Department of Veterans Affairs. Volume II Medical Programs and Information Technology Programs Congressional Submission

Transcription

1 Department of Veterans Affairs Volume II Medical Programs and Information Technology Programs Congressional Submission FY 2016 Funding and FY 2017 Advance Appropriations Table of Contents Page No. Part 1. Medical Programs Executive Summary of Medical Care... VHA-1 Medical Care Charts (Staffing, Workload, and Obligations)... VHA-15 Medical Services... VHA-45 Medical Support & Compliance... VHA-129 Medical Facilities... VHA-151 Veterans Choice Act... VHA-167 Enrollee Health Care Projection Model (EHCPM) and Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)... VHA-177 Appropriation Transfers & Supplementals... VHA-197 Proposed Legislation... VHA-199 VHA Performance Plan... VHA-219 Selected Program Highlights... VHA-243 Part 2. Joint Medical Care Special Programs DoD-VA Health Care Sharing Incentive Fund... VHA-265 Joint DoD/VA Medical Facility Demonstration Fund... VHA-271 Part 3. Medical and Prosthetic Research Medical & Prosthetic Research... VHA-277 Part 4. Revolving & Trust Activities Veterans Canteen Service Revolving Fund... VHA-315 Medical Center Research Organization... VHA-321 General Post Fund... VHA-325 Part 5. Information Technology Programs Information Technology Programs... IT-329 Appendix, Project Listing... IT Congressional Submission I

2 Abbreviations ARRA American Recovery and Reinvestment Act of 2009, Public Law CBOC CHAMPVA CNS CWVV FMP GOE HCCF HEC IT JIF MS MS&C MF Community-Based Outpatient Clinic Civilian Health and Medical Program of the Department of Veterans Affairs Construction Children of Women Vietnam Veterans Foreign Medical Program General Operating Expenses Health Care Center Facilities Health Executive Committee Information Technology VA/DoD Health Care Sharing Incentive Fund (more commonly known as the Joint Incentive Fund) Medical Services Medical Support and Compliance (formerly Medical Administration) Medical Facilities OEF/OIF/OND Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn II Table of Contents

3 Executive Summary of Medical Care Mission Honor America s Veterans by providing exceptional health care that improves their health and well-being. To fulfill President Lincoln s promise "To care for him who shall have borne the battle, and for his widow, and his orphan" by serving and honoring the men and women who are America s Veterans. President Lincoln s immortal words delivered in his Second Inaugural Address more than 140 years ago describe better than any others the mission of the Department of Veterans Affairs (VA). We care for Veterans, their families, and survivors men and women who have responded when their Nation needed help. Our mission is clear-cut, direct, and historically significant. It is a mission that every employee is proud to fulfill. VA fulfills these words by providing world-class benefits and services to the millions of men and women who have served this country with honor in the military. President Lincoln s words guide the efforts of all VA employees who are committed to providing the best medical care, benefits, social support, and lasting memorials that Veterans and their dependents deserve in recognition of Veterans service to this Nation. Vision The Veterans Health Administration (VHA) will continue to work to be the benchmark of excellence and value in health care and benefits by providing exemplary services that are both patient-centered and evidence-based. This care will be delivered by engaged, collaborative teams in an integrated environment that supports learning, discovery and continuous improvement. It will emphasize prevention and population health and contribute to the Nation s wellbeing through education, research and service in national emergencies. National Contribution VHA supports the public health of the Nation through medical, surgical, and mental health care, medical research, medical education and training. VHA also plays a key role in homeland security by serving as a resource in the event of a national emergency or natural disaster Congressional Submission VHA-1

4 Stakeholders Numerous stakeholders have a direct interest in VHA s delivery of health care, medical research and medical education. They include: Veterans and their Families The President and Congress DoD and other Federal Agencies Veteran Service Organizations State/County Veterans Offices State Veterans Homes Local Communities Academic Affiliates Health Care Professional Trainees Researchers Health Care Contract Providers VA Employees Public-at-Large Native American Tribes VA Medical Care Overview VA is committed to providing Veterans and other eligible beneficiaries timely access to high-quality health services. VA s health care mission covers the continuum of care providing inpatient and outpatient services, including pharmacy, prosthetics, and mental health; long-term care in both institutional and non-institutional settings; non-va care, and other health care programs, such as the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) and readjustment counseling. VA will meet all of its commitments to treat Operation Enduring Freedom (OEF), Operating Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans and Servicemembers in 2016 and Veterans Access, Choice, and Accountability Act of 2014 On August 7, 2014, President Obama signed into law the Veterans Access, Choice and Accountability Act of 2014 (Public Law ) (Veterans Choice Act). The 2016 budget supports implementation of the Veterans Choice Act and the Administration s goal of providing timely, high-quality health care for our Nation s veterans. The Veterans Choice Act provided $5 billion in mandatory funding in Section 801 to increase veterans' access to health care by hiring more physicians and staff and improving the VA s physical infrastructure. It also provided $10 billion in mandatory funding in Section 802 through 2017 to establish a temporary program ("Veterans Choice Program") improving veterans access to health care by allowing eligible veterans who meet certain wait-time or distance standards to use health care providers outside of the VA system. For more information please see the Veterans Access, Choice, and Accountability Act of 2014 chapter. VHA-2 Executive Summary of Medical Care

5 Medical Care Appropriation and Collections 1/ $70 $ $ $ $ $ $ $60 $3.069 $3.048 $3.204 $3.253 $3.227 $3.300 B i l l i o n s $50 $40 $30 $ $ $ $ $ $ $20 $10 $ Actual 2015 Budget Estimate 2015 Current Estimate 2016 Advanec Approp Revised Request 2017 Advance Approp. Appropriation Collections 1/Medical Care represents all three appropriations: Medical Services, Medical Support and Compliance, and Medical Facilities. Chart excludes funding appropriated in the Veterans Access, Choice, and Accountability Act of 2014 (Veterans Choice Act), P.L Collections exclude the portion of Medical Care Collections Fund (MCCF) collections actually, or anticipated to be, transferred to the Joint DOD-VA Medical Facility Demonstration Fund, in support of the Captain James A. Lovell Federal Health Care Center (FHCC). Medical Care Budgetary Resources (dollars in millions) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Appropriation 1/: Medical Services... $43,418,000 $45,383,412 $45,195,886 $47,603,202 $48,727,399 $51,673,000 $3,531,513 $2,945,601 Medical Support & Compliance. $5,983,000 $5,879,700 $5,874,091 $6,144,000 $6,213,961 $6,524,000 $339,870 $310,039 Medical Facilities... $4,957,000 $4,739,000 $4,737,000 $4,915,000 $5,020,132 $5,074,000 $283,132 $53,868 Total Net Appropriations... $54,358,000 $56,002,112 $55,806,977 $58,662,202 $59,961,492 $63,271,000 $4,154,515 $3,309,508 MCCF Collections 2/... $3,068,584 $3,048,303 $3,204,266 $3,252,857 $3,226,548 $3,299,954 $22,282 $73,406 Total... $57,426,584 $59,050,415 $59,011,243 $61,915,059 $63,188,040 $66,570,954 $4,176,797 $3,382,914 Full Time Equivalent (FTE) 3/ , , , , , ,216 5,543 11,782 Veterans Choice Act Sec $5,000,000 $0 $0 $0 $0 $0 $0 $0 Veterans Choice Act FTE 4/ , , ,807 (9,613) Veterans Choice Act Sec $10,000,000 $0 $0 $0 $0 $0 $0 $0 Veterans Choice Fund FTE 5/ / Includes all rescissions but not transfers to the two joint Department of Defense (DoD)-VA health care accounts Congressional Submission VHA-3

6 2/ Excludes the portion of MCCF collections actually, or anticipated to be, transferred to the Joint DOD-VA Medical Facility Demonstration Fund, in support of the Captain James A. Lovell Federal Health Care Center (FHCC). 3/ Does not include FTEs in the two joint DoD-VA health care accounts or FTEs funded by the Veterans Choice Act. 4/ Estimate assumes that Section 801 funding will be exhausted by the end of 2016; beginning in 2017, these additional FTEs are funded through the regular appropriation request. 5/ Estimate assumes that Section 802 funding will be available through Medical Care Program Funding Requirements The President s Budget submission for Medical Care is based predominately on an actuarial model, known as the Enrollee Health Care Projection Model (EHCPM), founded on actuarial methods employed by the nation s insurers and public providers, such as Medicare and Medicaid. The resource request is tied to actuarial estimates of the projected Veteran population, projected enrollment in VA health care, and projected changes in the demographic mix of enrollees over time. Demand is adjusted for expected utilization changes anticipated for an aging Veteran population and for services mandated by statute. The utilization projections are based on the following factors: private sector benchmarks adjusted to reflect the VA health care services package; Veteran enrollee age, gender, and morbidity; enrollee reliance on VA versus other health care providers; and VA s level of management in providing health care. The changing demand for VA health care reflects many factors, including changes in health care practice such as the increasing use of pharmaceuticals; the advanced aging of many World War II, Korean, and Vietnam Veterans in greater need of health care; and the outcome of high Veteran satisfaction with the health care delivery. Finally, the EHCPM projects the total cost of providing over 80 types of health care services by multiplying the expected VA utilization by the anticipated cost per service. Additional information on the EHCPM can be found in the separate chapter on the Enrollee Health Care Projection Model and the CHAMPVA Model. Not all requirements are projected by the EHCPM; see the Model and Non-Model Obligations chart in the Executive Summary Charts for more information. The 2017 funding level also reflects an initial estimated cost of continuing to fund investments made from section 801 of Public Law , the Veterans Access, Choice, and Accountability Act of 2014 (the Veterans Choice Act). The following table displays, on an obligation basis, the estimated resources by major category that VA projects to incur. For more information about each major category, please see the Medical Services Chapter. The table below excludes Veterans Choice Act funding. VHA-4 Executive Summary of Medical Care

7 VA Medical Care Obligations by Program Excludes Veterans Choice Act (dollars in millions) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate 1/ Estimate Approp. 1/ Request Approp. Decrease Decrease Health Care Services: Ambulatory Care 2/... $23,542 $24,470 $23,598 $26,222 $26,067 $27,099 $2,469 $1,032 New Hepatitis C Treatment... $379 $0 $697 $0 $690 $660 ($7) ($30) Inpatient Care... $10,806 $11,507 $11,300 $11,827 $11,717 $12,149 $417 $432 Rehabilitation Care... $595 $643 $624 $660 $638 $652 $14 $14 Mental Health 3/... $6,676 $7,178 $7,106 $7,449 $7,455 $7,715 $349 $260 Prosthetics... $2,449 $2,577 $2,645 $2,749 $2,842 $3,039 $197 $197 Dental Care... $888 $922 $992 $973 $1,073 $1,149 $81 $76 Health Care Services [Total] 4/... $45,335 $47,297 $46,962 $49,880 $50,482 $52,463 $3,520 $1,981 Veterans Choice Program Cost-Shift... ($452) ($733) ($452) ($281) Long-Term Services and Supports: VA Community Living Centers (VA CLC)... $3,340 $3,558 $3,376 $3,729 $3,453 $3,622 $77 $169 Community Nursing Home... $721 $753 $810 $777 $845 $908 $35 $63 State Nursing Home... $985 $963 $1,081 $1,001 $1,169 $1,257 $88 $88 State Home Domiciliary... $56 $64 $57 $66 $60 $62 $3 $2 Subtotal... $5,102 $5,338 $5,324 $5,573 $5,527 $5,849 $203 $322 Non-Institutional Care [Total]... $1,721 $1,708 $1,828 $1,837 $1,934 $2,027 $106 $93 Long-Term Services and Supports [Total]... $6,823 $7,046 $7,152 $7,410 $7,461 $7,876 $309 $415 Other Health Care Programs: CHAMPVA, Spina Bifida, FMP, & CWVV... $1,537 $1,716 $1,718 $1,855 $1,884 $2,062 $166 $178 Caregivers (Title 1)... $350 $306 $482 $306 $555 $642 $73 $87 Indian Health Servcies... $15 $39 $18 $39 $28 $28 $10 $0 Camp Lejeune - Veterans and Family... $5 $51 $18 $72 $20 $20 $2 $0 Readjustment Counseling... $213 $238 $238 $238 $243 $243 $5 $0 Other Health Care Programs [Total]... $2,120 $2,350 $2,474 $2,510 $2,730 $2,995 $256 $265 Homeless Veterans Programs: Ending Veterans Homelessness... $1,521 $1,641 $1,445 $1,265 $1,393 $1,393 ($52) $0 Congressional Action: Veterans Choice Act, Sec. 801: Staffing... $870 N/A $870 Veterans Choice Act, Sec. 801: Lease Costs... $121 N/A $121 Veterans Choice Act, Sec. 801: Legionella... $204 N/A $204 Congressional Action [Total]... $1,195 N/A $1,195 Healthcare Infrastructure Enhancements: VISTA Evolution... $74 $123 $68 $208 $160 $208 $92 $48 Non-Recurring Maintenance 4/... $998 $461 $636 $461 $708 $461 $72 ($247) Activations... $659 $534 $548 $130 $598 $598 $50 $0 Healthcare Infrastructure Enhancements [Total]... $1,731 $1,118 $1,252 $799 $1,466 $1,267 $214 ($199) VA Legislative Proposals: Total... $0 $46 $38 $50 $49 $49 $11 $0 VA Prior Year Recoveries... $737 N/A $737 Total Obligations... $57,530 $59,498 $59,323 $61,914 $63,129 $67,242 $3,806 $4,113 Note: Dollars may not add due to rounding in this and subsequent charts. 1/ The following initiatives, as previously shown in the 2015 Congressional Submission, are now included within Health Care Services for all columns: Affordable Care Act, VOW to Hire Heroes Act, and Proposed Savings. 2/ Funding for Ending Veterans Homelessness, VISTA Evolution and Activations have been removed from this line and displayed in their respective sections, below, so that the full amount of funding for these programs is displayed. 3/ This displays the full cost of Mental Health, which includes some overlapping obligations with Homeless Veterans Programs. In order to show the full value of Mental Health and Homeless Programs obligations, all Homeless Programs obligations were adjusted from Ambulatory Care. 4/ In prior Congressional Submissions, the obligations for non-recurring maintenance (NRM) were included within Health Care Services. This year, obligations for NRM have been removed from Health Care Services and displayed in the section on Healthcare Infrastructure Enhancements Congressional Submission VHA-5

