Charting a New Direction

Transcription

1 DEPARTMENT OF VETERANS AFFAIRS Veterans Health Admnstraton VHA VISION 2020 Chartng a New Drecton Aprl 2003

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3 FOREWORD Profound changes have occurred n the Department of Veterans Affars (VA) health care system and even more change s expected as we contnue to enhance qualty, ncrease access, mprove servce satsfacton and optmze patent functonng. The Veterans Health Admnstraton's (VHA) transformaton has led to a coordnated contnuum of care and a system characterzed by achevement of performance outcomes that mprove servces to veterans. For all 18 key health care ndcators, from dabetes care to cancer screenng and mmunzatons, we have exceeded the performance of prvate sector and Medcare provders. We wll contnue to develop our natonal, ntegrated health care delvery system. The future system wll requre VHA components to functon together and n concert wth publc and prvate health care facltes to meet the health care needs of the enrolled veteran populaton and to mnmze duplcaton of servces. As we chart a new drecton, ths system wll contnue to promote effcency, assure hgh qualty care, and provde optmal access for the veteran populaton. We wll acheve a level of qualty and access that sets a natonal standard of excellence for the health care ndustry. VHA Vson 2020 descrbes our achevements and dscusses the key strateges that wll enable us to contnue to provde comprehensve, frst-class health care to the naton s veterans and acheve our goals for research, educaton and emergency preparedness n the comng years. Robert H. Roswell, M.D. Under Secretary for Health

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5 CONTENTS FOREWORD... CONTENTS... INTRODUCTION... v CHAPTER 1 CHARTING A NEW DIRECTION VHA LEADERSHIP: THE NEXT GENERATION... 1 TURNING INFORMATION INTO INSIGHT... 2 REFOCUSING ON CORE VETERANS... 3 IMPLEMENTING CARES... 6 CHAPTER 2 STRATEGIC VISION FUTURE DIRECTION AND CHALLENGES... 9 ELEMENTS OF VHA S STRATEGIC VISION VHA S STRATEGIC PLAN CHAPTER 3 FOCUS ON VETERANS HEALTH CARE ACCESS SPECIAL EMPHASIS PROGRAMS (SEP) GERIATRICS AND LONG TERM CARE PATIENT SAFETY QUALITY INDICATORS VETERAN SATISFACTION AWARDS FOR QUALITY ACCREDITATION RESEARCH PROFESSIONAL EDUCATION AND TRAINING DISASTER RESPONSE CHAPTER 4 SERVICE EFFICIENCY AND EXCELLENCE INFORMATION TECHNOLOGY PROCUREMENT COMPETITIVE SOURCING WORKFORCE PLANNING GLOSSARY OF ACRONYMS VHA Vson 2020

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7 INTRODUCTION The Department of Veterans Affars (VA) has responsblty for provdng federal benefts to veterans and ther dependents. Headed by the Secretary of Veterans Affars, VA s the second largest of the 15 Cabnet Departments and operates natonwde programs of health care, ncome securty benefts, and natonal cemeteres. VA drectly touches the lves of mllons of veterans every day through ts three admnstratons. Veterans Health Admnstraton (VHA), wth 162 VA hosptals natonwde, operates the largest health care system n the Unted States. VA medcal facltes operate wthn a Veterans Integrated Servce Network (VISN), workng together to provde effcent, accessble health care to veterans. VHA also conducts research and educaton, and provdes emergency medcal preparedness and dsaster response. Veterans Benefts Admnstraton (VBA) provdes benefts and servces to the veteran populaton through 57 VA regonal offces. Some of the benefts and servces provded by VBA to veterans and ther dependents nclude compensaton and penson, educaton, loan guaranty, and nsurance. Natonal Cemetery Admnstraton (NCA) provdes bural benefts to veterans and elgble dependents. The delvery of these benefts nvolves managng 120 Natonal Cemeteres natonwde, admnsterng the State Cemetery Grants Program that complements the Natonal Cemeteres network, provdng grave markers worldwde, and Presdental Memoral Certfcates to next of kn of deceased veterans. Perhaps the most vsble of all VA benefts and servces s health care. From 54 hosptals n 1930, VA's health care system has grown to 162 hosptals, wth at least one n each of the 48 contguous states, Puerto Rco and the Dstrct of Columba. Durng the last fve years, VHA has put ts health care facltes under 21 networks, whch provde more medcal servces to more veterans and famly members than at any tme durng VA's long hstory. Veterans Health Admnstraton 21 Veterans Integrated Servce Networks The Under Secretary for Health n VA heads the I N J ANUARY 2002 VISN S 13 AND 14 VHA and s responsble for managng the naton's WERE INTEGRATED AND RENAMED VISN 23 largest ntegrated health care system. Wth a medcal care budget of more than $28 bllon, VHA employs more than 180,000 health care professonals VHA Vson 2020 v

8 at 162 hosptals, more than 850 communty and faclty-based clncs, 137 nursng homes, 43 domclares, 206 readjustment counselng centers, and varous other facltes throughout the country. VHA health care facltes provde a broad spectrum of medcal, surgcal and rehabltatve care. In addton to ts medcal care msson, the veterans health care system s the naton's largest provder of graduate medcal educaton and a major contrbutor to medcal and scentfc research. Who We Are Offce Of Under Secretary for Health v Department of Veterans Affars Veterans Health Admnstraton

9 Who We Serve Begnnng wth our Naton s struggle for freedom more than two centures ago, approxmately 42 mllon men and women have served our country durng wartme. Of the 25.6 mllon lvng veterans, most (75 percent) served durng a war or an offcal perod of hostlty. Veteran Populaton by Perod of Servce Mllons Peacetme Gulf War Era Korean Conflct Perod of Servce 4.8 World War II 8.3 Vetnam Era Source: VetPop 2001 Over 6.2 mllon enrolled veterans look to VHA for health care servces and more than 4.3 mllon veterans receved care n FY VHA Vson 2020 v

