Loma Linda Healthcare System Loma Linda, Calif. Jan. 12, 2004

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1 Loma Linda Healthcare System Loma Linda, Calif. Jan. 12, 2004 The Loma Linda Healthcare System is part of the Desert Pacific Healthcare Network. It consists of one VA Medical Center located in Loma Linda and five Community-Based Outpatient Clinics located in Corona, Palm Desert, Sun City, Upland and Victorville, all in California. It has over 1,600 employees serving more than 40,000 veterans. The medical center has 97 acute care beds and a 108-bed nursing home care unit. The hospital provides a wide variety of services through inpatient, outpatient, and home care programs. Its major healthcare services include medicine, surgery, behavioral medicine and neurology. According to VAMC Director Dean Stordahl, Loma Linda patient workload has more than doubled in the last six years CARES Draft Plan Assessment: The VISN 22 Market Plan Summary for Loma Linda (CA) VAMC calls for the expansion and improvement of research space achieved mainly through new construction. The proposed CARES strategy is the construction of a 281,000 square foot Clinical and Research addition on the Loma Linda campus. Research space in Building One is not contiguous and will be backfilled by adjacent administrative and/or clinical services. Funding: VAMC Loma Linda s FY 2002 budget was $180 million. In FY 2003 it was $219 million, a 22 percent increase. VAMC management stated that the increase would allow the VAMC to increase its FTE ceiling level to 1,623 from 1,515 by Sept. 30, 2003, to assist in meeting patient care needs and appropriate staffing levels. MCCF collections for FY 2003 were $9,891,878 of an $8,768,971 goal or 13 percent over goal (they also exceeded the Exceptional goal a sort of overachievers goal, but not a requirement which was $9,891,878). They do not expect to meet their FY 2004 goal of $12,004,312. In order to improve their future collection rates they have begun to hire additional collection staff and to increase verification of insurance coverage for third party payments. They will also begin utilizing Electronic Data Interface for all billings to increase the timeliness of collections. They are also cross-training collection staff for both first and third party collections to include contacting veterans to establish repayment plans. They have not had to use capital investment dollars to supplement the medical care budget. The major budget challenge at present is matching current fiscal year workload growth to two fiscal years before capitation. Enrollment and Access: Management states it has 336 CBOC patients at Palm Desert awaiting a primary care appointment as of December 15, A new provider has been added to the community clinic and a recent extension has been completed. At present, no veterans are waiting beyond 30 days for a follow-up appointment. The Palm Desert CBOC is nearing capacity. Six new exam rooms were completed November 2003, while two additional providers were oriented in January 2004 one for Palm Desert and one for Sun City CBOC. All the CBOCs have implemented Advanced Open Access. Apparently there is an electronic wait list that determines if any veterans are waiting beyond the 30- day timeframe, which can be tracked from within the system. There are 1,086 Priority 1

2 Group 8 veterans who have applied since the January 17, 2003 cutoff. The VAMC has appointed a health benefits advisor to track these veterans via an electronic spreadsheet, and to serve as a point of contact for these veterans and to handle all correspondence. However, the enrollment coordinator handles all Priority Group 8 veterans appeals, especially pertaining to hardship. Estimating a $30 fee lost for each veteran denied treatment (a very conservative estimate) and with 1,086 veterans denied since January 17, 2003 the VAMC lost $32,580 again a very conservative number. Community Based Outpatient Clinics: There are five CBOCs currently operated by VA or under contract. They are located in Corona, Palm Desert, Sun City, Upland and Victorville. Affiliations and Staffing: Postgraduate medical and dental education programs are conducted with the Loma Linda University. In addition, the VAMC is also affiliated with 36 other educational institutions and provides training for a variety of allied health specialists. Management has difficulty in hiring specialists in oncology, radiology, cardiovascular and surgical. They presently employ fee/contract physicians in medicine, surgical, behavioral health, compensation and pension examinations and the emergency room. They have one physician under a J-1 visa in cardiology, who has been fulfilling all contract obligations. They also have trouble recruiting and retaining FTEE