8 Funding Highlights: In 2016, the Budget requests $ billion for Veterans medical care, supporting continuing improvements in the delivery of mental health care, specialized care for women veterans, new treatments for Hepatitis C, and benefits for Veterans caregivers. In addition, the Budget includes $3.227 billion in estimated medical care collections for a combined resource of approximately $ billion. Requests $ billion in 2017 Advance Appropriations for medical care programs, to ensure continuity of Veterans health care services. In addition, the Budget includes $3.300 billion in estimated medical care collections for a combined resource of approximately $ billion. Provides $1.393 billion in 2016 to sustain the Administration s ongoing efforts to end Veteran homelessness, including $300 million for the Supportive Services for Veteran Families (SSVF) program, to prevent Veterans from becoming homeless in the future. Provides $7.455 billion in 2016 to ensure the availability of a range of mental health services, from treatment of common mental health conditions in primary care to more intensive interventions in specialty mental health programs for more severe and persisting mental health conditions. Provides $598 million in 2016 to ensure timely activation of new and renovated medical facilities already under construction. Invests $525 million in 2016, within the Medical Care accounts, to support medical and prosthetic research efforts to advance the care and quality of life for Veterans, such as the Million Veteran Program (MVP), a genomic medicine program that seeks to collect genetic samples and general health information; and post-deployment mental health studies Highlights The 2016 President s Budget is requesting direct appropriations of $ billion, $1.299 billion in additional funding above the 2016 advance enacted level to meet Veterans medical care needs, a 7.4 percent increase over the 2015 enacted level. In addition to the 2016 appropriation request, VA anticipates the Medical Care Collections Fund (MCCF) will achieve $3.248 billion in collections, of which $3.227 billion will be transferred to Medical Services and the remainder to the Joint DoD-VA Medical Facility Demonstration Fund (to support the operations of the Captain James A. Lovell Federal Health Care Center (FHCC)). VA will transfer at least $15 million to the DoD-VA Health Care Sharing Incentive Fund (known as the JIF ), as mandated by law, and $259.1 million in support of the FHCC from the Medical Services, Medical Support and Compliance, and Medical Facility appropriations. VA also estimates that it will receive $215 million in reimbursements largely from the Department of Defense (DoD) for treating their patients. VHA-6 Executive Summary of Medical Care

9 In addition, VA estimates it will obligate $2.345 billion from section 801 of the Veterans Choice Act, which will allow VHA to meet its 2016 total obligation authority of $ billion and support over 6.9 million unique patients and 9.4 million enrolled Veterans. Compared to the enacted 2016 advance appropriations level, as requested in the 2015 President s Budget, this year s 2016 request for VA health care services is $1.299 billion higher. This request for additional funding is necessary to ensure the delivery of highquality and timely health care services to veterans and other eligible beneficiaries. For the first time, VA is requesting an increase above the enacted advance appropriation in all three Medical Care accounts: $1.124 billion in Medical Services, $105 million in Medical Facilities, and $70 million in Medical Support and Compliance. The total net increase of $1.299 billion is due to the following factors: Ongoing health care services estimate increased by $599.9 million, driven largely by estimates of the cost of new Hepatitis C treatments and updated actuarial trends based on the latest actual data. A reduction in projected base appropriations health care costs due to enactment of the Veterans Choice Act; VA estimates that $452 million in requirements will shift from the regular program as Veterans who would otherwise receive care in the VA health care system instead choose to participate in the new Veterans Choice Program, as established in the Veterans Choice Act and funded by section 802 of the Act. Long-Term Services and Supports estimate has increased by $51.1 million, reflecting trends in the most recent actuals and the continued investment into noninstitutional settings. Ongoing health service programs not projected by the EHCPM increased by $221.6 million. The Caregivers program cost estimate increased by $249.4 million, driven largely by an increase in the projected number of Caregivers receiving stipend payments. The combined sum of the estimates for CHAMPVA, reimbursement to the Indian Health Service and tribal health programs, caring for eligible Camp Lejeune Veterans and families, and readjustment counseling decreased by $27.8 million based on updated actuals and revised assumptions in workload for Camp Lejeune and Indian Health Service. VA programs to end Veterans homelessness increased by $128 million, for a total of $1.393 billion. The increased estimate allows VA to fully support projected utilization in its homeless programs, including the Supportive Services for Veterans Families (SSVF) program and the Department of Housing and Urban Development-VA Supportive Housing program (HUD-VASH). Healthcare Infrastructure Enhancements increased by $666.9 million. Facility activation costs have increased by $468.2 million over the initial advance 2016 Congressional Submission VHA-7

10 appropriation estimate of $130 million to $598.2 million; the initial estimate was based on construction delays that have caused under-execution of activations in recent years. However, VA has made progress in resolving these issues, and as a result has increased confidence that the additional funding will be required in FY The cost estimate of supporting the Veterans Integrated System Technology Architecture (VISTA) evolution project has been revised downward from $208.3 million to $159.6 million. Estimated non-recurring maintenance obligations grew from $460.6 million to $708.0 million, to address high-priority emerging capital needs as identified through the Stratregic Capital Investment Planning (SCIP) process; this increase excludes funding provided by the Veterans Choice Act. See Volume 4, Chapter 7 for additional information on the SCIP process and the NRM program. The cost of VHA proposed legislation remains nearly unchanged with an estimated cost decrease of $0.5 million. The 2016 budget includes estimates for Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) healthcare benefits for beneficiaries up to age 26. Additional budgetary resources decreased by $84.4 million (collections, reimbursements and transfers). The estimate for the Medical Care Collections Fund decreased by $26.3 million. Reimbursements decreased by $51.0 million and transfers to the Joint DoD-VA Medical Facility Demonstration Fund increased by $7.1 million. VHA-8 Executive Summary of Medical Care

11 Update to the 2016 Advance Appropriations Request Excludes Veterans Choice Act (dollars in Thousands) 2016 Advance Current Increase/ Description Approp. Estimate Decrease Health Care Services... $49,882,074 $50,481,994 $599,920 Veterans Choice Program Cost-Shift... ($452,000) ($452,000) Long-Term Services and Supports: Institutional... $5,572,601 $5,526,958 ($45,643) Non-Institutional... $1,836,847 $1,933,555 $96,708 Long-Term Services and Supports [Total]... $7,409,448 $7,460,513 $51,065 Other Health Care Programs: CHAMPVA, Spina Bifida, FMP & CWVV... $1,854,870 $1,883,882 $29,012 Caregivers (Title 1)... $305,716 $555,096 $249,380 Indian Health Services (P.L )... $38,649 $28,062 ($10,587) Camp Lejeune - Veterans and Family (P.L ).. $71,906 $19,720 ($52,186) Readjustment Counseling... $237,544 $243,483 $5,939 Other Health Care Programs [Subtotal]... $2,508,685 $2,730,243 $221,558 Ending Veterans Homelessness... $1,265,000 $1,393,000 $128,000 Healthcare Infrastructure Enhancements: VISTA Evolution... $208,265 $159,596 ($48,669) Non-Recurring Maintenance... $460,600 $708,000 $247,400 Activations... $130,000 $598,174 $468,174 Healthcare Infrastructure Enhancements [Subtotal]... $798,865 $1,465,770 $666,905 VA Legislative Proposals... $49,914 $49,375 ($539) Obligations [Total]... $61,913,986 $63,128,895 $1,214,909 Funding Availability: Appropriation... $58,662,202 $58,662,202 $0 Trns to North Chicago Demo. Fund... ($252,073) ($259,145) ($7,072) Trns to DoD-VA Health Care Sharing Incentive Fund... ($15,000) ($15,000) $0 Medical Care Collections Fund... $3,252,857 $3,226,548 ($26,309) Reimbursements... $266,000 $215,000 ($51,000) Funding Availability [Total]... $61,913,986 $61,829,605 ($84,381) Annual Appropriation Adjustment... $1,299,290 $1,299, Congressional Submission VHA-9

12 2017 Advance Appropriations Request The President s Budget requests $ billion in advance appropriations for the VA medical care program in 2017, a 5.5 percent increase over the 2016 request. In addition to the 2017 appropriation request, VA anticipates the MCCF to reach $3.322 billion, with $265.7 million anticipated to be transferred to the FHCC. MCCF collections of $3.300 billion will be transferred to Medical Services. VA will also transfer at least $15 million to JIF and anticipates requesting the authority to transfer $265.7 million in support of the FHCC from the Medical Services, Medical Support & Compliance, and Medical Facilities appropriations. VA also estimates that it will receive $215 million in reimbursements largely from DoD for treating their patients and begin 2017 with no unobligated balances. Advance Appropriations enable timely and predictable funding for VA's medical care to prevent our Nation's Veterans from being adversely affected by budget delays, and provides opportunities to more effectively use resources in a constrained fiscal environment. This request for advance appropriations will support nearly 7.0 million unique patients and 9.5 million enrolled Veterans fulfilling our commitment to Veterans to provide timely and accessible high-quality medical services. However, future requirements for Veterans services and benefits are uncertain, and VA anticipates that more resources will be required to ensure that the VA system can provide timely, high-quality health care into the future. In the coming months, the Administration will submit legislation reallocation of a portion of the Veterans Choice Program funding to support essential investments in VA system priorities in a fiscally-responsible, budgetneutral manner. The $3.310 billion dollar 2017 Advance Appropriation increase over the 2016 appropriation request is due to the following factors: Ongoing health care services estimate increase by $1.981 million, driven largely by cost estimates provided by the EHPCM. Long-Term Services and Supports increase by $415 million, driven largely by cost estimates provided by the EHPCM and projected State Nursing Home growth. CHAMPVA, Caregivers and other health care programs increase by $265 million to fund annual increases in workload. Funding the recurring costs from Section 801 of the Veterans Choice Act: health care personnel, leasing costs, and legionella prevention and oversight projects will cost an estimated $1.195 billion. The impact of overlapping health care demand with the Veterans Choice Act Section 802 funding for the Veterans Choice Program is expected to increase from $452 million in 2016 to $733 million in 2017, reducing the net increase to the Medical Care appropriations request by $281 million. The initial 2017 estimate for healthcare infrastructure enhancements is $1.267 billion, a decrease of $199 million from the 2016 estimate of $1.466 billion, excluding the Veterans Choice Act. VHA-10 Executive Summary of Medical Care

13 Medical Patient Caseload Today s Veterans have a comprehensive medical benefits package, which VA administers through an annual patient enrollment system. The enrollment system is based on priority groups to ensure health care benefits are readily available to all enrolled Veterans. Complementing the comprehensive benefits package and improved access is our ongoing commitment to providing the very best in quality service. VA s goal is to ensure our patients receive the finest quality health care regardless of the treatment program, regardless of the location. Enrollment in the VA health care system provides Veterans with the assurance that comprehensive health care services will be available when and where they are needed during that enrollment period. Unique Patients 1/ to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Priorities ,658,956 4,729,341 4,795,656 4,827,386 4,918,891 5,028, , ,705 Priorities ,296,770 1,289,199 1,284,526 1,279,950 1,273,262 1,263,289 (11,264) (9,973) Subtotal Veterans... 5,955,725 6,018,540 6,080,182 6,107,336 6,192,154 6,291, ,972 99,731 Non-Veterans 2/ , , , , , ,601 11,239 9,366 Total Unique Patients... 6,632,735 6,741,933 6,772,178 6,844,729 6,895,389 7,004, , ,097 OEF/OIF/OND (Incl. Above). 697, , , , , ,292 71,182 71,597 1/ Unique patients are uniquely identified individuals treated by VA or whose treatment is paid for by VA. 2/ Non-veterans include active duty military and reserve, spousal collateral, consultations and instruction, CHAMPVA workload, reimbursable workload with affiliates, humanitarian care, and employees receiving preventive occupational immunizations such as Hepatitis A&B and flu vaccinations. Performance VHA tracks performance measures that cover a range of clinical, administrative and financial activity, which in turn, help support VHA s three strategic goals: (1) provide veterans personalized, proactive and patient-driven health care, (2) achieve measurable improvements in health outcomes, and (3) align resources to deliver sustained value to veterans. The following VHA performance measures support two of VA s Agency Priority Goals: (1) Improve Veteran Access to VA Benefits and Services and (2) End Veteran Homelessness: End Veteran Homelessness: Number of Homeless Veterans Permanently Housed. (Supports Agency Priority Goal) End Veteran Homelessness: Rapid engagement of street homeless Veterans. (Supports Agency Priority Goal) Access: Percent of patients who access VHA health care using a virtual format (Including telephone care) (New) (Supports Agency Priority Goal) Prevention Index V Clinical Practice Guidelines Index IV 2016 Congressional Submission VHA-11

14 This year s performance plan builds on the work to improve quality and timeliness of care and includes new performance and indicators that will help VA assess Veterans access to health care and services, as well as support VA s goal of ending homelessness. For further detail, please see the VHA Performance Plan chapter. Medical Care Collections Fund In 2016, VA estimates collections of $3.248 billion, representing an increase of $23.7 million, 0.7 percent over the 2015 current estimate. Medical Care Collections Fund 1/ (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Medical Care Collections Fund: Pharmacy Co-payments... $663,376 $753,000 $649,511 $853,000 $592,608 $573,847 ($56,903) ($18,761) 3rd Party Insurance Collections... $2,112,200 $1,962,375 $2,221,441 $2,058,075 $2,295,552 $2,382,422 $74,111 $86,870 3rd Party RX Insurance... $86,544 $90,000 $90,000 $94,000 $94,000 $99,000 $4,000 $5,000 1st Party Other Co-payments... $190,316 $192,000 $191,274 $198,000 $193,793 $194,597 $2,519 $804 Enhanced-Use Revenue... $1,432 $2,000 $2,000 $2,000 $2,000 $2,000 $0 $0 Long-Term Care Co-Payments... $2,725 $3,000 $2,706 $3,000 $2,705 $2,678 ($1) ($27) Comp. Work Therapy Collections... $65,887 $57,000 $61,000 $57,000 $61,000 $61,000 $0 $0 Parking Fees... $3,814 $4,000 $4,000 $4,000 $4,000 $4,000 $0 $0 Comp. & Pension Living Expenses... $1,603 $2,000 $2,000 $2,000 $2,000 $2,000 $0 $0 Total Collections... $3,127,897 $3,065,375 $3,223,932 $3,271,075 $3,247,658 $3,321,544 $23,726 $73,886 1/Estimates include collections actually or anticipated to be transferred to the Joint DoD-VA Medical Facility Demonstration Fund, in support of the FHCC: $ million in 2014, $ million in 2015, and $ million in In 2017, VA anticipates requesting the authority to transfer MCCF collections to the Demonstration Fund, with an estimated amount of $ million. 2/Collections of $3,127,896,804 were received by VA in Due to a one month lag in timing from when the funds are received and transferred into the Medical Services account, $3,068,584,188 was transferred to the Medical Services and $19,405,422 to the Joint DoD-VA Medical Demonstration Fund from September 2013 through August 2014 for an overall total of $3,087,989,610. The funds collected in September 2014 were transferred in The Balanced Budget Act of 1997 (P. L ) established the VA Medical Care Collections Fund. The legislation required that amounts collected or recovered after June 30, 1997, be deposited into the MCCF and used to furnish medical care and services to Veterans and to cover expenses incurred to collect amounts owed for the medical care and services furnished. The VHA Chief Business Office (CBO) has implemented an expanded revenue enhancement plan including a series of tactical and strategic objectives. This plan targets a combination of immediate, mid-term, and long-term improvements to the broad range of business processes encompassing VA revenue activities. This CBO-directed effort is a formalized validation of viable activities being pursued that are successful in addressing national issues, such as coding, payer agreements, site visits to lower performing facilities, and improved financial controls to increase collections. MCCF collections totaled nearly $3.128 billion in 2014, reflecting a greater than five-fold improvement in total collections since 2000, the result of these activities and an increased emphasis on improving revenue-cycle processes. VA is expecting MCCF total collections VHA-12 Executive Summary of Medical Care