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11 CHAPTER 1 CHARTING A NEW DIRECTION VHA LEADERSHIP: THE NEXT GENERATION TURNING INFORMATION INTO INSIGHT REFOCUSING ON CORE VETERANS IMPLEMENTING CARES VHA LEADERSHIP: THE NEXT GENERATION In May 2002, the Under Secretary for Health reorganzed Veterans Health Admnstraton (VHA) headquarters. Under ths reorganzaton, there s ncreased centralzaton and algnment, greater unformty, ncreased nteracton wth other federal agences, partcularly the Department of Health and Human Servces (HHS), and centralzaton of all busness functons. The reorganzaton created three Deputy Under Secretary postons to oversee Health, Health Polcy Coordnaton, and Operatons and Management. Prevously, VHA had only one Deputy Under Secretary overseeng all of VHA. To enhance our ablty to dentfy best practces and make our system a more unform natonal health care system for veterans, we wll be restructurng the functon of VHA s Natonal Leadershp Board, wth focus on corporate performance across the VISNs. Robert H. Roswell, MD, Under Secretary for Health In July 2002, followng recommendatons by a task force charged to examne VHA s governance structure, the Under Secretary for Health mplemented a new system to mprove VHA s management and leadershp functons. The task force recommended reconfguraton of the exstng Natonal Leadershp Board (NLB). Ths Board now serves n an advsory capacty to ts Char, the Under Secretary for Health, havng an actve and extensve role n determnng VHA polcy, strategy, and oversght of organzatonal performance. The NLB also serves as a forum to share responsblty for VHA governance, coordnates and oversees the actvtes of VHA, ensures algnment wth VA prortes and goals, develops and dssemnates nformaton both nternal and external to VHA, and facltates the ncluson of dverse vews of organzatonal components wthn VHA. The NLB s comprsed of key leaders wthn VHA, ncludng all Network Drectors, all Chef Offcers, and other senor leaders desgnated by the Under Secretary for Health. In addton, several senor leaders wthn VA are non-votng members of the NLB, ncludng sx Assstant Secretares, General Counsel, and the Under Secretares for the Natonal Cemetery Admnstraton and Veterans Benefts Admnstraton. VHA Vson

12 The NLB conssts of an Executve Commttee and sx functonal commttees (Strategc Plannng, Health Systems, Fnance, Informatcs and Data Management, Communcatons, and Human Resources). The Executve Commttee provdes leadershp to the VHA governance process and operaton of the NLB by ensurng effectve process management, determnng the NLB agenda, assessng NLB performance, nsttutng mprovements, and enhancng the focus and effcency of the NLB. The remanng sx commttees each have functonal areas of responsblty ncludng: Recommendng and formulatng polcy, strategc drecton and plannng; Identfyng legslatve proposals and ntatves; Provdng organzatonal performance oversght; Ensurng effectve deployment and communcaton of polces, plans, and strateges; Identfyng the educatonal and developmental needs of commttee and/or Board members; Developng performance and qualty measures for functonal areas of responsblty; Ensurng that all four VA mssons are approprately consdered; and Ensurng algnment of VHA and VA. The full NLB and ts commttees meet monthly to coordnate emergng ssues and develop ongong polcy and plannng ntatves to govern VHA s extensve health care system. TURNING INFORMATION INTO INSIGHT Turnng Informaton Into Insght s the theme of VHA s efforts to provde decson makers wth nsghtful, accurate data to support plannng, polcy, and budget decsons. The centerpece of ths effort was the development of an nnovatve health care actuaral model to project utlzaton and assocated expendtures for the enrolled veteran populaton. VA s budgetng, polcymakng, and captal asset realgnment ntatve have been transformed by the qualty of the data provded by the VHA Health Care Demand Model and ts ablty to analyze scenaros and proposed health care polces. Anthony J. Prncp, Secretary 2 Department of Veterans Affars Veterans Health Admnstraton

13 The VHA Health Care Demand Model was developed through a publc-prvate partnershp, and s based on prvate sector benchmarks that have been rsk adjusted for the characterstcs of the VHA enrollee populaton and on actual VHA unt costs. The model s also adjusted for the degree of health care management n VHA versus the communty standard and for veterans degree of relance on VHA versus other provders. The assumptons and methodologes have been subjected to rgorous revew, and the model has been enhanced each year by mprovng the methodology and ntegratng new data sources and plannng models. The model was also fne-tuned based on knowledge ganed from actual-to-projected analyses. The model s readly adaptable to changes n the underlyng assumptons. The VHA Health Care Demand Model projects veteran enrollment, utlzaton, and expendtures, ncludng detaled projectons for approxmately 50 health care servce categores. These forecasts, along wth data on health outcomes, access, system capacty, qualty, and patent satsfacton, are the foundaton of VHA s efforts wth Turnng Informaton Into Insght. The demand model has revolutonzed VHA s budget, plannng, and polcy-makng processes. In the past, VHA budgets (and most federal budgets) were based on hstorcal expendtures that were adjusted for nflaton and then ncreased based on proposed new ntatves. Usng the demand model, VHA developed ts FY 2003 and 2004 budgets based on actuaral forecasts of expendtures. Ths transton from a hstorcal to an actuaral model as the bass of budget formulaton represents not only a sgnfcant nnovaton for VHA, but for the federal government. The model has also become ntegral to plannng and polcy development. Durng the development of the FY 2003 and FY 2004 budgets, VHA compared the actuaral expendture projectons wth expected resources and dentfed sgnfcant gaps between veteran demand for VA health care and the resources to pay for that care. VHA then used the model to test the mpact of proposed polcy optons, such as requrng copayments and lmtng enrollment, on expendtures and revenue. Data from the model were also used to analyze the mpact of these polces on veteran access to care and VHA s performance ndcators. The proposed health care polces n VA s FY 2004 Presdent s Budget, whch are dscussed n the next secton, were developed through ths process. The model also supports local, regonal, and natonal strategc plannng by provdng demand projectons and scenaro analyses for VHA s natonwde captal asset evaluaton that s assessng the optmal algnment of VHA resources and servce stes. REFOCUSING ON CORE VETERANS The recent changes n VA s health care system have been profound, transformng t to a more effcent, effectve and accessble system. VA s provdng better care to our naton s veterans, closer to ther homes and usng the latest technology, whle contnung to place a strong emphass on comprehensve specalty VHA Vson