for: respiratory therapist, radiology technologist, ultrasound technologist, physical therapist, nurse anesthetist, anesthesiologist, custom equipment repair, bio medical technician, medical instruction technician, cytotechnician and nurses. Management hopes to receive help in hiring from the new physicians salary bill before Congress. Physician pay has not been addressed since However, they emphasized that rehabilitation and primary care physicians are presently near the top of the salary range for the Loma Linda Inland Empire region, and the salary bill might hurt future hiring of some non-specialist physicians. Presently the VAMC offers relocation bonuses, special salary rates above minimum and an education debt reduction program to encourage recruiting and retention. In order to recruit needed psychiatric nursing professionals, Loma Linda reports that they will need to increase the present salary pay scale. Physical Plant: Loma Linda VAMC was opened in 1977 and has a number of plant issues. The four boilers are beyond their scheduled economic life and are close to needing replacement. One of the four chillers that are being used as standby is old and inefficient. The Energy Management System computer and software are outdated. The elevator control is old and troublesome. Both the Energy Management System and elevator control system are scheduled for replacement with funding for both already in place. The hospital is planning to build three new major operating rooms with accompanying minor surgery rooms. They hope eventually to have their own radiation therapy facility to save patients the long two-hour plus commute to the nearest VAMC, or receive therapy at expensive local private facilities. The medical center is critically short of parking space and hopes to arrange a special lease for five adjoining acres shortly. Long Term Care, Mental Health and Homeless Services: The NHCU bed count has actually increased slightly since the Millennium Health Care Bill from 106 to 108 beds, 2

3 with 92 veterans in contract nursing home beds. The NHCU includes four hospice beds. There is no Alzheimer s unit at present. The homeless veterans program includes outreach to homeless veterans; VA supported housing that can provide subsidized housing (Section 8) and an eight-bed grant/per diem program with Frazee Community Center. The program includes an outreach clinician, a VASH clinician plus one clerical support person, and the coordinator. The Commission on Accreditation of Rehab Facilities recently accredited the program. Loma Linda received six exemplary practice notations and no recommendations. They recently established an agreement with US Vets at March Air Force Base to assist with the treatment process and housing for homeless veterans. The hospital treats many patients with dual diagnoses such as substance abuse and psychiatric disorders. Patients are provided mental health intensive case management using nurse practitioners. Patient, Family and Employee Surveys: None available. 3

4 Salem Veterans Affairs Medical Center Salem, Va. Feb. 3, 2004 The Salem VA Medical Center is a 288-bed, tertiary referral center and teaching hospital. Salem serves veterans throughout the State of Virginia for psychiatric, medical, and surgical care, and the medical center serves as a referral center for acute and long-term psychiatric care. All beds are currently in service. Salem VAMC is located on a sprawling campus just outside of Salem, Virginia. The area is largely rural, except for the mid-sized city of Roanoke and the smaller cities of Salem and Blacksburg CARES Draft Plan Assessment: The VISN 6 Northwest Executive Summary for Salem VAMC calls for collaboration with the National Cemetery Administration providing acreage for a possible new cemetery site. There are no Market Plans or VISNidentified planning initiatives for VAMC Salem. Funding: VAMC Salem s FY 2002 budget was $130.5 million. In FY 2003 it was $143.6 million, a 10 percent increase. MCCF collections in FY 2003 were $9.1 million of a $12.1 million goal (75 percent). FY 2004 goal is $10.4 million. Management states this represents a more reasonable goal based on historical collection rates. VAMC Salem s collection rates have increased an average of 27 percent per year since FY Based on collections through December 2003, they are 39 percent ahead of the amount collected through the same period last year. They expect this trend to continue through FY 2004 and the goal should be reached. VAMC management sees its major fiscal challenge as meeting patient care levels, pharmacy expenses, facility maintenance and improvements, new equipment needs and salary limitations for physicians. The VAMC Director stated that annual continuing resolutions make planning difficult