15 to be approximately $3.224 billion in Third-party collections have made significant improvements since the economic downturn and VA continues to pursue opportunities for improved revenue performance as addressed by initiatives described below. Tiered Copayment Structure VA is currently in the process of a rulemaking to implement a tiered copayment structure for medication copayments, which will further align VA s medication copayment structure with other Federal agencies and the commercial sector. Consolidated Patient Account Centers A major driver of VA s revenue optimization strategy is the Congressionally-mandated deployment of Consolidated Patient Account Centers (CPACs). In 2012, traditional VHA business office functions were consolidated into seven regional Centers of Excellence. This initiative has transformed VHA billing and collections activities to more closely align with industry best practices including standardized operating processes, extensive use of business tools and increased levels of accountability at all levels of the organization. National Revenue Contracts Office This initiative is designed to leverage VHA s size and financial purchasing power to develop national/regional contracts for vendors who provide support for revenue-cycle activities. The CPAC Payer Relations Office (PRO) continues to aggressively pursue strategies to effectively manage relationships with third-party payers. The CPAC PRO staff is currently working on new or re-verification of existing third-party payer agreements. VHA is also providing mentoring and training to payer relations staff to improve the operationalizing of completed payer agreements. ebusiness Initiatives In an effort to leverage the health care industry s migration to national standard electronic data exchanges under the Health Insurance Portability and Accountability Act (HIPAA) and to comply with other legal requirements, VA implemented a number of ebusiness initiatives to add efficiencies to the billing and collections processes, including Medicareequivalent Remittance Advices; insurance verification; inpatient/outpatient/pharmacy billing; and payments, including Electronic Funds Transfer. These electronic processes require ongoing updating to maintain compliance with industry standards for Electronic Data Interchange (EDI) processing Congressional Submission VHA-13

16 Reimbursements Dollars in Thousands to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Reimbursements... $215,000 $258,000 $215,000 $266,000 $215,000 $215,000 $0 $0 Appropriation: Medical Services... $150,840 $199,000 $171,106 $204,000 $171,106 $171,106 $0 $0 Medical Support & Compliance. $12,224 $35,000 $23,671 $36,000 $23,671 $23,671 $0 $0 Medical Facilities... $14,389 $24,000 $20,223 $26,000 $20,223 $20,223 $0 $0 Appropriation [Total]... $177,453 $258,000 $215,000 $266,000 $215,000 $215,000 $0 $0 Reimbursements in each year FY are projected to be $215 million, which represents a 14% decrease from the 2014 estimate, 2015 President s Submission. The decrease in 2015 is the result of seeing fewer Department of Defense patients than anticipated resulting in a decrease in reimbursements through Sharing Agreements revenue estimates. Estimates for all future years have been reevaluated based on 2014 actuals. Prior Year Recoveries Dollars in Thousands to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Prior Year Recoveries... $0 $0 $0 $0 $0 $736,500 $0 $736,500 Appropriation: Medical Services... $0 $0 $0 $0 $0 $721,190 $0 $721,190 Medical Support & Compliance. $0 $0 $0 $0 $0 $310 $0 $310 Medical Facilities... $0 $0 $0 $0 $0 $15,000 $0 $15,000 Appropriation [Total]... $0 $0 $0 $0 $0 $736,500 $0 $736,500 This is an accounting change to record prior year recoveries as required by Federal accounting policy under OMB Circular No. A-11 guidance and is being reflected for the first time in the 2017 Budget request. This is a technical change that does not affect the actual resource levels provide for Veterans services, only how they are accounted for. VA has modified its financial accounting system to be able to accurately monitor and record recoveries. Medical Care Support for Medical and Prosthetic Research VA estimates that $525 million of the Medical Care appropriation will support Medical and Prosthetic Research in These dollars provide resources for the station to establish and maintain the infrastructure necessary to conduct research. Support dollars compensate for clinician investigator salaries for time assigned to research activities, the Associate Chief of Staff for Research and the support and compliance staff, various committee support costs, and administrative and facility services such as financial services, human resources, housekeeping, and engineering support. For further detail on VHA s research program, please see the Medical and Prosthetic Research chapter. VHA-14 Executive Summary of Medical Care

17 Medical Care Charts Table of Contents Page No. Medical Care Budget Authority Summary... VHA-16 Medical Care Funding Tables... VHA-17 Unique Patients... VHA-23 Obligations by Priority Group... VHA-23 Obligations Per Unique Patient... VHA-23 Unique Enrollees... VHA-24 Users as a Percent of Enrollees... VHA-24 Summary of Workloads for VA and Non-VA Facilities... VHA-25 Employment Summary (FTE)... VHA-26 FTE by Type... VHA-26 Medical Services All Other FTE Type... VHA-28 Employment Summary, FTE by Grade, VHA Central Office and Field... VHA-29 Model & Non-Model Table... VHA-33 Obligations by Object, Medical Care Total... VHA-34 Administrative Contract Services Components... VHA Congressional Submission VHA-15

18 Medical Care Budget Authority Excludes Veterans Choice Act (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Medical Services: Advance Appropriation... $43,557,000 $45,015,527 $45,015,527 $47,603,202 $47,603,202 $51,673,000 $2,587,675 $4,069,798 Annual Appropriation Adjustment... $40,000 $367,885 $209,189 $0 $1,124,197 $0 $915,008 ($1,124,197) Subtotal Appropriation Request... $43,597,000 $45,383,412 $45,224,716 $47,603,202 $48,727,399 $51,673,000 $3,502,683 $2,945,601 Rescissions, P.L (From Unobligated Balances)... ($179,000) $0 $0 $0 $0 $0 $0 $0 Rescission, P.L $0 $0 ($28,830) $0 $0 $0 $28,830 $0 Net Appropriations... $43,418,000 $45,383,412 $45,195,886 $47,603,202 $48,727,399 $51,673,000 $3,531,513 $2,945,601 Transfers: To North Chicago Demo. Fund... ($176,831) ($187,433) ($190,185) ($192,531) ($195,358) ($200,172) ($5,173) ($4,814) To DoD-VA Hlth Care Svcs Incentive Fund... ($15,000) ($15,000) ($15,000) ($15,000) ($15,000) ($15,000) $0 $0 To Med. Services from Med. Support and Compliance... $59,830 $0 $0 $0 $0 $0 $0 $0 Subtotal Transfers... ($132,001) ($202,433) ($205,185) ($207,531) ($210,358) ($215,172) ($5,173) ($4,814) Medical Care Collections Fund... $3,068,584 $3,048,303 $3,204,266 $3,252,857 $3,226,548 $3,299,954 $22,282 $73,406 Subtotal Budget Authority... $46,354,583 $48,229,282 $48,194,967 $50,648,528 $51,743,589 $54,757,782 $3,548,622 $3,014,193 Medical Support & Compliance Advance Appropriation... $6,033,000 $5,879,700 $5,879,700 $6,144,000 $6,144,000 $6,524,000 $264,300 $380,000 Annual Appropriation Adjustment... $0 $0 $0 $0 $69,961 $0 $69,961 ($69,961) Subtotal Appropriation Request... $6,033,000 $5,879,700 $5,879,700 $6,144,000 $6,213,961 $6,524,000 $334,261 $310,039 Rescissions, P.L (From Medical Support & Compliance)... ($50,000) $0 $0 $0 $0 $0 $0 $0 Rescission, P.L $0 $0 ($5,609) $0 $0 $0 $5,609 $0 Net Appropriations... $5,983,000 $5,879,700 $5,874,091 $6,144,000 $6,213,961 $6,524,000 $339,870 $310,039 Transfers: To North Chicago Demo. Fund... ($24,740) ($26,222) ($26,608) ($26,935) ($27,332) ($28,067) ($724) ($735) To Med. Services from Med. Support and Compliance... ($59,830) $0 $0 $0 $0 $0 $0 $0 Subtotal Transfers... ($84,570) ($26,222) ($26,608) ($26,935) ($27,332) ($28,067) ($724) ($735) Subtotal Budget Authority... $5,898,430 $5,853,478 $5,847,483 $6,117,065 $6,186,629 $6,495,933 $339,146 $309,304 Medical Facilities Advance Appropriation... $4,872,000 $4,739,000 $4,739,000 $4,915,000 $4,915,000 $5,074,000 $176,000 $159,000 Annual Appropriation Adjustment... $85,000 $0 $0 $0 $105,132 $0 $105,132 ($105,132) Subtotal Appropriation Request... $4,957,000 $4,739,000 $4,739,000 $4,915,000 $5,020,132 $5,074,000 $281,132 $53,868 Rescission, P.L $0 $0 ($2,000) $0 $0 $0 $2,000 $0 Net Appropriations... $4,957,000 $4,739,000 $4,737,000 $4,915,000 $5,020,132 $5,074,000 $283,132 $53,868 Transfers: To North Chicago Demo. Fund... ($32,998) ($31,743) ($35,490) ($32,607) ($36,455) ($37,436) ($965) ($981) Subtotal Transfers... ($32,998) ($31,743) ($35,490) ($32,607) ($36,455) ($37,436) ($965) ($981) Subtotal Budget Authority... $4,924,002 $4,707,257 $4,701,510 $4,882,393 $4,983,677 $5,036,564 $282,167 $52,887 Subtotal, Medical Care Appropriations... $54,108,431 $55,741,714 $55,539,694 $58,395,129 $59,687,347 $62,990,325 $4,147,653 $3,302,978 Collections... $3,068,584 $3,048,303 $3,204,266 $3,252,857 $3,226,548 $3,299,954 $22,282 $73,406 Total Medical Care Appropriations... $57,177,015 $58,790,017 $58,743,960 $61,647,986 $62,913,895 $66,290,279 $4,169,935 $3,376,384 VHA-16 Executive Summary Charts

19 2014 Actual Medical Support & Description Care Services Compliance Facilities Advance Appropriation... $54,462,000 $43,557,000 $6,033,000 $4,872,000 Mandatory Appropriation (P.L )... $5,000,000 $5,000,000 $0 $0 Annual Appropriation Adjustment... $125,000 $40,000 $0 $85,000 Subtotal Appropriation Request... $59,587,000 $48,597,000 $6,033,000 $4,957,000 Rescissions, P.L (From Unobligated Balances)... ($179,000) ($179,000) $0 $0 Rescissions, P.L (From Medical Support & Compliance)... ($50,000) $0 ($50,000) $0 Net Appropriations... $59,358,000 $48,418,000 $5,983,000 $4,957,000 Transfers: To North Chicago Demo. Fund... ($234,569) ($176,831) ($24,740) ($32,998) To DoD-VA Hlth Care Svcs Incentive Fund... ($15,000) ($15,000) $0 $0 To Med. Services from Med. Support and Compliance... $0 $59,830 ($59,830) $0 Subtotal Transfers... ($249,569) ($132,001) ($84,570) ($32,998) Collections... $3,068,584 $3,068,584 $0 $0 Total Budget Authority... $62,177,015 $51,354,583 $5,898,430 $4,924,002 Reimbursements... $177,453 $150,840 $12,224 $14,389 Adjustments to Obligations: Unobligated Balance (SOY): No-Year... $418,196 $417,931 $0 $265 H1N1 No-Year (PL )... $2,749 $279 $2,368 $ Emergency Supplemental (PL ) (No-Yr)... $1,640 $1,313 $0 $327 Hurricane Sandy (PL 113-2)... $10,624 $9,962 $0 $662 2-Year... $110,106 $25,137 $84,121 $848 Subtotal... $543,315 $454,622 $86,489 $2,204 Unobligated Balance (EOY): Veterans Choice Access - PL , Section ($5,000,000) ($5,000,000) $0 $0 No-Year... ($170,076) ($168,252) ($1,503) ($321) H1N1 No-Year (PL )... ($113) ($113) $0 $ Emergency Supplemental (PL ) (No-Yr)... ($6,018) ($6) $0 ($6,012) Hurricane Sandy (PL 113-2)... $0 $0 $0 $0 2-Year... ($187,769) ($59,739) ($41,149) ($86,881) Subtotal... ($5,363,976) ($5,228,110) ($42,652) ($93,214) Change in Unobligated Balance (Non-Add)... ($4,820,661) ($4,773,488) $43,837 ($91,010) Lapse... ($3,977) ($3,387) ($510) ($80) Obligations... $57,529,830 $46,728,548 $5,953,981 $4,847,301 Less: Veterans Choice Act Obligations... $0 $0 $0 $0 Obligations Excluding Veterans Choice Act... $57,529,830 $46,728,548 $5,953,981 $4,847,301 FTE Excluding Veterans Choice Act Total FTE , ,003 50,323 23,023 Direct FTE , ,131 49,454 22,533 Reimbursable FTE... 3,231 1, Veterans Choice Act, Sec. 801, FTE Congressional Submission VHA-17