14 care. However, VA has been unable to provde all enrolled veterans wth tmely access to health care servces because of the tremendous growth n the number of veterans seekng VA health care. It s also clear that contnued workload growth of the magntude seen n recent years would be unsustanable n the current federal budget clmate. When we have veterans who are enttled to care, who aren t gettng the care as quckly as we would lke to provde t, then my oblgaton s to do everythng I possbly can to free up any resources that wll help address that ssue. Robert H. Roswell, MD, Under Secretary for Health Therefore, n both the FY 2003 and FY 2004 budgets, VA proposed health care polces to address the gap between full demand and antcpated resource avalablty through a combnaton of enrollment and beneft polcy changes and ncreased collectons. In FY 2004, VA s $27.5 bllon budget request, whch represents an unprecedented 7.7 percent ncrease over FY 2003 s expected level, also ncludes health care polces desgned to balance demand wth avalable resources. In FY 2002, Secretary Prncp took steps to assure that VA would afford prorty access to veterans wth servce-connected dsabltes. VA s refocusng attenton on ts core medcal care msson of provdng needed servces to veterans wth servce-connected dsabltes, lower ncome veterans, and those needng specalzed care. VA wll contnue open enrollment for servce-connected and low ncome veterans n Prortes 1-7; however, VA has suspended enrollment for Prorty 8 veterans who were not enrolled n VA pror to or on January 17, The suspenson of Prorty 8 enrollment s the frst n a seres of polces desgned to better algn veteran demand and VA s health care resources. Although an estmated 164,000 veterans would be mpacted n FY 2003, the contnuaton of ths polcy has a profound mpact on future demand and budget requrements. Ths polcy results n 520,000 fewer enrollees and an $800 mllon cost avodance by FY 2005, growng to 1.1 mllon fewer enrollees and a $2.8 bllon cost avodance by FY 2012 were Prorty 8 enrollment suspenson to contnue. Ths acton alone does not address the remanng budget requrements to provde health care for VA s veterans n Prortes 1-7, who are expected to cost, on average, an addtonal $2.1 bllon each year, reachng a total annual budget of over $43 bllon by FY In addton, $3.4 bllon wll be requred by FY 2012 to support the care for those currently enrolled Prorty 8 veterans unaffected by ths enrollment suspenson. Chart 1.1 contans a descrpton of each of the prorty groups. 4 Department of Veterans Affars Veterans Health Admnstraton

15 Chart 1.1 VA Health Care Enrollment Prorty Groups Enrollment Prorty 1 Veterans wth servce-connected dsabltes rated 50% or more dsablng Enrollment Prorty 2 Veterans wth servce-connected dsabltes rated 30% or 40% dsablng Enrollment Prorty 3 Veterans who are former POWs Veterans awarded the Purple Heart Veterans whose dscharge was for a dsablty that was ncurred or aggravated n the lne of duty Veterans wth servce-connected dsabltes rated 10% or 20% dsablng Veterans awarded specal elgblty classfcaton under Ttle 38, U.S.C., Secton 1151, "benefts for ndvduals dsabled by treatment or vocatonal rehabltaton" Enrollment Prorty 4 Veterans who are recevng ad and attendance or housebound benefts Veterans who have been determned by VA to be catastrophcally dsabled Enrollment Prorty 5 Non-servce-connected veterans and non-compensable servceconnected veterans rated 0% dsabled whose annual ncome and net worth are below the establshed VA Means Test thresholds Veterans recevng VA penson benefts Veterans elgble for Medcad benefts Enrollment Prorty 6 World War I veterans Mexcan Border War veterans Veterans solely seekng care for dsorders assocated wth: exposure to herbcdes whle servng n Vetnam; or exposure to onzng radaton durng atmospherc testng or durng the occupaton of Hroshma and Nagasak; or for dsorders assocated wth servce n the Gulf War; for any llness assocated wth servce n combat n a war after the Gulf War or durng a perod of hostlty after November 11, 1998; or Compensable 0% servce-connected veterans Enrollment Prorty 7 Veterans wth ncome and/or net worth above the VA Means Test threshold and ncome below the HUD geographc ndex who agree to pay specfed co-payments Subprorty a: Non-compensable 0% servce-connected veterans who were enrolled n the VA Health Care System on a specfed date and who have remaned enrolled snce that date Subprorty c: Non-servce-connected veterans who were enrolled n the VA Health Care System on a specfed date and who have remaned enrolled snce that date Subprorty e: Non-compensable 0% servce-connected veterans not ncluded n Subprorty a above Subprorty g: Non-servce-connected veterans not ncluded n Subprorty c above Enrollment Prorty 8 Veterans wth ncome and/or net worth above the VA Means Test threshold and the HUD geographc ndex who agree to pay specfed copayments Subprorty a: Non-compensable 0% servce-connected veterans enrolled as of January 16, 2003 and who have remaned enrolled snce that date Subprorty c: Non-servce-connected veterans enrolled as of January 16, 2003 and who have remaned enrolled snce that date Subprorty e: Non-compensable 0% servce-connected veterans applyng for enrollment after January 16, 2003 Subprorty g: Non-servce-connected veterans applyng for enrollment after January 16, 2003 Addtonal Informaton: The term servce-connected means, wth respect to a condton or dsablty that VA has determned that the condton or dsablty was ncurred n or aggravated by mltary servce. Some veterans may have to agree to pay copayments to be placed n certan prorty groups. Although VA expects to have 7 mllon veterans enrolled by the end of FY 2003, there are another 17.5 mllon veterans who have yet to seek care from VA. There are approxmately 6 mllon veterans age 65 and over who are not enrolled. These veterans, because of ther age, are hgh consumers of health care and are partcularly attracted to VA for ts pharmaceutcal benefts. Suspendng the enrollment of Prorty 8 veterans who have hgher ncomes and are more lkely to have nsurance and other care choces, allows VA to contnue efforts towards elmnatng watng lsts and longer watng tmes to beneft those who need VA most. VHA Vson