and the lag time between the passage of a budget in Congress and receipt of new funding makes it difficult to make timely job offers to prospective medical staff. Enrollment and Access: Management states it has no patients waiting beyond thirty days for primary care appointments or for follow-up appointments. Eighty-three percent of its patients are enrolled in primary care. Sixty-seven percent of admissions in CY 2003 were through the emergency room. In order to insure maintenance of a zero wait list, enrollment and scheduling of new primary care patients is centralized with a PCMM coordinator. The veteran is then assigned to one of three primary care teams and consults are entered for either the VAMC or a CBOC. Since January 2003 there have been 594 Priority Group 8 veterans denied enrollment. This information is kept on file and the veterans are enrolled if they receive a service-connected disability or if income drops to the established thresholds for Priority Group 7. Community Based Outpatient Clinics: Salem VAMC has CBOCs in Danville and Tazewell. The Danville CBOC operates two satellite clinics in Martinsville and Axton. All CBOCs are contractor operated. A new CBOC in Lynchburg, Va., is on hold pending the CARES process. 4

5 Affiliations and Staffing: Salem has an active affiliation with the University of Virginia School of Medicine for the training of residents, medical students, and fellows in seven specialties. A new affiliation with the Edward Via Virginia College of Osteopathic Medicine is being developed. In addition, 39 associated health-training programs are offered in affiliation with 26 colleges and universities. An active research program includes 16 investigators working on 45 approved projects. VAMC management states it is increasingly difficult to recruit U.S. citizen physicians due to the disparity in salaries between VA and the private sector. They currently employ 11 J-1 visa physicians. Feefor-service doctors are employed primarily in the ER and some are utilized in most specialties. Two reservists, a psychologist and a gerontologist are currently deployed to Iraq. Physical Plant: VAMC Salem was opened in 1938 and has been extensively renovated, however concerns about the steam distribution system, roofs, exterior paint, and air conditioning and indoor air quality remain. Salem typically receives $1.5 million per year in funding for infrastructure and physical plant improvements but says it is difficult to obtain funding for minor construction projects above the $500,000 threshold and uses funds for temporary labor to contract for extensive local construction projects. Salem operates a 23-bed hotel on campus for visitors. With the numbers of female veterans returning from combat duty in Afghanistan and Iraq, a serious need exists in the area of women s mental health patient safety and privacy. Long Term Care, Mental Health and Homeless Services: A 90-bed ECRC reflects emphasis on wellness, preservation of function and rehabilitation. This bed count is the same as before the implementation of the Millennium Act. Salem provides contract Adult Day Care, hospice and home health care. There are currently five patients in community contract nursing homes. They provide NHCU care and inpatient respite in-house. They do not operate a dedicated Alzheimer s unit, but have a nationally recognized memory disorder unit with 25 authorized beds. The need for an enhanced geriatric assessment program is needed. MH services have expanded significantly at Salem over the past five years, adding additional staff including psych nurses, two psychiatrists and two psychologists. New funding has been received to add longer stay SA residential rehab beds, staff a memory disorder clinic, MH intensive case management, a military sexual trauma unit, outpatient depression primary care medicine, and a telepsychiatry link to an isolated region of rural Virginia. Salem runs an HCHV program for homeless veterans who utilize the medical center. Homeless outreach is actively conducted in the area by a full-time outreach clinician and Salem has a per-diem contract with the Roanoke Valley Veterans Council Housing Corporation. Patient, Family and Employee Surveys: Five each of inpatients, outpatients and family members were interviewed. The average inpatient traveled 25 miles to VAMC Salem and was transported by a family member who traveled 28 miles on average. Inpatients were positive about the quality of care and food (there were no negative comments). Outpatients traveled 80 miles on average and waited 30 minutes to be seen for a specialty care appointment. They were also positive about the quality of care. Employees interviewed commuted an average of 20 minutes. They were motivated by the people 5

