between four and 165 miles of Minneapolis. Their average wait time to see a provider ranged from ten minutes to two hours. The patients overall feelings of treatment at the facility ranged from okay to very good.