16 VHA s lookng for further management effcences and ncreasng nteragency coordnaton wth Department of Defense (DoD) and HHS. To that end, VA has reached a landmark agreement wth HHS to establsh a Medcare+Choce (M+C) employer group plan through whch VA wll provde nonenrolled Prorty Group 8 veterans aged 65 or older who cannot enroll n VA s health care system, the opton of recevng ther Medcare beneft through VA. Ths agreement s fully supported by the Whte House, the Offce of Management and Budget (OMB), and the Centers for Medcare and Medcad Servces (CMS). The plan calls for VA to contract wth an M+C organzaton to offer a specal M+C plan called VA+Choce. VA would defne the benefts under VA+Choce, and enrollees n VA+Choce would be able to receve Medcare benefts through VA facltes and provders. At a mnmum, the plan wll nclude the benefts requred under M+C, ncludng all Medcare Parts A and B servces. VA wll determne any addtonal benefts t wshes the M+C organzaton to offer and member cost sharng for those benefts. The VA+Choce plan wll become effectve later n 2003 as detals are fnalzed between VA and HHS. HHS s happy to jon the Department of Veterans Affars n developng ths new opton for veterans who mght otherwse be unable to obtan health care through the VA. Ths s a creatve marrage of our federal health programs to serve our veterans effcently and effectvely. Tommy G. Thompson, Secretary, Department of Health and Human Servces IMPLEMENTING CARES VA operates and mantans more than 4,700 buldngs and 18,000 acres of land. Some of the buldngs and land VA owns are not well suted to veterans health care needs. The cost to mantan and operate VA health care facltes that cannot provde effcent and accessble servces dmnshes resources that could otherwse be used to provde better care n more approprate settngs. VA developed CARES Captal Asset Realgnment for Enhanced Servces n response to a March 1999 General Accountng Offce (GAO) report that concluded VA could sgnfcantly reduce the amount of funds necessary to operate and mantan ts captal nfrastructure by developng and mplementng market-based plans for restructurng assets and apply the savngs to health care for veterans. CARES wll mprove qualty as measured by access and mprove the delvery of health care n a cost-effectve manner, whle maxmzng postve opportuntes and mnmzng any adverse mpacts on staffng, communtes, and other VA mssons. Through CARES, VA s realgnng and enhancng ts health care system to meet veterans needs effectvely and effcently, now and n the future. 6 Department of Veterans Affars Veterans Health Admnstraton

17 As VA begns the process of makng CARES decsons n communtes across the country, t s mportant to remember the program s objectves: more effectve use of VA resources to provde more care, to more veterans, n places where veterans need that care most. Leo S. Mackay, Jr., PhD, Deputy Secretary The CARES process wll strategcally address the future nfrastructure,.e., beds, outpatent capacty, and other servces, to meet the health care needs of veterans ncludng emergency backup needs. VA recognzes there s a cost for mantanng readness and must balance ths cost wth provdng qualty and tmely health care for veterans. Preparng staff and facltes for emergency stuatons also preserves the department s ablty to care for veterans. VA currently has a system n place that develops perodc estmates of the number of beds that can be made avalable to fulfll ts Department of Defense (DoD) backup requrements. The plannng process ncorporates network-based data, strategc health care plannng nput, and cooperatve partcpaton toward achevng the stated vson and goals of the CARES program. In an effort to save federal dollars, ths process also seeks to mprove the sharng of facltes and servces between VA and DoD. CARES plannng wll ensure that enhanced use opportuntes are addressed n a comprehensve manner and also dentfy opportuntes for convertng vacant space nto alternatve uses or dsposng of excess assets n the most effectve manner. The plot study for CARES was completed n 2001 for Network 12 (Chcago, Wsconsn, and the Upper Pennsula of Mchgan). VA s now conductng CARES n the remanng 20 Networks. A draft Natonal CARES Plan wll be publshed for publc comment and evaluated by an ndependent CARES Commsson apponted by the Secretary of Veterans Affars. The ndependent commsson wll hold hearngs and solct stakeholder comments from Veterans Servce Organzatons (VSOs), medcal school afflates, government enttes and local communty groups. Optons wll then be developed based on consstent, objectve crtera to ensure a cost-effectve health care system that best serves Amerca's veterans today and nto Followng ths process, the Commsson wll forward ts recommendatons to the Secretary, who wll make hs decson on the Natonal CARES Plan n late The CARES Commsson wll respond as Stewards of Amerca s Resources to any fnal stakeholders concerns or Congressonal nqures. Ths comprehensve analyss and restructurng of VA health care wll change only the way VA delvers care health care servces wll not be reduced. The goal of CARES s to enhance outpatent and npatent care, as well as specal programs such as spnal cord njury, blnd rehabltaton and serously mentally ll, and long-term care. Once CARES s completed, VA wll have a natonal plan for drectng resources where they are most needed; preservng VA s mssons and specal servces; and, at the same tme, contnung to provde hgh qualty care to more veterans n more locatons. CARES s not a one-tme process; the ntatves and plans dentfed wll be valdated and reassessed to ensure they reflect current VA polces. VHA Vson