6 with whom they work and serve, citing the work environment and people as the most satisfying parts of their jobs and enjoy working with veterans and colleagues. Negatives include inconsistencies in methods of operation and swings shifts for nursing, an issue even with non-nursing personnel raised on behalf of nurses. One suggested resolution to perceived problem is to put nursing under nursing, which the Director indicated is going to happen. Los Angeles Veterans Affairs Medical Center Los Angeles, Calif. Jan. 13, 2004 The Greater Los Angeles Healthcare System has 953 employees and a budget of approximately $400 million. It is a tertiary and teaching hospital that provides a full range of patient care services. In January 2004 it had a total of 981 beds in use out of a total number of 1,103 authorized beds GLA provides comprehensive services including primary care, tertiary care, and long-term care in areas of medicine, psychiatry, physical medicine and rehabilitation, neurology, oncology, dentistry, geriatric extended care, infectious disease, and radiology. GLA oversees a large transitional care program providing medical care in a therapeutic, institutional environment helping veteran patients reenter a community setting. GLA has many consolidated services in the western US, especially for VISNs 21 and 22. Those services include consolidated laundry, consolidated pharmacy, radiation therapy, central dental laboratory, prosthetics treatment center, fast neutron beam therapy, behavioral improvement, refractory programs, substance abuse programs, hospice program, open-heart center, regional acute psychiatric treatment ward, and DoD sharing agreements CARES Draft Plan Assessment: The VISN 22 Market Plan Summary for the Los Angeles VAMC calls for demolition of vacated buildings on the north side of the West Los Angeles campus with all care (except for long term care) consolidated on the south side of the campus as part of a new clinical addition on the south side. This move would be in addition to a collocation project with VBA: moving the VA Regional Office from high-priced space in a West LA office building to new quarters in a brand new structure with the VAMC. This will be accomplished through an Enhanced Use Lease project. A range of outpatient mental health programs and support staff would also be located within this new clinical addition to accommodate the increasing workload. The north side of the campus, freed up by the move of clinical services to the new south campus structure, would see its many, older buildings demolished and the construction of a State Nursing Home, along with expansion of the Los Angeles National Cemetery onto 20 acres on the north campus in order to build a columbarium. An additional $64.4 million is also projected for seismic upgrades to the West LA campus. There are also plans for a 130,000 sq. ft. replacement for the VAMC s nursing home facility. Funding: GLA s FY 2002 budget was $358 million. In FY 2003 it was $438 million, a 22 percent increase. The budget increase allowed the VAMC to maintain levels of service and staffing levels, though enrollment was restricted because of the Jan. 17, 2003 cut off. 6

7 MCCF collections in FY 2003 were $12,228,047 of a $13,323,258 goal or 8 percent short of the goal. The FY 2004 goal is $14,323,258. Management is uncertain as to whether it will meet that goal. To help improve collection rates management has added new staffing, acquired new software, and focused on customer service. Major budgetary challenges are considered to be: obtaining competitive pay for highly trained staff, assuring adequate funding to maintain the considerable infrastructure within the 368 acre campus, and to procure and maintain medical equipment. Keeping the later up-to-date in the present technological environment is a huge challenge. Maintaining and expanding the staff required to operate the new equipment is a challenge as well. Enrollment and Access: Management states that at present there are no veterans waiting beyond 30 days for their first primary care appointment. It is less clear about the wait for follow-up appointments since management simply refers to clinical need as the criterion. Some 80 percent of patients are enrolled in primary care. According to management, a wait for primary care is avoided thusly: Veterans present for services, their eligibility is established, and we enroll and/or schedule their appointments immediately. Some 2,195 Priority Group 8 veterans have applied since Jan. 17, There was no estimate available for lost income. Community Based Outpatient Clinics: GLA operates 10 CBOCs and none at present are at or near capacity. To avoid delays GLA consolidates appointments, moves patients to other facilities if patient prefers and attempts to