20 2015 Budget Estimate Medical Support & Description Care Services Compl. Facilities Advance Appropriation... $55,634,227 $45,015,527 $5,879,700 $4,739,000 Annual Appropriation Adjustment... $367,885 $367,885 $0 $0 Subtotal Appropriation Request... $56,002,112 $45,383,412 $5,879,700 $4,739,000 Rescission, P.L $0 $0 $0 $0 Net Appropriations... $56,002,112 $45,383,412 $5,879,700 $4,739,000 Transfers: To North Chicago Demo. Fund... ($245,398) ($187,433) ($26,222) ($31,743) To DoD-VA Hlth Care Svcs Incentive Fund... ($15,000) ($15,000) $0 $0 To Office of Information Technology... $0 $0 $0 $0 Subtotal Transfers... ($260,398) ($202,433) ($26,222) ($31,743) Collections... $3,048,303 $3,048,303 $0 $0 Total Budget Authority... $58,790,017 $48,229,282 $5,853,478 $4,707,257 Reimbursements... $258,000 $199,000 $35,000 $24,000 Adjustments to Obligations: Unobligated Balance (SOY): No-Year... $407,750 $405,000 $0 $2,750 H1N1 No-Year (P.L )... $2,000 $500 $1,500 $ Emergency Supplemental (P.L ) (No-Yr)... $250 $0 $0 $250 Hurricane Sandy (PL 113-2)... $0 $0 $0 $0 2-Year... $40,000 $0 $40,000 $0 Subtotal... $450,000 $405,500 $41,500 $3,000 Unobligated Balance (EOY): No-Year... $0 $0 $0 $0 H1N1 No-Year (P.L )... $0 $0 $0 $ Emergency Supplemental (P.L ) (No-Yr)... $0 $0 $0 $0 Hurricane Sandy (PL 113-2)... $0 $0 $0 $0 2-Year... $0 $0 $0 $0 Subtotal... $0 $0 $0 $0 Change in Unobligated Balance (Non-Add)... $450,000 $405,500 $41,500 $3,000 Lapse... $0 $0 $0 $0 Obligations... $59,498,017 $48,833,782 $5,929,978 $4,734,257 Less: Veterans Choice Act Obligations... $0 $0 $0 $0 Obligations Excluding Veterans Choice Act... $59,498,017 $48,833,782 $5,929,978 $4,734,257 FTE Excluding Veterans Choice Act Total FTE , ,290 49,014 22,818 Direct FTE , ,418 48,145 22,328 Reimbursable FTE... 3,231 1, Veterans Choice Act, Sec. 801, FTE VHA-18 Executive Summary Charts

21 2015 Current Estimate Medical Support & Description Care Services Compl. Facilities Advance Appropriation... $55,634,227 $45,015,527 $5,879,700 $4,739,000 Annual Appropriation Adjustment... $209,189 $209,189 $0 $0 Subtotal Appropriation Request... $55,843,416 $45,224,716 $5,879,700 $4,739,000 Rescission, P.L ($36,439) ($28,830) ($5,609) ($2,000) Net Appropriations... $55,806,977 $45,195,886 $5,874,091 $4,737,000 Transfers: To North Chicago Demo. Fund... ($252,283) ($190,185) ($26,608) ($35,490) To DoD-VA Hlth Care Svcs Incentive Fund... ($15,000) ($15,000) $0 $0 To Office of Information Technology... $0 $0 $0 $0 Subtotal Transfers... ($267,283) ($205,185) ($26,608) ($35,490) Collections... $3,204,266 $3,204,266 $0 $0 Total Budget Authority... $58,743,960 $48,194,967 $5,847,483 $4,701,510 Reimbursments/Prior Year Recoveries: Reimbursements... $215,000 $171,106 $23,671 $20,223 Subtotal... $215,000 $171,106 $23,671 $20,223 Adjustments to Obligations: Unobligated Balance (SOY): Veterans Access - PL , Section $5,000,000 $5,000,000 $0 $0 No-Year... $170,076 $168,252 $1,503 $321 H1N1 No-Year (PL )... $113 $113 $0 $ Emergency Supplemental (PL ) (No-Yr)... $6,018 $6 $0 $6,012 Hurricane Sandy (PL 113-2)... $0 $0 $0 $0 2-Year... $187,769 $59,739 $41,149 $86,881 Subtotal... $5,363,976 $5,228,110 $42,652 $93,214 Transfer of Unobligated Balance, PL , Section ($887,800) ($2,686,900) $27,500 $1,771,600 Unobligated Balance (EOY): Veterans Access - PL , Section ($2,344,900) ($1,572,900) ($17,000) ($755,000) No-Year... $0 $0 $0 $0 H1N1 No-Year (PL )... $0 $0 $0 $ Emergency Supplemental (PL ) (No-Yr)... $0 $0 $0 $0 Hurricane Sandy (PL 113-2)... $0 $0 $0 $0 2-Year... $0 $0 $0 $0 Subtotal... ($2,344,900) ($1,572,900) ($17,000) ($755,000) Change in Unobligated Balance (Non-Add)... $3,019,076 $3,655,210 $25,652 ($661,786) Lapse... $0 $0 $0 $0 Obligations... $61,090,236 $49,334,383 $5,924,306 $5,831,547 Less: Veterans Choice Act Obligations... ($1,767,300) ($740,200) ($10,500) ($1,016,600) Obligations Excluding Veterans Choice Act... $59,322,936 $48,594,183 $5,913,806 $4,814,947 FTE Excluding Veterans Choice Act Total FTE , ,979 52,814 24,098 Direct FTE , ,107 51,945 23,608 Reimbursable FTE... 3,231 1, Veterans Choice Act, Sec. 801, FTE... 4,806 4, Congressional Submission VHA-19

22 2016 Advance Appropriation Medical Support & Description Care Services Compl. Facilities Advance Appropriation... $58,662,202 $47,603,202 $6,144,000 $4,915,000 Net Appropriations... $58,662,202 $47,603,202 $6,144,000 $4,915,000 Transfers: To North Chicago Demo. Fund... ($252,073) ($192,531) ($26,935) ($32,607) To DoD-VA Hlth Care Svcs Incentive Fund... ($15,000) ($15,000) $0 $0 Subtotal Transfers... ($267,073) ($207,531) ($26,935) ($32,607) Collections... $3,252,857 $3,252,857 $0 $0 Total Budget Authority... $61,647,986 $50,648,528 $6,117,065 $4,882,393 Reimbursments/Prior Year Recoveries: Reimbursements... $266,000 $204,000 $36,000 $26,000 Subtotal... $266,000 $204,000 $36,000 $26,000 Adjustments to Obligations: Unobligated Balance (SOY): No-Year... $0 $0 $0 $0 H1N1 No-Year (PL )... $0 $0 $0 $ Emergency Supplemental (PL ) (No-Yr)... $0 $0 $0 $0 Hurricane Sandy (PL 113-2)... $0 $0 $0 $0 2-Year... $0 $0 $0 $0 Subtotal... $0 $0 $0 $0 Unobligated Balance (EOY): No-Year... $0 $0 $0 $0 H1N1 No-Year (PL )... $0 $0 $0 $ Emergency Supplemental (PL ) (No-Yr)... $0 $0 $0 $0 Hurricane Sandy (PL 113-2)... $0 $0 $0 $0 2-Year... $0 $0 $0 $0 Subtotal... $0 $0 $0 $0 Change in Unobligated Balance (Non-Add)... $0 $0 $0 $0 Lapse... $0 $0 $0 $0 Obligations... $61,913,986 $50,852,528 $6,153,065 $4,908,393 Less: Veterans Choice Act Obligations... $0 $0 $0 $0 Obligations Excluding Veterans Choice Act... $61,913,986 $50,852,528 $6,153,065 $4,908,393 FTE Excluding Veterans Choice Act Total FTE , ,782 49,014 22,818 Direct FTE , ,910 48,145 22,328 Reimbursable FTE... 3,231 1, Veterans Choice Act, Sec. 801, FTE VHA-20 Executive Summary Charts

23 2016 Current Estimate Medical Support & Description Care Services Compl. Facilities Advance Appropriation... $58,662,202 $47,603,202 $6,144,000 $4,915,000 Annual Appropriation Adjustment... $1,299,290 $1,124,197 $69,961 $105,132 Subtotal Appropriation Request... $59,961,492 $48,727,399 $6,213,961 $5,020,132 Net Appropriations... $59,961,492 $48,727,399 $6,213,961 $5,020,132 Transfers: To North Chicago Demo. Fund... ($259,145) ($195,358) ($27,332) ($36,455) To DoD-VA Hlth Care Svcs Incentive Fund... ($15,000) ($15,000) $0 $0 Subtotal Transfers... ($274,145) ($210,358) ($27,332) ($36,455) Collections... $3,226,548 $3,226,548 $0 $0 Total Budget Authority... $62,913,895 $51,743,589 $6,186,629 $4,983,677 Reimbursments/Prior Year Recoveries: Reimbursements... $215,000 $171,106 $23,671 $20,223 Subtotal... $215,000 $171,106 $23,671 $20,223 Adjustments to Obligations: Unobligated Balance (SOY): Veterans Access - PL , Section $2,344,900 $1,572,900 $17,000 $755,000 No-Year... $0 $0 $0 $0 H1N1 No-Year (PL )... $0 $0 $0 $ Emergency Supplemental (PL ) (No-Yr)... $0 $0 $0 $0 Hurricane Sandy (PL 113-2)... $0 $0 $0 $0 2-Year... $0 $0 $0 $0 Subtotal... $2,344,900 $1,572,900 $17,000 $755,000 Transfer of Unobligated Balance, PL , Section $0 $0 $0 $0 Unobligated Balance (EOY): Veterans Access - PL , Section $0 $0 $0 $0 No-Year... $0 $0 $0 $0 H1N1 No-Year (PL )... $0 $0 $0 $ Emergency Supplemental (PL ) (No-Yr)... $0 $0 $0 $0 Hurricane Sandy (PL 113-2)... $0 $0 $0 $0 2-Year... $0 $0 $0 $0 Subtotal... $0 $0 $0 $0 Change in Unobligated Balance (Non-Add)... $2,344,900 $1,572,900 $17,000 $755,000 Lapse... $0 $0 $0 $0 Obligations... $65,473,795 $53,487,595 $6,227,300 $5,758,900 Less: Veterans Choice Act Obligations... ($2,344,900) ($1,572,900) ($17,000) ($755,000) Obligations (Excluding Veterans Choice Act Obligations)... $63,128,895 $51,914,695 $6,210,300 $5,003,900 FTE Excluding Veterans Choice Act Total FTE , ,205 54,020 24,209 Direct FTE , ,333 53,151 23,719 Reimbursable FTE... 3,231 1, Veterans Choice Act, Sec. 801, FTE... 9,613 9, Congressional Submission VHA-21

24 2017 Advance Appropriation Medical Support & Description Care Services Compl. Facilities Advance Appropriation... $63,271,000 $51,673,000 $6,524,000 $5,074,000 Net Appropriations... $63,271,000 $51,673,000 $6,524,000 $5,074,000 Transfers: To North Chicago Demo. Fund... ($265,675) ($200,172) ($28,067) ($37,436) To DoD-VA Hlth Care Svcs Incentive Fund... ($15,000) ($15,000) $0 $0 Subtotal Transfers... ($280,675) ($215,172) ($28,067) ($37,436) Collections... $3,299,954 $3,299,954 $0 $0 Total Budget Authority... $66,290,279 $54,757,782 $6,495,933 $5,036,564 Reimbursments/Prior Year Recoveries: Reimbursements... $215,000 $171,106 $23,671 $20,223 Subtotal... $215,000 $171,106 $23,671 $20,223 Adjustments to Obligations: Unobligated Balance (SOY): Veterans Access - PL , Section $0 $0 $0 $0 No-Year... $0 $0 $0 $0 H1N1 No-Year (PL )... $0 $0 $0 $ Emergency Supplemental (PL ) (No-Yr)... $0 $0 $0 $0 Hurricane Sandy (PL 113-2)... $0 $0 $0 $0 2-Year... $0 $0 $0 $0 Subtotal... $0 $0 $0 $0 Recovery of Prior Year Obligations... $736,500 $721,190 $310 $15,000 Unobligated Balance (EOY): Veterans Access - PL , Section $0 $0 $0 $0 No-Year... $0 $0 $0 $0 H1N1 No-Year (PL )... $0 $0 $0 $ Emergency Supplemental (PL ) (No-Yr)... $0 $0 $0 $0 Hurricane Sandy (PL 113-2)... $0 $0 $0 $0 2-Year... $0 $0 $0 $0 Subtotal... $0 $0 $0 $0 Change in Unobligated Balance (Non-Add)... $0 $0 $0 $0 Lapse... $0 $0 $0 $0 Obligations... $67,241,779 $55,650,078 $6,519,914 $5,071,787 FTE Total FTE , ,485 55,300 24,431 Direct FTE , ,613 54,431 23,941 Reimbursable FTE... 3,231 1, Veterans Choice Act, Sec. 801, FTE VHA-22 Executive Summary Charts

25 Unique Patients 1/ to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Priorities ,658,956 4,729,341 4,795,656 4,827,386 4,918,891 5,028, , ,705 Priorities ,296,770 1,289,199 1,284,526 1,279,950 1,273,262 1,263,289 (11,264) (9,973) Subtotal Veterans... 5,955,725 6,018,540 6,080,182 6,107,336 6,192,154 6,291, ,972 99,731 Non-Veterans 2/ , , , , , ,601 11,239 9,366 Total Unique Patients. 6,632,735 6,741,933 6,772,178 6,844,729 6,895,389 7,004, , ,097 Obligations by Priority Group Excludes Veterans Choice Act (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Priorities $50,050,190 $51,737,793 $51,576,277 $53,970,937 $54,994,871 $58,760,963 $3,418,594 $3,766,092 Priorities $5,552,288 $5,615,224 $5,637,829 $5,645,522 $5,879,151 $6,187,498 $241,322 $308,347 Subtotal Veterans... $55,602,478 $57,353,017 $57,214,106 $59,616,459 $60,874,022 $64,948,461 $3,659,916 $4,074,439 Non-Veterans... $1,927,352 $2,145,000 $2,108,830 $2,297,527 $2,254,873 $2,293,318 $146,043 $38,445 Total Obligations... $57,529,830 $59,498,017 $59,322,936 $61,913,986 $63,128,895 $67,241,779 $3,805,959 $4,112,884 Obligations Per Unique Patient (dollars) to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Priorities $10,743 $10,940 $10,755 $11,180 $11,180 $11,685 $425 $505 Priorities $4,282 $4,356 $4,389 $4,411 $4,617 $4,898 $228 $281 Subtotal Veterans... $9,336 $9,529 $9,410 $9,761 $9,831 $10,323 $421 $492 Non-Veterans... $2,847 $2,965 $3,047 $3,116 $3,206 $3,218 $159 $12 Total Unique Patients. $8,674 $8,825 $8,760 $9,045 $9,155 $9,600 $395 $445 1/ Unique patients are uniquely identified individuals treated by VA or whose treatment is paid for by VA. 2/ Non-veterans include active duty military and reserve, spousal collateral, consultations and instruction, CHAMPVA workload, reimbursable workload with affiliates, humanitarian care, and employees receiving preventive occupational immunizations such as Hepatitis A&B and flu vaccinations Congressional Submission VHA-23