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19 CHAPTER 2 STRATEGIC VISION FUTURE DIRECTION AND CHALLENGES ELEMENTS OF VHA S STRATEGIC VISION VHA S STRATEGIC PLAN FUTURE DIRECTION AND CHALLENGES Health care s remakng tself. There are powerful socetal, demographc, and ndustry-wde forces at work. In the 20th century, brcks and mortar consttuted the basc nfrastructure of the health care delvery system. The Insttute of Medcne s report, Crossng the Qualty Chasm: A New Health System for the 21st Century (2001), called for fundamental changes n a troubled and alng health care system. The report defned the qualty chasm as the gap between what scentfc evdence has proven s best for the patent and the care the patent actually receves. Ths report called for changes at four levels patent experences; small practce settngs or mcrosystems that delver care (e.g., provder groups, multdscplnary teams); health care organzatons (e.g., hosptals); and the health care envronment (e.g., payment polces, legal lablty, regulatory processes). These changes requre substantal mprovements bult around the core need for health care to be safe, effectve, patent-centered, tmely, effcent, and equtable. The changes n the VA health care system have been profound, and the benefts have been recognzed both nsde and outsde the Department. We provde better care to our naton s veterans, closer to ther homes, and usng the latest technology. However, we also face sgnfcant challenges, whch we must meet to assure that our naton mantans a comprehensve, ntegrated health care system for all veterans who choose to come to VA for ther care. Robert H. Roswell, MD, Under Secretary for Health VA health care s now far more patent-centered and s ncreasngly the benchmark for health care management and delvery. VHA s the benchmark for all 18 clncal performance ndcators crtcal to the care of veterans and drectly comparable externally. The results of VA s hard work and culture of qualty measurement were further valdated by the Insttute of Medcne s Leadershp by Example (2002) report, whch prased VA s use of performance measures to mprove qualty n clncal dscplnes and n ambulatory, hosptal and long-term care, statng that VA s ntegrated health care system s one of the best n the naton. VHA Vson

20 Accountablty for mprovement and achevement s mportant n VA. Dynamc performance contracts between Chef Offcers/Network Drectors and the Under Secretary for Health are the foundaton of VA s qualty mprovements. These performance contracts provde a bass for focusng and evaluatng the work of all VHA employees throughout the system. Performance measures have led to consstent applcaton of clncal gudelnes and have supported mprovements n qualty and n each of the other strategc goal areas. By the end of 2004, VHA plans to ncrease ts medcal work force of 180,000 by more than 800 doctors and 2,500 nurses. Wth a natonwde nursng shortage, an agng workforce and non-compettve wages, the recrutment effort wll be challengng, but VHA plans to move aggressvely. VHA management s workng on a comprehensve workforce plan, ncludng proposed legslaton to mprove physcans pay and benefts that wll be submtted to Congress n the sprng. The bll would base physcan salares on regonal market condtons. Boostng physcan recrutment and enrollment and beneft polcy changes wll not be enough to elmnate the wat lst. VHA also s developng a care coordnaton program to provde home care to more patents, whch would allow practtoners to manage more patents n settngs approprate to ther condton and desred by the patent. Ths new program wll elmnate the need for frequent vsts by patents, as care wll be moved to the home and to the workplace, allowng patents to manage care themselves. Interactve sessons va the Internet, telephone lnes, and telemedcne unts wll help physcans determne whether complcatons have developed and, f so, arrange for care when needed. ELEMENTS OF VHA S STRATEGIC VISION In recent years, VHA has emerged as a well-respected, benchmark-settng leader n health care. However, we have a professonal oblgaton to not only mantan that excellence but buld upon t to address the ever-changng challenges to provde the rght servces to veterans, at the rght tme, and n the rght place. To gude those decsons, and to delver an ntegrated health care system n the 21st Century, VHA has dentfed a new vson for the future. As VHA focuses on our role n the future of health care, we see an organzaton that wll: Be a patent-centered health care system for veterans; Provde comprehensve servces to an expandng patent base; Be a fully ntegrated health care system provdng consstent, unform, and predctable care across the naton; Promote a dversfed fundng base; Serve as a major component of natonal emergency response; 10 Department of Veterans Affars Veterans Health Admnstraton

21 Lead n understandng and provdng servces that are unquely related to veterans health; Provde contnuously mprovng, cost-effectve care through a dedcated, well-qualfed staff; Be the leader n the use of health nformaton technology; Focus on core servce delvery; Coordnate publcly funded health care for the beneft of veterans; Be a leader n expandng the evdence base for health care and translatng t nto changes n delvery; Mantan a promnent role n health care professonal educaton; and Practce effectve populaton health care for enrolled veterans partcularly those wth specal needs. VHA S STRATEGIC PLAN To acheve our strategc vson, VHA s Natonal Leadershp Board (NLB), through the Strategc Plannng Commttee (SPC), developed a comprehensve framework for a new strategc drecton. A new VHA Strategc Plan outlnes the steps we wll take and the mlestones of ths new strategc drecton, and algns VHA s Goals and Objectves wth those of the Department of Veterans Affars. To complete the Strategc Plan, I have, along wth the Secretary, endorsed a set of 30 specfc Strateges to acheve our Goals and Objectves that wll be the focus of our efforts, resources, and ntatves n the months and years ahead (see Chart 2.1). Durng the past few years, VHA has wtnessed unprecedented growth n patent demand that has created new challenges and the need to operate more effcently and effectvely. As a system, we have responded to these challenges n creatve and nnovatve ways whch have resulted n mprovng clncal outcomes and access to care, mantanng reasonable wat tmes n the face of ncreased patent demand for servces, enhancng patent satsfacton, and reducng costs. Clearly the road ahead wll fnd us facng new challenges n our quest to provde more and better servces to a growng number of veterans. The VHA Strategc Plan wll focus our efforts, creatng solutons to these challenges, gudng decson-makng, and showng us the way to be the provder of choce for Amerca s veterans and a health system unparalleled n the ndustry n offerng outstandng clncal care, research advancements, and educatonal opportuntes for health care professonals. VHA Vson