recruit more staff where needed. CBOCs are located at: Gardena, East Los Angeles Valley, Lancaster, Lompoc, Pasadena, Oxnard, San Luis Obispo, Santa Paula and a satellite clinic at Patriotic Hall in downtown Los Angeles. Affiliations and Staffing: GLA maintains academic affiliations with the University of California, Los Angeles, and 45 other universities, colleges and vocational schools in 17 different medical, nursing, paramedical and administrative programs. Budget limitations and difficulties in hiring and retaining qualified staff have resulted in reduced nursing coverage and closed nursing home wards. This has reduced the number of patients who can be admitted to the NHCU. Physician salaries are not competitive with the community, most notably radiation therapy and anesthesiology. Nurses and technologists in general are hard to recruit. At present there are no physicians at the medical center with J-1 visas. To help with recruitment, the VAMC pays moving costs and recruitment bonuses. Finally, GLA s mental health department is seeking a permanent Chief of Psychiatry. Physical Plant: A number of improvements and upgrades are slated for West LA s main hospital tower, including some urgently needed seismic work (the seismic work will take the lion s share of the $25 million appropriated for GLA). GLA sits on 368 acres adjoining the communities of Beverly Hills and Bel Air; it represents some of the most valuable real estate in the nation. Because of community pressure, the choice of uses for this real estate is limited beyond the current array of buildings including two theatres and even oil well (income from which unfortunately mostly goes to the Bureau of Mines). Other sharing and enhanced use projects include renting out space for a school bus 7

8 parking lot, renting out additional space for parking of cars through a local car dealership, renting a baseball field to a local college, renting land to a private elementary school, and sharing buildings for homeless veterans shelters with community organizations. To address the need for additional space in the main hospital building, West LA is planning to build a new structure that would accommodate administrative services that are presently housed in the main building and provide space for the VA Regional Office, now housed in an expensive nearby office tower. Long Term Care, Mental Health and Homeless Services: GLA has the largest mental health program in VA with almost 20,000 veterans served in 2002, an increase of 61 percent over five years. However, the number of veterans served as inpatients declined 44 percent from 1,974 to 1,131. This is part of a national trend de-emphasizing inpatient care, particularly in mental health. At GLA there has been a major emphasis on mental health services at the CBOCs: Santa Barbara, Bakersfield, East Los Angeles, Antelope Valley, Lompoc and Oxnard. Direct referrals are available to veterans using the Pasadena, San Luis Obispo, Santa Paula and Ventura CBOCs. An Alzheimer unit is planned for the California State Home Project. At present GLA has a palliative care section whose beds are integrated with other sections. It is managed on a consultative basis. Budget limitations and the aforementioned difficulties in hiring and retaining qualified staff have resulted in reduced nursing coverage, and the closing of some nursing home wards. This has reduced the number of patients admitted to the nursing home. Patient, Family and Employee Surveys: None available. VA Long Beach Healthcare System Long Beach, Calif. Jan. 14, 2004 The VA Long Beach Healthcare System is part of the Desert Pacific Healthcare Network including facilities in Las Vegas, Loma Linda, San Diego, and the Greater Los Angeles area. The VA Long Beach Healthcare System is a teaching hospital providing a full range of patient services. There are a total of 327 operating beds in the facility as compared to 426 authorized overall. Comprehensive health care is provided through primary care, tertiary care, and long-term care in areas of medicine, surgery, psychiatry, physical medicine and rehabilitation, neurology, oncology, dentistry, spinal cord injury, geriatrics, and extended care. The VA Long Beach Healthcare System currently is comprised of the Anaheim Vet Center, four community clinics, located in Anaheim, Santa Ana, Villages at Cabrillo in Long Beach, and Whittier-Santa Fe Spring, and the main 100-acre campus adjacent to California State University, Long Beach CARES Draft Plan Assessment: The VISN 22 Market Plan for the Long Beach Healthcare System calls for the renovation of 64,000 square feet of the Long Beach location to expand and improve the Long Beach Nursing Home. $39 million will be spent for urgently needed seismic improvements to the facility. Also in the works are a new 24-8