26 Unique Patients 1/ to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Priorities ,658,956 4,729,341 4,795,656 4,827,386 4,918,891 5,028, , ,705 Priorities ,296,770 1,289,199 1,284,526 1,279,950 1,273,262 1,263,289 (11,264) (9,973) Subtotal Veterans... 5,955,725 6,018,540 6,080,182 6,107,336 6,192,154 6,291, ,972 99,731 Non-Veterans 2/ , , , , , ,601 11,239 9,366 Total Unique Patients. 6,632,735 6,741,933 6,772,178 6,844,729 6,895,389 7,004, , ,097 Unique Enrollees 3/ Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Priorities ,759,379 6,908,717 6,912,450 7,038,596 7,056,268 7,180, , ,367 Priorities ,319,236 2,378,575 2,323,837 2,397,197 2,326,337 2,323,770 2,500 (2,567) Total Enrollees... 9,078,615 9,287,292 9,236,287 9,435,793 9,382,605 9,504, , ,800 Users as a Percent of Enrollees Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Priorities % 68.5% 69.4% 68.6% 69.7% 70.0% 0.3% 0.3% Priorities % 54.2% 55.3% 53.4% 54.7% 54.4% -0.6% -0.3% Total Enrollees % 64.8% 65.8% 64.7% 66.0% 66.2% 0.2% 0.2% 1/ Unique patients are uniquely identified individuals treated by VA or whose treatment is paid for by VA. 2/ Non-Veterans include active duty military and reserve, spousal collateral, consultations and instruction, CHAMPVA workload, reimbursable reimbursable workload with affiliates, humanitarian care, and employees receiving preventive occupational immunizations such as Hepatitis A&B and flu vaccinations. 3/ Similar to unique patients, the count of unique enrollees represents the count of Veterans enrolled for Veterans health care sometime during the course of the year. VHA-24 Executive Summary Charts

27 Summary of Workloads for VA and Non-VA Facilities to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Outpatient Visits (000): Ambulatory Care: Staff... 79,626 81,138 82,251 83,084 84,564 86,628 2,313 2,064 Fee... 14,169 14,470 14,549 14,795 14,965 15, Subtotal... 93,795 95,608 96,800 97,879 99, ,965 2,729 2,436 Readjustment Counseling: Visits... 1,589 1,637 1,637 1,702 1,680 1, Grand Total... 95,384 97,245 98,437 99, , ,685 2,772 2,476 Patients Treated: Inpatient Care , , , , , ,353 (2,309) (2,613) Rehabilitation Care... 16,234 16,249 16,234 16,323 16,234 16, Mental Health Care Total , , , , , , Acute Psychiatry... 92,876 93,445 91,291 92,161 89,200 87,694 (2,091) (1,506) Contract Hospital (Psych)... 19,926 18,267 20,734 18,933 22,796 24,160 2,062 1,364 Psy Residential Rehab... 17,518 10,246 18,072 11,304 18,326 18, Dom Residential Rehab... 24,423 33,325 24,599 33,472 24,910 25, Long-Term Care: Institutional , , , , , ,455 2,548 2,179 Subacute Care... 1,910 2,013 1,685 1,942 1,516 1,351 (169) (165) Inpatient Facilities, Total , , , , , , (223) Average Daily Census: Inpatient Care... 8,882 8,590 8,866 8,522 8,920 9, Rehabilitation Care... 1,166 1,146 1,169 1,138 1,163 1,171 (6) 8 Mental Health Care Total... 9,428 9,108 9,465 8,866 9,487 9, Acute Psychiatry... 2,634 2,549 2,554 2,468 2,474 2,435 (80) (39) Contract Hospital (Psych) Psy Residential Rehab... 1,949 1,207 2,048 1,212 2,123 2, Dom Residential Rehab... 4,463 5,062 4,465 4,908 4,469 4, Long-Term Care: Institutional... 40,646 40,697 40,867 40,764 40,970 41, Subacute Care (5) (3) Inpatient Facilities, Total... 60,208 59,602 60,447 59,342 60,615 61, Length of Stay: Inpatient Care Rehabilitation Care (0.1) 0.1 Mental Health Care Long-Term Care: Institutional (2.1) (1.5) Subacute Care Dental Procedures (000)... 4,292 4,529 4,590 4,645 4,783 4, CHAMPVA/FMP/Spina Bifida: Outpatient Workloads (000)... 14,207 14,710 14,913 15,816 15,655 16, Congressional Submission VHA-25

28 Employment Summary (FTE) to to Budget Current Advance Revised Advance Increase/ Increase/ Account Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Medical Services , , , , , ,485 4,226 10,280 Medical Support & Compliance... 50,323 49,014 52,814 49,014 54,020 55,300 1,206 1,280 Medical Facilities... 23,023 22,818 24,098 22,818 24,209 24, Total , , , , , ,216 5,543 11, to to Budget Current 2016 Advance Increase/ Increase/ Actual Estimate Estimate Estimate Approp. Decrease Decrease Veterans Choice Act, Sec. 801, FTE... 4,806 9, ,807 (9,613) Veterans Choice Act, Sec. 802, FTE to Budget Current 2016 Increase/ Actual Estimate Estimate Estimate Decrease Canteen Service... 3,258 3,425 3,425 3, Medical & Prosthetic Research... 3,446 3,491 3,491 3, DoD-VA Health Care Sharing Fund 1/ Joint DoD-VA Med. Fac. Demo. Fund: Civilian... 2,082 2,136 2,162 2,167 5 DoD Uniformed Military 2/ Joint DoD-VA Med. Fac. Demo. Fund Total... 2,985 2,994 2,998 3, / In the past, VA generated estimates based on the projected number of FTE identified in the business cases for approved proposals. Therefore, these estimates were obtained through self-reported means from the field as opposed to a verifiable financial system. The new FTE count of 44 reflects the number reported in the VA Financial Management System (FMS) in FY 2014, and VA assumes a steday-state number of FTEs in FY 2015 and FY During FY 2015, VA will work to develop a reliable and valide system of tracking FTEs in this account. 2/ FY 2014 is corrected for actual on-board DoD Uniform Military FTE. FY 2015 is based on estimates from the Navy Manning Plan in FY No change is expected in FY Does not reflect the number of DoD Uniform Military FTE subject to reconciliation in the FHCC Joint Areas. FTE by Type Medical Care Excludes Veterans Choice Act to to Budget Current Advance Revised Advance Increase/ Increase/ Account Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Physicians... 19,166 19,031 20,208 19,257 20,594 22, ,853 Dentists... 1,017 1,029 1,098 1,041 1,118 1, Registered Nurses... 52,535 52,723 55,103 53,333 56,165 57,764 1,062 1,599 LP Nurse/LV Nurse/Nurse Assistant... 24,432 24,648 24,940 24,949 25,428 26, Non-Physician Providers... 12,722 12,563 13,606 12,714 13,861 14, ,135 Health Technicians/Allied Health... 63,848 63,088 65,540 63,845 66,882 69,696 1,342 2,814 Wage Board/Purchase & Hire... 25,337 25,060 26,352 25,128 26,575 26, All Other 1/... 79,292 76,980 83,044 77,347 84,811 88,158 1,767 3,347 Total , , , , , ,216 5,543 11,782 1/ All Other category includes personnel such as medical support assistance, administrative support clerks, administrative specialist, police, personnel management specialists, management and program analysts, medical records clerks/technicians, budget/fiscal, contract administrators, supply technicians, and other staff that are necessary for the effective operations of VHA medical facilities. VHA-26 Executive Summary Charts

29 FTE by Type Medical Services Excludes Veterans Choice Act to to Budget Current Advance Revised Advance Increase/ Increase/ Account Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Physicians... 18,550 18,420 19,572 18,646 19,943 21, ,838 Dentists... 1,004 1,014 1,088 1,026 1,108 1, Registered Nurses... 49,458 49,763 51,812 50,373 52,800 54, ,523 LP Nurse/LV Nurse/Nurse Assistant... 24,338 24,558 24,837 24,859 25,323 26, Non-Physician Providers... 12,482 12,328 13,385 12,479 13,634 14, ,129 Health Technicians/Allied Health... 62,607 61,759 64,328 62,516 65,643 68,427 1,315 2,784 Wage Board/Purchase & Hire... 5,432 5,537 5,538 5,605 5,647 5, All Other 1/... 31,132 29,911 32,419 30,278 33,107 35, ,181 Total , , , , , ,485 4,226 10,280 1/ Details on Medical Services "All Other" FTE occupation types can be found in the chart on the next page. FTE by Type Medical Support & Compliance Excludes Veterans Choice Act to to Budget Current Advance Revised Advance Increase/ Increase/ Account Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Physicians Dentists Registered Nurses... 3,074 2,960 3,291 2,960 3,365 3, LP Nurse/LV Nurse/Nurse Assistant Non-Physician Providers Health Technicians/Allied Health... 1,143 1,206 1,092 1,206 1,119 1, Wage Board/Purchase & Hire , All Other 1/... 44,216 42,994 46,490 42,994 47,550 48,678 1,060 1,128 Total... 50,323 49,014 52,814 49,014 54,020 55,300 1,206 1,280 1/ All Other category includes: Administrative Support Clerk, Administrative Specialist, Police, Personnel Management Specialist, Management And Program Analyst, Medical Records Clerk/Technician, Budget/Fiscal, Contract Administrator, Supply Technician, Medical Support Assistance, and other staff that are necessary for the effective operations of VHA Medical Support & Compliance. FTE by Type Medical Facilities Excludes Veterans Choice Act to to Budget Current Advance Revised Advance Increase/ Increase/ Account Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Physicians Dentists Registered Nurses LP Nurse/LV Nurse/Nurse Assistant Non-Physician Providers Health Technicians/Allied Health Wage Board/Purchase & Hire... 18,975 18,620 19,843 18,620 19,935 20, All Other 1/... 3,944 4,075 4,135 4,075 4,154 4, Total... 23,023 22,818 24,098 22,818 24,209 24, /All Other category includes maintenance controllers, engineers/architects, administrative support clerks, safety and occupational health specialists, fire protection and prevention staff, engineering technicians, hospitals housekeepers and managers, industrial hygienists, administrative specialists, and other staff that are necessary for the effective operations of VHA medical facilities Congressional Submission VHA-27

30 Medical Services FTE by Type 'All Other' Occupational Series FTE Medical Support Assistance 14, Administrative Support Clerk 3, Administrative Specialist 1, Administrative Support Clerk 1, Secretary (OA) 1, Administrative Officer 1, Maintenance Controller Purchasing Agent Management And Program Analyst Chaplain Health Systems Specialist Social Science Aid & Technician Social Science Psychologist Contact Representative Management Assistant Clinical/Biomedical Engineer Medical Radiology Technician Office Automation Clerk/Asst Program Manager Health Technician Medical Records Clerk/Technician Civilian Pay Clerk/Technician Inventory Management Specialist Supply Technician Pharmacist Supply Technician Transportation Clerk/Asst Visual Information Specialist File Clerk Librarian Dietician & Nutritionist Student Trainee (Admin) Library Aid/Technician Medical & Health Student Trainee General Arts & Information Information Receptionist Audiologist/Speech Pathologist Student Trainee (Admin) Photographer Claims Assistant 53 Occupational Series Not Covered Above 905 Medical Services All Other FTE Type Total 31,132 *Excludes Veteran's Choice Act VHA-28 Executive Summary Charts

31 Medical Care Employment Summary, FTE by Grade, Field (Excludes Veterans Choice Act) 2015 to to Increase/ Increase/ GS Grade or Title 38 Actual Estimate Estimate Estimate Decrease Decrease SES Title ,674 87,000 88,751 92,871 1,751 4, or higher ,244 2,340 2,385 2, ,891 12,375 12,615 13, ,831 19,601 19,982 20, ,446 21,308 21,736 22, ,377 2,473 2,521 2, ,208 14,816 15,120 15, ,504 7,833 8,000 8, ,354 18,089 18,455 19, ,223 37,752 38,535 40, , ,911 30,119 30,744 32, , ,780 6,046 6,179 6, , Wage Board... 25,393 26,550 26,783 27, Total Number of FTE , , , ,459 5,543 11,782 Medical Care Employment Summary, FTE by Grade, VHA Central Office (Excludes Veterans Choice Act) 2015 to to Increase/ Increase/ GS Grade or Title 38 Actual Estimate Estimate Estimate Decrease Decrease SES Title or higher Wage Board Total Number of FTE... 1,757 1,757 1,757 1, Congressional Submission VHA-29

32 Medical Services Employment Summary, FTE by Grade (Excludes Veterans Choice Act) 2015 to to Increase/ Increase/ GS Grade or Title 38 Actual Estimate Estimate Estimate Decrease Decrease SES Title ,899 83,008 84,654 88,662 1,646 4, or higher ,049 8,362 8,528 8, ,097 13,607 13,877 14, ,152 15,742 16,054 16, ,181 2,266 2,311 2, ,235 9,594 9,785 10, ,291 5,497 5,606 5, ,520 9,890 10,087 10, ,956 29,044 29,620 31, , ,837 24,764 25,256 26, , ,692 3,836 3,912 4, Wage Board... 5,410 5,620 5,732 6, Total Number of FTE , , , ,485 4,226 10,280 Medical Support & Compliance Employment Summary, FTE by Grade VA Medical Centers, VISNs, & Other Field Activities (Excludes Veterans Choice Act) 2015 to to Increase/ Increase/ GS Grade or Title 38 Actual Estimate Estimate Estimate Decrease Decrease SES Title ,461 3,678 3,783 3, or higher ,022 1,052 1, ,340 2,487 2,558 2, ,500 3,719 3,826 3, ,743 3,978 4,091 4, ,697 3,929 4,041 4, ,929 2,050 2,108 2, ,500 5,845 6,012 6, ,782 7,208 7,413 7, ,294 4,563 4,694 4, ,884 2,002 2,059 2, Wage Board ,025 1, Total Number of FTE... 39,733 42,224 43,430 44,710 1,206 1,280 VHA-30 Executive Summary Charts