22 Chart 2.1 VHA Strategc Plan VA STRATEGIC GOALS VHA GOALS VHA OBJECTIVES VHA STRATEGIES 1. Restore the capablty of veterans wth dsabltes to the greatest extent possble and mprove the qualty of ther lves and that of ther famles. 1. Maxmze the physcal, mental, and socal functonng of veterans wth dsabltes and be recognzed as a leader n the provson of specalzed health care servces. (VA Objectve 1.1) 1. Maxmze the ndependent functonng of veterans n the least restrctve settng. ( 1) Improve and enhance home care servces and develop an asssted lvng strategy. ( 2) Promote the use of care management to facltate care n the least restrctve and most effcent settng. 2. Provde coordnated, comprehensve, and ntegrated care to promote health and mprove patent functonng. 3. Optmze the use of health care nformaton and technology for the beneft of the veteran. ( 3) Reduce varablty of health outcomes by provdng for a more consstent delvery of servces. 2. Ensure a smooth transton for veterans from actve mltary servce to cvlan lfe. 3. Honor and serve veterans n lfe and memoralze them n death for ther sacrfces on behalf of the Naton. 2. Ease the reentry of new veterans nto cvlan lfe by ncreasng awareness of, access to, and use of VA health care, benefts and servces. (VA Objectve 2.1) 3. Provde hgh qualty, relable, accessble, tmely and effcent health care that maxmzes the health and functonal status for all enrolled veterans, wth specal focus on veterans wth servce-connected condtons, those unable to defray the cost, and those statutorly elgble for care. (VA Objectve 3.1) 4. Increase provder and veterans knowledge of the mpact of mltary servce on health. 5. Contnuously mprove the qualty and safety of health care for veterans to be the benchmark for health care outcomes. 6. Improve patents satsfacton wth ther VA health care. 7. Improve access, convenence, and tmelness of VA health care servces. 8. Create a health care envronment characterzed by patent-centered servces where ndvdual health care decsons are made on the bass of current medcal knowledge, consstent wth patents nformed preferences and needs. ( 4) Accelerate development of Health Data Repostory, HealtheVet, and telehealth ntatves. ( 5) Increase collaboraton between VBA, VHA, and DoD durng the mltary dscharge process. ( 6) Collaborate wth DoD to develop a complete lfelong health record for veterans. ( 7) Collaborate wth VBA to nvgorate and update the Transtonal Assstance Program. ( 8) Intensfy efforts to mplement Veterans' Health Intatve, ncludng fully ncorporatng each veteran's mltary hstory and potental consequences of servce nto the Computerzed Patent Record System. ( 9) Be a leader n the advancement of knowledge and practce of qualty and patent safety ntatves to nclude: (a) the use of preventve medcne practces and gudelnes for chronc dsease management; (b) ncreasng the use of valdated standardzed processes such as ncreasng the use of automated systems to reduce the occurrence of adverse events; and (c) developng a culture of safety where reportng of close calls and adverse events results n the development and mplementaton of correctve actons that prevent harm to patents whle under our care. (10) Implement a "servce-recovery" program. (11) Standardze patent satsfacton surveys wth real tme results. (12) Provde ncentves for ongong, contnuous healthcare system redesgns to streamlne work, and to analyze, dentfy, and promulgate mproved health care practces. (13) Collaborate wth publc and prvate organzatons to reduce redundances and fll gaps n servces to veterans. (14) Implement ntatves to support shared decson-makng and patent empowerment. 12 Department of Veterans Affars Veterans Health Admnstraton

23 VA STRATEGIC GOALS VHA GOALS VHA OBJECTIVES VHA STRATEGIES 4. Contrbute to the publc health, emergency management, socoeconomc well-beng, and hstory of the Naton. 4. Improve the Naton s preparedness for response to war, terrorsm, natonal emergences, and natural dsasters by developng plans and takng actons to ensure contnued servce to veterans as well as support to natonal, state, and local emergency management and homeland securty efforts. (VA Objectve 4.1) 5. Advance VA medcal research and development programs that address veterans needs, wth an emphass on servce-connected njures and llnesses, and contrbute to the Naton s knowledge of dsease and dsablty. (VA Objectve 4.2) 6. Sustan partnershps wth the academc communty that enhance the qualty of care to veterans and provde hgh qualty educatonal experences for health care tranees. (VA Objectve 4.3) 9. Prepare to respond to dsasters and natonal emergences. 10. Conduct medcal research that leads to demonstrable mprovements n veterans health. 11. Promote excellence and nnovaton n the educaton of future health care professonals. VA ENABLING GOAL VHA ENABLING GOALS VHA ENABLING OBJECTIVES Delver world-class servce to veterans and ther famles by applyng sound busness prncples that result n effectve management of people, communcatons, technology, and governance. 7. Recrut, develop, and retan a competent, commtted and dverse workforce that provdes hgh qualty servce to veterans and ther famles. (VA Enablng Goal E-1) 8. Improve the overall governance and performance of VA by applyng sound busness prncples, ensurng accountablty, and enhancng our management of resources through mproved captal asset management; acquston and compettve sourcng; and lnkng strategc plannng, budgetng, and performance plannng. (VA Enablng Goal E-4) 12. Recrut, support, and retan a knowledgeable, dverse, engaged, and contnuously learnng workforce. 13. Effectvely communcate the contrbutons of VA health care, research, and educaton. 14. Expand Federal, state, local, and prvate partnershps to foster mprovements n the coordnaton and delvery of health care and other servces. 15. Promote cooperaton and collaboraton throughout VA to provde seamless servce to veterans. 16. Optmze the avalablty and effcent use of resources and servces. 17. Increase revenue and effcency through prvate sector partnershps, technology, and mproved busness practces. 18. Develop nnovatve approaches to the desgn and evaluaton of health care delvery systems. (15) Partner wth other Federal, state, and communty agences to develop a natonal emergency preparedness plan that clearly artculates VA s role and capabltes to respond to emergences. (16) Conduct tranng and emergency preparedness drlls usng standardzed scenaros consstent wth VA's Emergency Management Program Gudebook. (17) Mantan full research complance and standardzed protecton of human subjects. (18) Increase the proporton of research fundng drected to projects addressng veteran-related ssues, cooperatve studes, and translatonal research. (19) Improve the tranng and awareness n mltary health related ssues. (20) Provde approprate support for tranng, educaton, and resdent supervson. VHA ENABLING STRATEGIES (21) Develop a comprehensve and coherent workforce development plan that ncorporates Hgh Performance Development Model, successon plannng, dversty tranng, and Alternate Dspute Resoluton orentaton. (22) Implement pay polces and Human Resource practces to facltate hrng and retanng suffcent health care workers to meet capacty demands across the full contnuum of care. (23) Implement the VHA communcaton plan. (24) Expand VA sharng and collaboraton wth DoD, Indan Health Servce, and state veterans' organzatons. (25) Expand the Compensaton and Penson Record Interchange. (26) Deploy VHA ntatve to ncrease compettve sourcng. (27) Fully mplement Procurement Reform Task Force recommendatons. (28) Assess the feasblty of Federal magng, lab, and prescrpton centers. (29) Take full advantage of researchrelated ntellectual property opportuntes (30) Re-engneer health care processes to ncorporate technologc advances and to address shortages of health care professonals. VHA Vson