9 bed Blind Rehabilitation Center and the conversion of 30 acute SCI beds to long term care SCI beds. Funding: VA Long Beach s FY 2002 budget was $171 million. In FY 2003 it was $192 million, a 12 percent increase. The 2003 budget allowed Long Beach to maintain the previous year s level of services, open enrollment and staffing level. The MCCF goal for FY 2003 was $9.7 million, whereas collections exceeded that by 10 percent at $10.7 million. The MCCF collection goal for FY 2004 is approximately $11.3 million, which management thinks they will exceed or come very close to exceeding. To improve collections, management has contracted out collection of receivables for third party follow up with the insurance companies, activated an electronic payment account for more expeditious reimbursement for federal receivables, established payroll deductions for employee debts, use EDI software to expedite claims and reimbursements, use QudraMed coding/billing, which helps in coding, and decreased unfilled receivables from $4 million to $250,000. Management sees its major fiscal challenge to be the chronic delay in the Congressional appropriations for the fiscal year, the complex new appropriations process and the restrictions, need for additional funds for ADP equipment, need for additional funds for construction projects, and the ever-rising cost of drugs. Enrollment and Access: Management states that it has no patients waiting beyond thirty days for primary care appointments, or follow up appointments. Virtually all patients are enrolled in primary care. Veterans are enrolled at the time they come in to the facility, without delay. They are planning to implement Open Access appointments that will eliminate delays in scheduling in all primary care clinics. They do not have figures on the numbers of Priority 8 veterans who have attempted to enroll since the January 17, 2003 cutoff. Community Based Outpatient Clinics: Long Beach has four CBOCs, only one of which is contracted. At present two of these are close to capacity. The monitor patient visits and panel size to appropriately assign staff. Waits and delays are minimized. Mental Health services are also available at CBOCs: psychology, social work and psychiatry. It would appear that patient access requires that a fifth CBOC be established in the southern Orange County area. Affiliations and Staffing: Long Beach s medical school affiliations include the University of California Irvine School of Medicine, California State University Long Beach School of Nursing, University of California Los Angeles School of Nursing, Long Beach City College School of Nursing and School of Radiology, and Bryman College. Due to the high pay scale in southern California, the Long Beach VA finds itself priced out of the labor market in many areas. FTEE that are difficult to recruit and retain include diagnostic radiologic technologist, ultrasound technologist, nuclear medicine technologist, radiological therapeutic technologist, radiation therapy physicist, occupational therapist, nursing assistants, speech pathologists, RN (critical care), RN clinical nurse specialist, RN (spinal cord injury), and police officers. As hiring incentives, the medical center offers a recruitment bonus and retention allowances, when necessary, an all-new salary structure for RN s, placement of new employs above the normal 9

10 starting pay amount. There are no J-1 Visa holders among the medical center s physicians. The following specialties are contracted out: radiologist, anesthesiologist, urologist, oncologist, and emergency room physician. Physical Plant: Long Beach reports $100 million is needed for seismic upgrades. Management is looking for additional major construction on the Long Beach campus to accommodate patient care areas, rehabilitation and surgery to compensate for the loss of Building 122. The domestic hot water system is over 25 years old, and must be replaced in stages. Repair and replacement is needed for two elevated domestic water towers, valves, and various roads have been requested. Seismic deficient buildings are planned for demolition or upgrade. Due to the demolition of building 122 there is a shortage of space. Security considerations: increase of police services and addition of decontamination capabilities. Long Term Care, Mental Health and Homeless Services: The medical center s level of long-term/extended care has remained the same since enactment of the Millennium Bill of 1999 at 105 beds. There are 58 veterans in contract nursing homes as well. Mental health care has continued to stress outpatient over inpatient, including an emphasis of the team approach, with representatives from psychiatry, psychology, social work, nursing and pharmacy. Each