33 Medical Support & Compliance Employment Summary, FTE by Grade VHA Central Office (Excludes Veterans Choice Act) 2015 to to Increase/ Increase/ GS Grade or Title 38 Actual Estimate Estimate Estimate Decrease Decrease SES Title or higher Wage Board Total Number of FTE... 1,757 1,757 1,757 1, Medical Support & Compliance Employment Summary, FTE by Grade VHA National Consolidated Activities (Excludes Veterans Choice Act) 2015 to to Increase/ Increase/ GS Grade or Title 38 Actual Estimate Estimate Estimate Decrease Decrease SES Title or higher ,352 1,352 1,352 1, ,913 1,913 1,913 1, ,154 1,154 1,154 1, Wage Board Total Number of FTE... 8,833 8,833 8,833 8, Congressional Submission VHA-31

34 Medical Facilities Employment Summary, FTE by Grade (Excludes Veterans Choice Act) 2015 to to Increase/ Increase/ GS Grade or Title 38 Actual Estimate Estimate Estimate Decrease Decrease SES Title or higher Wage Board... 19,026 19,914 20,007 20, Total Number of FTE... 23,023 24,098 24,209 24, VHA-32 Executive Summary Charts

35 2016 Revised Estimate and 2017 Advance Appropriation Obligations - Model and Non-Model Excludes Veterans Choice Act (dollars in thousands) 2016 Revised Estimate 2017 Advance Appropriation Description Model Non-Model Total Model Non-Model Total Health Care Services... $50,567,390 ($85,396) $50,481,994 $52,877,048 ($414,773) $52,462,275 Long-Term Care... $6,230,461 $1,230,052 $7,460,513 $6,555,479 $1,320,183 $7,875,662 Veterans Choice Program Cost Shift... $0 ($452,000) ($452,000) $0 ($733,000) ($733,000) Other Health Care Programs: CHAMPVA... $1,714,390 $169,492 $1,883,882 $1,878,900 $183,030 $2,061,930 Caregivers (Title 1)... $0 $555,096 $555,096 $0 $641,509 $641,509 Indian Health Service (PL )... $6,714 $21,348 $28,062 $6,883 $21,179 $28,062 Camp Lejeune - Veterans and Family... $0 $19,720 $19,720 $0 $19,720 $19,720 Readjustment Counseling... $0 $243,483 $243,483 $0 $243,483 $243,483 Homeless Veterans Programs: Ending Veterans Homelessness... $1,365,175 $27,825 $1,393,000 $1,649,234 ($256,234) $1,393,000 Congressional Action: Veterans Choice Act, Sec. 801: Staffing... $0 $0 $0 $0 $870,400 $870,400 Veterans Choice Act, Sec. 801: Lease Costs... $0 $0 $0 $0 $121,379 $121,379 Veterans Choice Act, Sec. 801: Legionella... $0 $0 $0 $0 $204,430 $204,430 Healthcare Infrastructure Enhancements: VISTA Evolution... $58,669 $100,927 $159,596 $60,147 $148,118 $208,265 Non-Recurring Maintenance... $0 $708,000 $708,000 $0 $460,600 $460,600 Activations... $671,495 ($73,321) $598,174 $688,417 ($90,243) $598,174 VA Legislative Proposals... $0 $49,375 $49,375 $0 $49,390 $49,390 VA Prior Year Recoveries... $0 $0 $0 $0 $736,500 $736,500 Obligations [Grand Total]... $60,614,294 $2,514,601 $63,128,895 $63,716,108 $3,525,671 $67,241, Congressional Submission VHA-33

36 Obligations by Object Medical Care Total (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease 10 Personnel Compensation and Benefits: Physicians... $5,404,588 $5,551,200 $5,861,200 $5,811,400 $6,180,000 $6,979,200 $318,800 $799,200 Dentists... $241,968 $252,100 $266,800 $262,400 $279,400 $288,700 $12,600 $9,300 Registered Nurses... $6,222,438 $6,321,000 $6,649,300 $6,550,400 $6,950,900 $7,323,000 $301,600 $372,100 LP Nurse/LV Nurse/Nurse Assistant... $1,588,314 $1,645,400 $1,649,700 $1,705,200 $1,723,600 $1,819,600 $73,900 $96,000 Non-Physician Providers... $1,761,267 $1,777,100 $1,917,400 $1,842,100 $2,002,200 $2,213,200 $84,800 $211,000 Health Technicians/Allied Health... $5,943,269 $6,004,300 $6,194,400 $6,210,300 $6,463,800 $6,867,300 $269,400 $403,500 Wage Board/Purchase & Hire... $1,532,940 $1,579,400 $1,615,200 $1,631,000 $1,661,000 $1,707,000 $45,800 $46,000 All Other 1/... $6,020,635 $6,062,500 $6,413,500 $6,271,900 $6,704,500 $7,118,300 $291,000 $413,800 Permanent Change of Station... $14,119 $15,500 $14,500 $15,800 $14,700 $15,000 $200 $300 Employee Compensation Pay... $228,934 $227,500 $233,600 $232,200 $238,300 $243,200 $4,700 $4,900 Subtotal... $28,958,472 $29,436,000 $30,815,600 $30,532,700 $32,218,400 $34,574,507 $1,402,800 $2,356, Travel & Transportation of Persons: Employee... $85,033 $81,700 $106,200 $83,100 $132,800 $166,100 $26,600 $33,300 Beneficiary... $838,869 $968,600 $873,300 $1,007,400 $908,200 $944,500 $34,900 $36,300 Other... $62,302 $59,300 $68,900 $60,800 $76,400 $84,800 $7,500 $8,400 Subtotal... $986,204 $1,109,600 $1,048,400 $1,151,300 $1,117,400 $1,195,400 $69,000 $78, Transportation of Things... $46,336 $41,600 $51,400 $48,700 $57,100 $63,700 $5,700 $6, Rent, Communications, and Utilities: Rental of Equipment... $169,185 $194,500 $189,400 $237,600 $212,100 $237,600 $22,700 $25,500 Communications... $325,139 $330,600 $349,200 $369,800 $375,400 $404,000 $26,200 $28,600 Utilities... $538,315 $519,200 $551,100 $546,000 $564,900 $579,000 $13,800 $14,100 GSA Rent... $26,011 $25,700 $25,500 $30,600 $26,900 $37,700 $1,400 $10,800 Other Real Property Rental... $453,058 $651,600 $443,300 $777,800 $466,400 $654,200 $23,100 $187,800 Subtotal... $1,511,708 $1,721,600 $1,558,500 $1,961,800 $1,645,700 $1,912,500 $87,200 $266, Printing & Reproduction:... $26,939 $34,500 $27,600 $35,500 $28,300 $29,000 $700 $ Other Contractual Services: Non-VA Outpatient Dental Care 2/... $137,656 $146,300 $163,300 $160,200 $193,700 $229,800 $30,400 $36,100 Medical and Nursing Non-VA Care 3/... $1,774,347 $2,153,600 $1,865,900 $2,321,800 $1,962,300 $2,063,600 $96,400 $101,300 Repairs to Furniture/Equipment... $242,301 $215,200 $248,500 $239,500 $254,900 $261,500 $6,400 $6,600 Maintenance & Repair Contract Services... $206,850 $182,500 $210,500 $220,800 $215,800 $221,200 $5,300 $5,400 Non-VA Hospital Care 4/... $1,900,885 $2,429,800 $2,081,800 $2,757,200 $2,280,000 $2,497,100 $198,200 $217,100 Community Nursing Homes... $676,129 $787,100 $759,300 $811,900 $792,400 $851,600 $33,100 $59,200 Repairs to Prosthetic Appliances... $227,976 $250,200 $259,800 $270,700 $279,100 $298,500 $19,300 $19,400 Home Oxygen... $165,642 $201,600 $191,200 $218,200 $205,400 $219,700 $14,200 $14,300 Personal Services Contracts... $108,171 $116,100 $110,900 $121,600 $113,600 $116,400 $2,700 $2,800 House Staff Disbursing Agreement... $607,919 $672,200 $630,800 $711,600 $654,600 $679,300 $23,800 $24,700 Scarce Medical Specialists... $145,033 $178,100 $148,700 $185,000 $152,400 $156,200 $3,700 $3,800 VHA-34 Executive Summary Charts

37 Obligations by Object Medical Care Total (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease 25 Other Contractual Services (continued) Other Medical Contract Services... $3,182,293 $3,877,182 $2,528,183 $3,680,528 $3,486,695 $4,232,231 $958,512 $745,536 Administrative Contract Services... $2,006,089 $2,335,635 $1,941,653 $2,158,758 $2,043,500 $2,145,741 $101,847 $102,241 Training Contract Services... $54,577 $54,100 $56,000 $55,500 $57,400 $58,900 $1,400 $1,500 CHAMPVA... $1,141,793 $1,157,800 $1,258,400 $1,251,200 $1,378,100 $1,508,300 $119,700 $130,200 Subtotal... $12,577,661 $14,757,417 $12,454,936 $15,164,486 $14,069,895 $15,540,072 $1,614,959 $1,470, Supplies & Materials: Provisions... $121,249 $121,500 $121,000 $125,300 $124,800 $128,700 $3,800 $3,900 Drugs & Medicines... $4,948,445 $4,697,200 $5,335,300 $4,941,600 $5,544,700 $5,792,500 $209,400 $247,800 Blood & Blood Products... $64,463 $82,400 $69,500 $86,700 $72,200 $75,500 $2,700 $3,300 Medical/Dental Supplies... $1,399,941 $1,578,800 $1,468,900 $1,684,400 $1,544,800 $1,624,600 $75,900 $79,800 Operating Supplies... $288,058 $279,100 $301,400 $304,700 $315,500 $330,200 $14,100 $14,700 Maintenance & Repair Supplies... $168,269 $119,600 $145,500 $162,800 $149,100 $152,800 $3,600 $3,700 Other Supplies... $235,795 $235,900 $241,700 $252,800 $247,700 $254,000 $6,000 $6,300 Prosthetic Appliances... $2,001,294 $2,279,900 $2,163,800 $2,467,300 $2,324,800 $2,486,200 $161,000 $161,400 Home Respiratory Therapy... $37,456 $52,600 $49,100 $56,900 $52,700 $56,400 $3,600 $3,700 Subtotal... $9,264,970 $9,447,000 $9,896,200 $10,082,500 $10,376,300 $10,900,900 $480,100 $524, Equipment... $1,351,729 $620,000 $968,100 $535,000 $986,700 $548,800 $18,600 ($437,900) 32 Lands & Structures: Non-Recurring Maintenance... $998,259 $460,600 $636,200 $460,600 $708,000 $460,600 $71,800 ($247,400) All Other Lands & Structures... $223,135 $207,800 $225,300 $241,200 $230,900 $236,700 $5,600 $5,800 Subtotal... $1,221,394 $668,400 $861,500 $701,800 $938,900 $697,300 $77,400 ($241,600) 41 Grants, Subsidies & Contributions: State Home... $1,072,732 $946,900 $1,130,000 $985,200 $1,220,000 $1,309,400 $90,000 $89,400 Grants 5/... $511,469 $715,000 $510,700 $715,000 $470,200 $470,200 ($40,500) $0 Subtotal... $1,584,201 $1,661,900 $1,640,700 $1,700,200 $1,690,200 $1,779,600 $49,500 $89, Imputed Interest... $216 $0 $0 $0 $0 $0 $0 $0 Total, Obligations... $57,529,830 $59,498,017 $59,322,936 $61,913,986 $63,128,895 $67,241,779 $3,805,959 $4,112,884 1/All Other category includes personnel such as medical support assistance, administrative support clerks, administrative specialist, police, personnel management specialists, management and program analysts, medical records clerks/technicians, budget/fiscal, contract administrators, supply technicians, and other staff that are necessary for the effective operations of VHA medical care. 2/ Formerly known as Medical & Nursing Fees. No change in methodology. 3/ Formerly known as Outpatient Dental Fees. No change in methodology. 4/ Formerly known as Contract Hospital. No change in methodology. 5/ Formerly known as Homeless Programs revised to Grants to better represent all grants, not just grants associated with VA's Homeless programs. No change in methodology Congressional Submission VHA-35