24 14 Department of Veterans Affars Veterans Health Admnstraton

25 CHAPTER 3 FOCUS ON VETERANS HEALTH CARE ACCESS SPECIAL EMPHASIS PROGRAMS GERIATRICS AND LONG TERM CARE PATIENT SAFETY QUALITY INDICATORS VETERAN SATISFACTION AWARDS FOR QUALITY ACCREDITATION RESEARCH PROFESSIONAL EDUCATION AND TRAINING DISASTER RESPONSE ACCESS Publc Law , the Veterans Health Care Elgblty Reform Act of 1996, effectve October 1, 1998, mandated VA to establsh and mplement a natonal enrollment system to manage the delvery of health care servces to veterans. Enactment of ths legslaton precptated serous problems wth clnc watng tmes, delays, and long cycle tmes. The number of veterans enrolled s a statstc that s both frustratng and encouragng. Whle the ncrease has straned the health care system, t ndcates the desrablty of VHA s nexpensve and hgh-qualty care. Snce 1997, VHA has reduced the cost of care per veteran by 26 percent, not by cuttng corners, but by delverng care more effcently and more effectvely. VHA has more than 1,300 stes of care and provdes health care servces at locatons much closer to where patents lve. Eghty-seven percent of VHA s patents now lve wthn 30 mnutes of a VHA medcal faclty. The VA health care system s not only focused on the qualty of care a veteran receves, but also on mprovng a veteran s access to care. VHA expects to treat 66 percent more patents n FY 2003 than were treated n Ths ncrease, mostly from nonservce-connected veterans, sgnfcantly reduced VHA s ablty to treat patents n a tmely manner, ncludng the hghest prorty veterans those wth servce-connected condtons, those wth lower ncomes and those wth specal health care needs, such as blndness, amputatons or spnal cord njures. FY 2004 s proposed budget for the medcal care program, together wth a comprehensve set of legslatve and regulatory proposals, wll allow VHA to focus ts health care assets on provdng medcal care to those wth servce-connected dsabltes, the ndgent and those wth specal health care needs. VHA Vson

26 Chart 3.1 Albers Projecton Generated by VHA Plannng Systems Support Group Centr al Merdan: -96 1st Std Parallel: 20 2nd Std Parallel: 60 Lattude of Orgn: 40 Travel Tme Servce Areas wth VHA Servce Stes August 2002 Source: Census 2000 total populaton by tract; 2002 Urban Moblty Report 2000 major roads August, 2002 VHA Servce Stes -70 Legend Travel Areas n Mnutes Canada 30 Mexco Atlantc Ocean State Bnd Alaska Pacfc Ocean Hawa Puerto Rco Gulf of Mexco Pacfc Ocean VHA Stes as of 8/1/ Pacfc Ocean SOURCE: PSSG webste We expect to treat 4.8 mllon patents n fscal year 2004, whle contnung to reduce the tme veterans must wat to see a doctor. Our goal s to have veterans wat no more than 30 days for a non-emergency, prmary care vst. Anthony J. Prncp, Secretary As of January 2003, approxmately 200,000 veterans were on watng lsts. These numbers are not statc. As new enrollees jon the lst, enrollees come off of the watng lst to become new patents n the system. VHA s fosterng multple efforts to reduce watng tmes. Developng the Advanced Clnc Access (ACA) ntatve n collaboraton wth the Insttute for Healthcare Improvement: The core of ACA s a tranng program that provdes strateges and change concepts to assst clnc staff n makng ther processes more effcent to reduce wat tmes, mprove access, and decrease costs. Developng a natonal Watng Tmes Web Ste and computerzed wat lst and schedulng package: Ths effort enhances measurement of wat tmes for every patent seekng access to VHA servces and mproves schedulng, effcency and effectveness. Developng montors to dentfy the percent of actve patents assgned to prmary care provders and the percent of prmary care provder capacty that s utlzed by actve patents. 16 Department of Veterans Affars Veterans Health Admnstraton