team covers a panel of patients who are seen in both inpatient and outpatient settings. All patients covered by the teams have a primary psychiatrist. The mental health intensive case management program has been actively implemented as well as a geropsychiatry inpatient unit for elderly patients in need of acute inpatient stabilization. Long Beach has a very active health care for homeless veterans program. At present the facility has 15 hospice beds but no Alzheimer s unit. Long Beach also has 152 grant and per diem beds through its relationship with the US Vets and Villages at Cabrillo. Patient, Family and Employee Surveys: None available. VA San Diego Healthcare System San Diego, Calif. Jan. 15, 2004 The VA San Diego Healthcare System is part of the Desert Pacific Healthcare Network. It provides services to more than 238,000 veterans in the San Diego and Imperial Valley regions of southern California. The Healthcare System consists of the major medical center on La Jolla Village Drive in San Diego; six CBOCs located in Chula Vista, Escondido, Imperial Valley, Mission, Valley, Wave and Vista, and two Vet Centers located in San Diego and Vista. Medical, surgical, mental health, geriatric, spinal cord injury, and advanced rehabilitation services are provided. With an operating budget of $253 million, the healthcare system has 242 authorized beds with 238 presently in use, including skilled nursing beds. The system also operates several regional referral programs including cardiovascular surgery, and spinal cord injury. 10

11 2003 CARES Draft Plan Assessment: The VISN 22 Market Plan Summary for San Diego calls for new construction of 260,000 sq. ft. for the San Diego campus and renovation of another 16,000 sq ft. Seismic retrofitting is funded at $49.1 million for San Diego. CARES also calls for closer collaboration with Balboa Naval Hospital in San Diego. Funding: San Diego s FY 2002 budget was $253 million. In FY 2003 it was $277 million, a 9 percent increase. Management stated that despite the modest increase in funding they still experience delays in hiring caused by a shortage of applicants, especially for complex jobs such as nursing and IT. VA salaries are simply not competitive in this market. MCCF collections in FY 2003 were $9,562,160 million of a $9,020,492 goal or 6 percent over. The FY 2004 goal is $12,004,312. Management feels that it is unlikely that they will meet their new goal. To improve its collections, management has contracted with an outside vendor to help with follow-up on open receivables. They have not had to use capital investment to supplement their medical care budget. Budgetary challenges are seen as: the need to selectively increase hiring. There is a need for additional FTEE to meet performance goals and to insure that there are not long waiting times for elective operations and there are adequate beds for admissions. The biggest complaint that management has is, as elsewhere, the belated budget process and the continuing resolutions that hinder the medical center s planning and spending decisions. Enrollment and Access: Management states that it has no patients waiting beyond thirty days for their first primary care appointments. There are no veterans waiting beyond thirty days for a follow-up appointment. Some 51 percent of patients are enrolled to receive primary care. Approximately 875 Priority Group 8 veterans have applied since the Jan. 17, 2003 cutoff. This information is kept on file electronically and as hard copy. Community Based Outpatient Clinics: San Diego operates six CBOCs. VA staff operates four CBOCs. Only the Vista location is nearing capacity. However, there is an intake physician available and patients can be seen within 30 days. Patients are then set up for another appointment as necessary. Management is presently negotiating for additional lease space in Vista to obviate the capacity concerns. Affiliations and Staffing: The San Diego Healthcare System has affiliations with the University of California, San Diego School of Medicine, and provides training for 809 medical interns, residents and fellows, as well as 64 other teaching affiliations for nursing, pharmacy, dental and dietetics. San Diego also has one of the largest research programs in the VA with a budget of over $47.2 million (FY 2002), 220 principal investigators and more than 965 projects. The healthcare system is also home to several specialty research programs including health sciences research and development, mental illness rehabilitation, education, and clinical centers, the research center for AIDS and HIV, and the San Diego Center for Patient Safety. San Diego s most critical challenge in physician recruitment is the current VA physician salary structure. They are not able to offer salaries that are competitive with the salaries offered in the community, however, strong affiliations with local universities counteracts this to some extent for physicians 11