38 Obligations by Object Medical Services (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease 10 Personnel Compensation and Benefits: Physicians... $5,219,472 $5,355,200 $5,666,300 $5,606,500 $5,975,300 $6,763,800 $309,000 $788,500 Dentists... $238,247 $247,400 $263,900 $257,500 $276,300 $285,400 $12,400 $9,100 Registered Nurses... $5,834,827 $5,929,500 $6,227,000 $6,146,300 $6,508,500 $6,859,500 $281,500 $351,000 LP Nurse/LV Nurse/Nurse Assistant... $1,582,389 $1,639,600 $1,643,000 $1,699,200 $1,716,400 $1,812,000 $73,400 $95,600 Non-Physician Providers... $1,725,341 $1,740,300 $1,883,800 $1,804,000 $1,966,900 $2,176,200 $83,100 $209,300 Health Technicians/Allied Health... $5,815,656 $5,865,300 $6,068,600 $6,066,800 $6,331,900 $6,728,900 $263,300 $397,000 Wage Board/Purchase & Hire... $302,572 $314,400 $313,600 $325,700 $327,500 $336,000 $13,900 $8,500 All Other 1/... $2,035,457 $1,992,000 $2,157,500 $2,064,000 $2,258,700 $2,457,100 $101,200 $198,400 Permanent Change of Station... $3,970 $2,700 $4,100 $2,800 $4,100 $4,200 $0 $100 Employee Compensation Pay... $153,372 $152,600 $156,500 $155,700 $159,700 $162,900 $3,200 $3,200 Subtotal... $22,911,303 $23,239,000 $24,384,300 $24,128,500 $25,525,300 $27,586,047 $1,141,000 $2,060, Travel & Transportation of Persons: Employee... $35,773 $38,800 $44,700 $38,800 $55,900 $69,900 $11,200 $14,000 Beneficiary... $837,569 $968,600 $873,300 $1,007,400 $908,200 $944,500 $34,900 $36,300 Other... $29,352 $27,900 $33,700 $28,500 $38,700 $44,400 $5,000 $5,700 Subtotal... $902,694 $1,035,300 $951,700 $1,074,700 $1,002,800 $1,058,800 $51,100 $56, Transportation of Things... $15,230 $15,600 $18,100 $16,800 $21,500 $25,500 $3,400 $4, Rent, Communications, and Utilities: Rental of Equipment... $117,696 $152,100 $132,000 $168,400 $148,000 $166,000 $16,000 $18,000 Communications... $250,879 $248,600 $274,000 $264,700 $299,200 $326,800 $25,200 $27,600 Utilities... $648 $0 $0 $0 $0 $0 $0 $0 GSA Rent... ($2) $0 $0 $0 $0 $0 $0 $0 Other Real Property Rental... $905 $0 $0 $0 $0 $0 $0 $0 Subtotal... $370,126 $400,700 $406,000 $433,100 $447,200 $492,800 $41,200 $45, Printing & Reproduction:... $9,023 $23,700 $9,200 $24,200 $9,400 $9,600 $200 $ Other Contractual Services: Non-VA Outpatient Dental Care 2/... $137,655 $146,300 $163,300 $160,200 $193,700 $229,800 $30,400 $36,100 Medical and Nursing Non-VA Care 3/... $1,770,453 $2,149,500 $1,862,000 $2,317,300 $1,958,300 $2,059,500 $96,300 $101,200 Repairs to Furniture/Equipment... $214,641 $205,600 $220,000 $212,300 $225,500 $231,100 $5,500 $5,600 Maintenance & Repair Contract Services... $27,435 $39,400 $28,100 $42,400 $28,800 $29,500 $700 $700 Non-VA Hospital Care 4/... $1,900,885 $2,429,800 $2,081,800 $2,757,200 $2,280,000 $2,497,100 $198,200 $217,100 Community Nursing Homes... $676,129 $787,100 $759,300 $811,900 $792,400 $851,600 $33,100 $59,200 Repairs to Prosthetic Appliances... $227,975 $250,200 $259,800 $270,700 $279,100 $298,500 $19,300 $19,400 Home Oxygen... $165,642 $201,600 $191,200 $218,200 $205,400 $219,700 $14,200 $14,300 Personal Services Contracts... $79,503 $103,700 $81,500 $105,800 $83,500 $85,600 $2,000 $2,100 House Staff Disbursing Agreement... $607,861 $672,200 $630,800 $711,600 $654,600 $679,300 $23,800 $24,700 Scarce Medical Specialists... $145,033 $178,100 $148,700 $185,000 $152,400 $156,200 $3,700 $3,800 VHA-36 Executive Summary Charts

39 Obligations by Object Medical Services (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease 25 Other Contractual Services (continued) Other Medical Contract Services... $3,160,922 $3,862,982 $2,516,283 $3,665,728 $3,474,495 $4,219,731 $958,212 $745,236 Administrative Contract Services... $563,567 $691,300 $604,000 $711,500 $647,400 $693,900 $43,400 $46,500 Training Contract Services... $39,952 $42,000 $41,000 $42,800 $42,000 $43,100 $1,000 $1,100 CHAMPVA... $1,141,793 $1,157,800 $1,258,400 $1,251,200 $1,378,100 $1,508,300 $119,700 $130,200 Subtotal... $10,859,446 $12,917,582 $10,846,183 $13,463,828 $12,395,695 $13,802,931 $1,549,512 $1,407, Supplies & Materials: Provisions... $117,373 $121,500 $121,000 $125,300 $124,800 $128,700 $3,800 $3,900 Drugs & Medicines... $4,948,431 $4,697,200 $5,335,300 $4,941,600 $5,544,700 $5,792,500 $209,400 $247,800 Blood & Blood Products... $64,463 $82,400 $69,500 $86,700 $72,200 $75,500 $2,700 $3,300 Medical/Dental Supplies... $1,396,704 $1,578,800 $1,468,900 $1,684,400 $1,544,800 $1,624,600 $75,900 $79,800 Operating Supplies... $142,658 $145,300 $151,400 $150,900 $160,700 $170,500 $9,300 $9,800 Maintenance & Repair Supplies... $26,226 $0 $0 $0 $0 $0 $0 $0 Other Supplies... $112,860 $108,300 $115,700 $110,500 $118,600 $121,600 $2,900 $3,000 Prosthetic Appliances... $2,001,294 $2,279,900 $2,163,800 $2,467,300 $2,324,800 $2,486,200 $161,000 $161,400 Home Respiratory Therapy... $37,456 $52,600 $49,100 $56,900 $52,700 $56,400 $3,600 $3,700 Subtotal... $8,847,465 $9,066,000 $9,474,700 $9,623,600 $9,943,300 $10,456,000 $468,600 $512, Equipment... $1,226,639 $474,000 $863,300 $387,600 $879,300 $438,800 $16,000 ($440,500) 32 Lands & Structures: Non-Recurring Maintenance... $46 $0 $0 $0 $0 $0 $0 $0 All Other Lands & Structures... $2,375 $0 $0 $0 $0 $0 $0 $0 Subtotal... $2,421 $0 $0 $0 $0 $0 $0 $0 41 Grants, Subsidies & Contributions: State Home... $1,072,732 $946,900 $1,130,000 $985,200 $1,220,000 $1,309,400 $90,000 $89,400 Grants 5/... $511,469 $715,000 $510,700 $715,000 $470,200 $470,200 ($40,500) $0 Subtotal... $1,584,201 $1,661,900 $1,640,700 $1,700,200 $1,690,200 $1,779,600 $49,500 $89, Imputed Interest... $0 $0 $0 $0 $0 $0 $0 $0 Total, Obligations... $46,728,548 $48,833,782 $48,594,183 $50,852,528 $51,914,695 $55,650,078 $3,320,512 $3,735,383 1/ All Other category includes personnel such as medical support assistance, administrative support clerks, administrative specialists, secretaries, social science aid & technicians, administrative officer, purchasing agents, chaplains, management and program analysts, health systems specialists, and other staff that are necessary for the effective operations of VHA medical services. 2/ Formerly known as Medical & Nursing Fees. No change in methodology. 3/ Formerly known as Outpatient Dental Fees. No change in methodology. 4/ Formerly known as Contract Hospital. No change in methodology. 5/ Formerly known as Homeless Programs revised to Grants to better represent all grants, not just grants associated with VA's Homeless programs. No change in methodology Congressional Submission VHA-37

40 Obligations by Object Medical Support and Compliance (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease 10 Personnel Compensation and Benefits: Physicians... $185,048 $196,000 $194,900 $204,900 $204,700 $215,400 $9,800 $10,700 Dentists... $3,721 $4,700 $2,900 $4,900 $3,100 $3,300 $200 $200 Registered Nurses... $387,611 $391,500 $422,300 $404,100 $442,400 $463,500 $20,100 $21,100 LP Nurse/LV Nurse/Nurse Assistant... $5,777 $5,800 $6,700 $6,000 $7,200 $7,600 $500 $400 Non-Physician Providers... $35,815 $36,800 $33,600 $38,100 $35,300 $37,000 $1,700 $1,700 Health Technicians/Allied Health... $121,331 $130,600 $118,000 $134,800 $123,900 $130,200 $5,900 $6,300 Wage Board/Purchase & Hire... $55,890 $57,200 $59,100 $58,900 $61,700 $64,400 $2,600 $2,700 All Other 1/... $3,612,535 $3,658,400 $3,861,300 $3,780,000 $4,042,400 $4,247,200 $181,100 $204,800 Permanent Change of Station... $9,298 $11,500 $9,500 $11,700 $9,700 $9,900 $200 $200 Employee Compensation Pay... $40,858 $44,900 $41,700 $45,800 $42,500 $43,400 $800 $900 Subtotal... $4,457,884 $4,537,400 $4,750,000 $4,689,200 $4,972,900 $5,221,890 $222,900 $248, Travel & Transportation of Persons: Employee... $45,703 $41,600 $57,100 $41,600 $71,400 $89,300 $14,300 $17,900 Beneficiary... $30 $0 $0 $0 $0 $0 $0 $0 Other... $5,388 $4,100 $6,000 $4,300 $6,700 $7,500 $700 $800 Subtotal... $51,121 $45,700 $63,100 $45,900 $78,100 $96,800 $15,000 $18, Transportation of Things... $15,314 $11,300 $17,100 $12,400 $19,000 $21,200 $1,900 $2, Rent, Communications, and Utilities: Rental of Equipment... $45,982 $36,500 $51,800 $56,700 $58,400 $65,800 $6,600 $7,400 Communications... $72,026 $80,500 $72,900 $102,100 $73,800 $74,700 $900 $900 Utilities... $0 $0 $0 $0 $0 $0 $0 $0 GSA Rent... $26 $0 $0 $0 $0 $0 $0 $0 Other Real Property Rental... $844 $0 $0 $0 $0 $0 $0 $0 Subtotal... $118,878 $117,000 $124,700 $158,800 $132,200 $140,500 $7,500 $8, Printing & Reproduction:... $17,852 $10,700 $18,300 $11,100 $18,800 $19,300 $500 $ Other Contractual Services: Non-VA Outpatient Dental Care 2/... $0 $0 $0 $0 $0 $0 $0 $0 Medical and Nursing Non-VA Care 3/... $3,894 $4,100 $3,900 $4,500 $4,000 $4,100 $100 $100 Repairs to Furniture/Equipment... $3,137 $3,500 $3,400 $6,900 $3,700 $4,100 $300 $400 Maintenance & Repair Contract Services... $1,482 $0 $0 $0 $0 $0 $0 $0 Non-VA Hospital Care 4/... $0 $0 $0 $0 $0 $0 $0 $0 Community Nursing Homes... $0 $0 $0 $0 $0 $0 $0 $0 Repairs to Prosthetic Appliances... $1 $0 $0 $0 $0 $0 $0 $0 Home Oxygen... $0 $0 $0 $0 $0 $0 $0 $0 Personal Services Contracts... $19,800 $5,000 $20,300 $5,400 $20,800 $21,300 $500 $500 House Staff Disbursing Agreement... $58 $0 $0 $0 $0 $0 $0 $0 Scarce Medical Specialists... $0 $0 $0 $0 $0 $0 $0 $0 VHA-38 Executive Summary Charts

41 Obligations by Object Medical Support and Compliance (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease 25 Other Contractual Services (continued) Other Medical Contract Services... $11,637 $14,200 $11,900 $14,800 $12,200 $12,500 $300 $300 Administrative Contract Services... $1,089,226 $1,033,078 $755,906 $1,055,765 $799,800 $825,724 $43,894 $25,924 Training Contract Services... $12,613 $10,500 $12,900 $10,500 $13,200 $13,500 $300 $300 CHAMPVA... $0 $0 $0 $0 $0 $0 $0 $0 Subtotal... $1,141,848 $1,070,378 $808,306 $1,097,865 $853,700 $881,224 $45,394 $27, Supplies & Materials: Provisions... $3,843 $0 $0 $0 $0 $0 $0 $0 Drugs & Medicines... $0 $0 $0 $0 $0 $0 $0 $0 Blood & Blood Products... $0 $0 $0 $0 $0 $0 $0 $0 Medical/Dental Supplies... $2,611 $0 $0 $0 $0 $0 $0 $0 Operating Supplies... $29,837 $29,400 $30,600 $29,400 $31,400 $32,200 $800 $800 Maintenance & Repair Supplies... $67 $0 $0 $0 $0 $0 $0 $0 Other Supplies... $67,038 $70,800 $68,700 $70,800 $70,400 $72,200 $1,700 $1,800 Prosthetic Appliances... $0 $0 $0 $0 $0 $0 $0 $0 Home Respiratory Therapy... $0 $0 $0 $0 $0 $0 $0 $0 Subtotal... $103,396 $100,200 $99,300 $100,200 $101,800 $104,400 $2,500 $2, Equipment... $46,685 $37,300 $33,000 $37,600 $33,800 $34,600 $800 $ Lands & Structures: Non-Recurring Maintenance... $0 $0 $0 $0 $0 $0 $0 $0 All Other Lands & Structures... $1,003 $0 $0 $0 $0 $0 $0 $0 Subtotal... $1,003 $0 $0 $0 $0 $0 $0 $0 41 Grants, Subsidies & Contributions: State Home... $0 $0 $0 $0 $0 $0 $0 $0 Grants 5/... $0 $0 $0 $0 $0 $0 $0 $0 Subtotal... $0 $0 $0 $0 $0 $0 $0 $0 43 Imputed Interest... $0 $0 $0 $0 $0 $0 $0 $0 Total, Obligations... $5,953,981 $5,929,978 $5,913,806 $6,153,065 $6,210,300 $6,519,914 $296,494 $309,614 1/ The All Other category includes: Administrative Support Clerk, Administrative Specialist, Police, Personnel Management Specialist, Management And Program Analyst, Medical Records Clerk/Technician, Budget/Fiscal, Contract Administrator, Supply Technician, Medical Support Assistance, and other staff that are necessary for the effective operations of VHA Medical Support & Compliance. 2/ Formerly known as Medical & Nursing Fees. No change in methodology. 3/ Formerly known as Outpatient Dental Fees. No change in methodology. 4/ Formerly known as Contract Hospital. No change in methodology. 5/ Formerly known as Homeless Programs revised to Grants to better represent all grants, not just grants associated with VA's Homeless programs. No change in methodology Congressional Submission VHA-39