27 Suspendng new enrollment for Prorty Group 8 veterans. Effectve January 17, 2003, new enrollments were suspended n VA s health care system for veterans n Prorty Group 8, those who are not beng compensated for a mltary-related dsablty, and whose ncomes are above HUD low-ncome levels. The decson wll affect approxmately 164,000 Prorty Group 8 veterans projected to enroll n FY 2003; the 1.4 mllon Group 8 veterans enrolled pror to January 17 wll contnue to receve VA health care. Recrutng addtonal prmary care and specalty provder staff to keep pace wth the current demand for care and assure VHA s ablty to meet the comprehensve needs of veterans. VHA contnues to place a strong emphass on comprehensve specalty care for whch t has long been hghly respected wthn the medcal communty, whle now also emphaszng coordnaton of care through the unversal assgnment of prmary care provders. Wth ths transformaton to a prmary care delvery model, and by employng new models of care coordnaton and delvery, veterans have ganed access to an ntegrated health care system, focused on addressng ther needs before hosptalzaton becomes necessary. Hstorcally, health care n ths naton has been managed from the perspectve and needs of the provder. As a hosptal system, VHA wated untl veterans requred hosptal care. Even now, appontments are scheduled based on the provder s best guess as to when the patent wll need to be seen and when an appontment mght be avalable, rather than based on when the patent actually requres care. VHA s not alone; ths s the approach taken by most health care systems today. However, VHA beleves that better health care management strateges are now possble. VHA s dentfyng new ways to partner wth patents to more effectvely manage health and dsease processes contnuously, 24 hours a day, 365 days a year. VHA needs to be able to see the patent just n tme when a complcaton or need starts to develop. Ths shft consttutes a fundamental change n how VHA vews health care and ths approach wll have a groundbreakng mpact on both prmary care and long-term care. Whle the mpact on prmary care and the management of many chronc condtons wll be substantal, the mpact on long-term care wll be even more profound, especally as the VHA system wll experence a sgnfcant ncrease n veterans over 85 years of age by 2010 (1.02 mllon n 2000, 2.65 mllon n 2010). VA s health care system s growng and changng at a very rapd pace to provde the best possble care to our Naton s veterans. Laura J. Mller, Deputy Under Secretary for Health for Operatons and Management VHA Vson

28 To oversee many of the ntatves needed to mplement a patent-centered model for prmary and longterm care, the Under Secretary for Health has created a Care Coordnaton Offce. Whle the responsbltes of ths offce have not been formalzed, t wll foster the use of technology n care coordnaton and wll gude the development and mplementaton of polces and ntatves n chronc dsease management and long term care. SPECIAL EMPHASIS PROGRAMS VHA seeks to maxmze the ablty of the specal veteran populaton to become full and productve members of socety. To ths end, VHA has developed world-class facltes, staffed by world-class doctors, nurses, and other alled health care professonals who are devoted to treatng our Naton s veterans. Today s VA health care system supports a number of clncal and admnstratve ntatves that have been desgnated as Specal Emphass Programs (SEPs). Typcally, SEPs are clncal servces that address llnesses specfc to the servce-connected veteran populaton, consttute areas of specal VA expertse, or are unque programs that address the psychosocal needs of certan dentfed veterans. Publc Law , the Veterans Health Care Elgblty Reform Act of 1996, effectve October 1, 1998, mandated that the VHA ensure capacty for veterans wth spnal cord njures and dseases, blnded veterans, veterans wth amputatons, and veterans wth chronc dsablng mental llnesses. The law also requres the publcaton of data n an annual report (the Capacty Report ) to Congress demonstratng VA s complance wth the provsons of ths mandate. Ths secton presents a bref overvew of selected SEPs and a few hghlghts of accomplshments. SEP OVERVIEWS Homeless Veterans Programs Nearly 25% of the homeless populaton are veterans. Many more veterans who lve n poverty are at rsk of becomng homeless. VHA provdes substantal hands-on assstance and mantans the largest network of homeless assstance programs n the country. VHA s specalzed homeless veterans treatment programs strve to offer a contnuum of servces that nclude: aggressve outreach to those veterans lvng on streets and n shelters, who otherwse would not seek assstance; clncal assessment and referral to needed medcal treatment for physcal and psychatrc dsorders, ncludng substance abuse; long-term sheltered transtonal assstance, case management, and rehabltaton; employment assstance and lnkage wth avalable ncome supports; and supported permanent housng. 18 Department of Veterans Affars Veterans Health Admnstraton

29 Approxmately 75% of veterans n a Domclary Care for Homeless Veterans Program or Communty-based Contract Resdental Care Program were dscharged to an ndependent or a secured nsttutonal lvng arrangement. In FY 2003, more than 7,000 transtonal and permanent beds wll be avalable for veterans who are homeless. Durng the past year, more than 20,000 homeless and at-rsk veterans receved medcal care from VHA, and more than 19,000 veterans receved transtonal and supported housng, drectly or n partnershps wth grant and per dem or contract resdental care provders. On January 27, 2003, the Department of Housng and Urban Development (HUD), HHS and VA announced a $35 mllon program to provde permanent housng, health care and other supportve servces to those experencng chronc or long-term homelessness. For more nformaton vst homeless programs onlne at or Serously Mentally Ill (SMI) VHA has commtted tself to expandng state-of-the-art treatments of serous mental llness, usng the Assertve Communty Treatment (ACT) model. VHA now operates one of the naton s largest networks of ACT-lke programs, called Mental Health Intensve Case Management (MHICM). Another aspect of VHA s care for the serously mentally ll s a commtment to usng state-of-the-art medcatons. Ths results n mproved clncal outcomes, decreased ncdence of sde effects and ncreased complance wth prescrbed medcatons. In FY 2002, VHA provded support to more than 293,000 veterans who are severely mentally ll. Approxmately 20% of those veterans were hosptalzed durng the past year and over 80% were dscharged to a communty lvng stuaton at the end of ther hosptalzaton. For more nformaton vst Serously Mentally Ill programs onlne at or Readjustment Counselng Readjustment counselng s provded through a natonal system of communty-based counselng or Vet Centers. The Vet Center program servce msson features a holstc mx of drect counselng and multple communty-access functons: psychologcal counselng for veterans exposed to war trauma to nclude post-traumatc stress dsorder (PTSD), and/or veterans who were sexually assaulted durng mltary servce; famly counselng when needed for the veteran s readjustment; communty outreach and educaton; and extensve case management and referral actvtes. The latter actvtes nclude a full range VHA Vson