12 interested in academic pursuits. The pay issue is particularly problematic in some specialties such as radiology, anesthesiology, and some surgical and medical subspecialties in which local salaries are close to double that which VA is able to offer. San Diego has had recent serious difficulties (lasting two years or more) recruiting a hepatologist, neurosurgeon, and a chief for the spinal cord injury unit. San Diego currently contracts for urgent care physicians. They have two contract outpatient clinics in Escondido and Brawley. They periodically use a locum tenens contract for primary care providers when new enrollments push waiting times for first appointments beyond 30 days. They have some physicians providing periodic fee basis care during extended absences or for vacation coverage. Hiring incentives include: specialty pay schedules for urgent care, ICU and OR. They have also employee referral bonuses and are launching recruitment and retention bonuses for SCI staff. They are using the full flexibilities afforded to us through appointments above the minimum for Title 38 employees. Recruitment of nurses continues to be difficult, reflecting the national nursing shortage. At San Diego the shortage is particularly acute with RN vacancies in the operating room, urgent care center, and general medical/surgery areas. They are currently 2 percent to 5 percent below the local labor market in pay, but the turnover rate at San Diego is 11.6 percent, well below the national average of 15.8 percent. Physical Plant: The plant is over 35-years-old and much of the piping, air conditioning, electrical and other systems are in need of upgrade or replacement. Building 1 has serious seismic and structural issues including exposed asbestos. In addition to the outmoded configuration there is a shortage of useful space including lack of patient privacy in many four-patient rooms, outdated outpatient clinics and lack of capacity in subspecialty clinics. There are 242 authorized beds in the facility of which 238 are operational. They have not had to close any inpatient beds. The emergency room is open 24 hours each day. The medical center is located on 26 acres of government-owned land. Much of this land is used for parking and is owned by the University of California, not VA. Next year UC will build a bridge across Interstate 5 to connect its separated campuses and will need VA to sacrifice 150 parking spaces which, added to the 100 spaces it is already short, will make a deficit of 250 spaces. As a result they will need to build a parking structure to make up the deficit. Long Term Care, Mental Health and Homeless Services: In the last five years San Diego has seen significant changes including a psychiatric primary care clinic, combining service for both mental health and medical problems of a mild to moderate degree. The mental health intensive case management program was begun last year for veterans with severe and chronic mental illnesses. The post combat stress disorder program has been allocated additional FTEE to allow an annual 20 percent plus in veterans treated. Nurse practitioners have been added to outpatient services. Policies and procedures were revised to allow enhanced admissions to VA San Diego. Mental health services were added to the Vista CBOC. A methadone program was begun this year. Mental health care has shifted from primarily an inpatient program to an outpatient program over the last several years. Mental health professionals in San Diego question how much longer that can continue as patients mental conditions tend to deteriorate as they age, and ever-larger numbers of veterans in the vicinity seek care. Presently (December 2003) there are 75 veterans in 12

13 contract nursing homes, more than before passage of the Millenium Bill. Finally there is no Alzheimer s unit, though patients are admitted with dementia for respite program stays. There is no hospice program per se but there is a palliative care program for four to eight patients at a time. There is a hoptel operated as well. There is also a homeless program made up of homeless chronically mentally ill, VA supported housing, per diem program, and critical time intervention. The program is Certified Accredited Rehabilitation Facility certified. Patient, Family and Employee Surveys: Three outpatients were interviewed. The patients lived between seven and 43 miles from the medical center. Remarks concerning quality of care: not treated all that well, treated wonderfully, and treated well. Getting an appointment when needed: not too good, very easy, and no problem. 13