42 Obligations by Object Medical Facilities (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease 10 Personnel Compensation and Benefits: Physicians... $68 $0 $0 $0 $0 $0 $0 $0 Dentists... $0 $0 $0 $0 $0 $0 $0 $0 Registered Nurses... $0 $0 $0 $0 $0 $0 $0 $0 LP Nurse/LV Nurse/Nurse Assistant... $148 $0 $0 $0 $0 $0 $0 $0 Non-Physician Providers... $111 $0 $0 $0 $0 $0 $0 $0 Health Technicians/Allied Health... $6,282 $8,400 $7,800 $8,700 $8,000 $8,200 $200 $200 Wage Board/Purchase & Hire... $1,174,478 $1,207,800 $1,242,500 $1,246,400 $1,271,800 $1,306,600 $29,300 $34,800 All Other 1/... $372,643 $412,100 $394,700 $427,900 $403,400 $414,000 $8,700 $10,600 Permanent Change of Station... $851 $1,300 $900 $1,300 $900 $900 $0 $0 Employee Compensation Pay... $34,704 $30,000 $35,400 $30,700 $36,100 $36,900 $700 $800 Subtotal... $1,589,285 $1,659,600 $1,681,300 $1,715,000 $1,720,200 $1,766,570 $38,900 $46, Travel & Transportation of Persons: Employee... $3,557 $1,300 $4,400 $2,700 $5,500 $6,900 $1,100 $1,400 Beneficiary... $1,270 $0 $0 $0 $0 $0 $0 $0 Other... $27,562 $27,300 $29,200 $28,000 $31,000 $32,900 $1,800 $1,900 Subtotal... $32,389 $28,600 $33,600 $30,700 $36,500 $39,800 $2,900 $3, Transportation of Things... $15,792 $14,700 $16,200 $19,500 $16,600 $17,000 $400 $ Rent, Communications, and Utilities: Rental of Equipment... $5,507 $5,900 $5,600 $12,500 $5,700 $5,800 $100 $100 Communications... $2,234 $1,500 $2,300 $3,000 $2,400 $2,500 $100 $100 Utilities... $537,667 $519,200 $551,100 $546,000 $564,900 $579,000 $13,800 $14,100 GSA Rent... $25,987 $25,700 $25,500 $30,600 $26,900 $37,700 $1,400 $10,800 Other Real Property Rental... $451,309 $651,600 $443,300 $777,800 $466,400 $654,200 $23,100 $187,800 Subtotal... $1,022,704 $1,203,900 $1,027,800 $1,369,900 $1,066,300 $1,279,200 $38,500 $212, Printing & Reproduction:... $64 $100 $100 $200 $100 $100 $0 $0 25 Other Contractual Services: Non-VA Outpatient Dental Care 2/... $1 $0 $0 $0 $0 $0 $0 $0 Medical and Nursing Non-VA Care 3/... $0 $0 $0 $0 $0 $0 $0 $0 Repairs to Furniture/Equipment... $24,523 $6,100 $25,100 $20,300 $25,700 $26,300 $600 $600 Maintenance & Repair Contract Services... $177,933 $143,100 $182,400 $178,400 $187,000 $191,700 $4,600 $4,700 Non-VA Hospital Care 4/... $0 $0 $0 $0 $0 $0 $0 $0 Community Nursing Homes... $0 $0 $0 $0 $0 $0 $0 $0 Repairs to Prosthetic Appliances... $0 $0 $0 $0 $0 $0 $0 $0 Home Oxygen... $0 $0 $0 $0 $0 $0 $0 $0 Personal Services Contracts... $8,868 $7,400 $9,100 $10,400 $9,300 $9,500 $200 $200 House Staff Disbursing Agreement... $0 $0 $0 $0 $0 $0 $0 $0 Scarce Medical Specialists... $0 $0 $0 $0 $0 $0 $0 $0 VHA-40 Executive Summary Charts

43 Obligations by Object Medical Facilities (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease 25 Other Contractual Services (continued) Other Medical Contract Services... $9,734 $0 $0 $0 $0 $0 $0 $0 Administrative Contract Services... $353,296 $611,257 $581,747 $391,493 $596,300 $626,117 $14,553 $29,817 Training Contract Services... $2,012 $1,600 $2,100 $2,200 $2,200 $2,300 $100 $100 CHAMPVA... $0 $0 $0 $0 $0 $0 $0 $0 Subtotal... $576,367 $769,457 $800,447 $602,793 $820,500 $855,917 $20,053 $35, Supplies & Materials: Provisions... $33 $0 $0 $0 $0 $0 $0 $0 Drugs & Medicines... $14 $0 $0 $0 $0 $0 $0 $0 Blood & Blood Products... $0 $0 $0 $0 $0 $0 $0 $0 Medical/Dental Supplies... $626 $0 $0 $0 $0 $0 $0 $0 Operating Supplies... $115,563 $104,400 $119,400 $124,400 $123,400 $127,500 $4,000 $4,100 Maintenance & Repair Supplies... $141,976 $119,600 $145,500 $162,800 $149,100 $152,800 $3,600 $3,700 Other Supplies... $55,897 $56,800 $57,300 $71,500 $58,700 $60,200 $1,400 $1,500 Prosthetic Appliances... $0 $0 $0 $0 $0 $0 $0 $0 Home Respiratory Therapy... $0 $0 $0 $0 $0 $0 $0 $0 Subtotal... $314,109 $280,800 $322,200 $358,700 $331,200 $340,500 $9,000 $9, Equipment... $78,405 $108,700 $71,800 $109,800 $73,600 $75,400 $1,800 $1, Lands & Structures: Non-Recurring Maintenance... $998,213 $460,600 $636,200 $460,600 $708,000 $460,600 $71,800 ($247,400) All Other Lands & Structures... $219,757 $207,800 $225,300 $241,200 $230,900 $236,700 $5,600 $5,800 Subtotal... $1,217,970 $668,400 $861,500 $701,800 $938,900 $697,300 $77,400 ($241,600) 41 Grants, Subsidies & Contributions: State Home... $0 $0 $0 $0 $0 $0 $0 $0 Grants 5/... $0 $0 $0 $0 $0 $0 $0 $0 Subtotal... $0 $0 $0 $0 $0 $0 $0 $0 43 Imputed Interest... $216 $0 $0 $0 $0 $0 $0 $0 Total, Obligations... $4,847,301 $4,734,257 $4,814,947 $4,908,393 $5,003,900 $5,071,787 $188,953 $67,887 1/All Other category includes maintenance controllers, engineers/architects, administrative support clerks, safety and occupational health specialists, fire protection and prevention staff, engineering technicians, hospitals housekeepers and managers, industrial hygienists, administrative specialists, and other staff that are necessary for the effective operations of VHA medical facilities. 2/ Formerly known as Medical & Nursing Fees. No change in methodology. 3/ Formerly known as Outpatient Dental Fees. No change in methodology. 4/ Formerly known as Contract Hospital. No change in methodology. 5/ Formerly known as Homeless Programs revised to Grants to better represent all grants, not just grants associated with VA's Homeless programs. No change in methodology Congressional Submission VHA-41

44 Administrative Contract Services Components Budget Object Code/Title Definition 2507 Data Processing Services and Information Technology Services Includes maintenance (scheduled, preventive, and/or performance) contract charges for videoconferencing systems Data Processing Services and Information Technology Support Includes labor, consulting services and programming support for Information Technology. Such as system design, analysis, performance, etc. Also includes services to assist and advise management on efficient and effective operation of IT systems Automated Data Processing Equipment Time/Data Processing Service (Commercial Supplier) Includes purchase of computer processing time and support such as database processing applications and computer server time ADP Operations and Maintenance Support Services (Commercial Supplier) Includes maintenance (scheduled, preventive, and/or performance) contract charges for computer server and systems Advisory and Assistance Contract 2515 Systems Analysis and Programming (Commercial Supplier) To record costs of contracts related to management and/or professional (non-medical) support services. This would include, studies, analyses, evaluations, which improve overall organization of program management, logistics management, project monitoring and reporting, data collecting, surveys and other studies, analyses and evaluations; and engineering and technical services. Includes studies, analyses and evaluation costs incurred for internal use software. Internal use software may be commercial off-the-shelf software, internally developed software with or without a contractor s assistance or contractor-developed software. These costs are limited to the costs incurred prior to the point management determines that it is more likely than not that the software project will be completed and used to perform the intended function. Software includes the application and operating systems, programs, procedures, rules and any associated documentation pertaining to the operation of a computer system or program. For costs incurred after the decision is made to authorize and commit to the project, see BOC 3124 or BOC 2515 also includes costs incurred to convert data from a legacy system to the new internal use software Services Other Supply Fund - 1 VA+Fund Includes all services purchased through the One VA+ Fund in accordance with 38 U.S.C Information Resources Studies (Commercial Supplier) Studies or reports including requirements analysis; cost-benefit analysis; conversion studies; feasibility studies; security, risk or vulnerability analyses. For use by all appropriations Service and Reclamation (S&R) Outsource Program Includes customer request for maintenance and repair of small medical equipment such as endoscopes Interest Payments - Back Pay Settlements Interest paid as a result of retroactive adjustments on court awarded or agency approved settlements Fee Basis Purchase Card Payment Processing To record costs for transactional processing and vendor recruitment for Central Fee Program Storage of Household Goods (After 30 Days) Includes charges incurred after the thirtieth day for storage and care of vehicles and storage of household goods and personal effects associated with a permanent change of station. VHA-42 Executive Summary Charts

45 Administrative Contract Services Components Budget Object Code/Title Definition 2528 Department of Homeland Security Services To record charges for security services billed for by the Department of Homeland Security Goods and Services - Other - Supply Fund One VA + Fund Program Includes all goods purchased through the One VA+ Fund in accordance with 38 U.S.C Storage of Household Goods (First 30 days) Includes charges incurred for storage and care of vehicles and storage of household goods and personal effects associated with a permanent change of station Relocation Services Includes commercial relocation services for the sale of personal residences in connection with a permanent change of station move Special services provided by GSA services, over and above the basic SLUC rental charges Special services provided by GSA services, over and above the basic SLUC rental charges. Includes extra protection, interior and exterior cleaning, alterations or modifications to the existing rented/leased facility or utility services provided over and above the normal tour of duty charges 2535 Interior Decorating Services Interior Decorating Services. Includes the cost of all contract services for an interior design project Laundry and Dry-cleaning Services Laundry and Dry-Cleaning Services. Includes charges for laundry and dry cleaning services Cleaning and Janitorial Services for Buildings and Other Items Includes contracts for janitorial and cleaning services as well as window washing, pest control, disposal of waste and ashes and recycling (including tire and oil removal, etc.) ADP Equipment and Computer Maintenance Contracts Commercial Includes maintenance (scheduled, preventive, and/or performance) contract charges for laptops, netbooks, ultrabooks, tablets, etc Utility Plant Operations Includes operation, maintenance and repair of heating and air conditioning plants and emergency generators Audit Recovery Transactions Includes costs associated with the audit of inpatient fee claims under the disposition of the National DRG Recovery Program Non-Medical Contracts and Agreements with Institutions and Organizations Includes contractual services with the public or another Federal agency. Examples include contracted security guards; transcription services contracts; advertising expenses; licensing for bus drivers; and court reporter contracts for EEO cases. These contracts are not executed under the sharing authority C&P Medical Examinations To record costs for contract and non-contract services for medical disability examinations Burial Costs for Unclaimed Bodies Includes all costs for the burial of unclaimed bodies including transportation Congressional Submission VHA-43

46 This Page Intentionally Left Blank VHA-44 Executive Summary Charts

47 Medical Services Medical Care Appropriation and Collections 1/ $70 $ $ $ $ $ $ $60 B i l l i o n s $50 $40 $30 $20 $3.069 $ $3.048 $ $3.204 $ $3.253 $ $3.227 $ $3.300 $ $10 $ Actual 2015 Budget Estimate 2015 Current Estimate Appropriation 2016 Advance Approp. Collections 2016 Revised Request 2017 Advance Approp. 1/Medical Care represents all three appropriations: Medical Services, Medical Support and Compliance, and Medical Facilities. Charts excludes funding appropriated in the Veterans Access, Choice, and Accountability Act of 2014 (Veterans Choice Act), P.L Collections exclude the portion of Medical Care Collections Fund (MCCF) collections actually, or anticipated to be, transferred to the Joint DOD-VA Medical Facility Demonstration Fund, in support of the Captain James A. Lovell Federal Health Care Center (FHCC) Congressional Submission VHA-45

48 Medical Services Net Appropriations & Collections Excludes Veterans Choice Act (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Advance Appropriation... $43,557,000 $45,015,527 $45,015,527 $47,603,202 $47,603,202 $51,673,000 $2,587,675 $4,069,798 Annual Appropriation Adjustment... $40,000 $367,885 $209,189 $0 $1,124,197 $0 $915,008 ($1,124,197) Subtotal Appropriation Request... $43,597,000 $45,383,412 $45,224,716 $47,603,202 $48,727,399 $51,673,000 $3,502,683 $2,945,601 Rescissions, P.L (From Unobligated Balances)... ($179,000) $0 $0 $0 $0 $0 $0 $0 Rescission, P.L $0 $0 ($28,830) $0 $0 $0 $28,830 $0 Net Appropriations... $43,418,000 $45,383,412 $45,195,886 $47,603,202 $48,727,399 $51,673,000 $3,531,513 $2,945,601 Collections... $3,068,584 $3,048,303 $3,204,266 $3,252,857 $3,226,548 $3,299,954 $22,282 $73,406 Total... $46,486,584 $48,431,715 $48,400,152 $50,856,059 $51,953,947 $54,972,954 $3,553,795 $3,019,007 Appropriation Language For necessary expenses for furnishing, as authorized by law, inpatient and out- patient care and treatment to beneficiaries of the Department of Veterans Affairs and veterans described in section 1705(a) of title 38, United States Code, including care and treatment in facilities not under the jurisdiction of the Department, and including medical supplies and equipment, bioengineering services, food services, and salaries and expenses of healthcare employees hired under title 38, United States Code, aid to State homes as authorized by section 1741of title 38, United States Code, assistance and support services for caregivers as authorized by section 1720G of title 38, United States Code, loan repayments authorized by section 604 of the Caregivers and Veterans Omnibus Health Services Act of 2010 (Public Law ; 124 Stat. 1174; 38 U.S.C. 7681note), and hospital care and medical services authorized by section 1787 of title 38, United States Code; [$209,189,000]$1,124,197,000, which shall be in addition to funds previously appropriated under this heading that became available on October 1, [2014]2015; and, in addition, [$47,603,202,000]$51,673,000,000, plus reimbursements, shall become available on October 1, [2015]2016, and shall remain available until September 30, [2016]2017: Provided, That, of the amount made available on October 1, 2016, under this heading, $1,400,000,000 shall remain available until September 30, 2018: Provided further, That notwithstanding any other provision of law, the Secretary of Veterans Affairs shall establish a priority for the provision of medical treatment for veterans who have service-connected disabilities, lower income, or have special needs: Provided further, That notwithstanding any other provision of law, the Secretary of Veterans Affairs shall give priority funding for the provision of basic medical benefits to veterans in enrollment priority groups 1 through 6: Provided further, That notwithstanding any other provision of law, the Secretary of Veterans Affairs may authorize the dispensing of prescription drugs from Veterans Health Administration facilities to enrolled veterans with privately written prescriptions based on requirements established by the Secretary: Provided further, That the implementation of the program described in the previous proviso shall incur no additional cost to the Department of Veterans Affairs. (Military Construction and Veterans Affairs, and Related Agencies Appropriations Act, 2015.) Appropriation Transfers See Appropriation Transfers & Supplementals chapter for a detailed explanation of the appropriation transfers that affect the Medical Service appropriation. VHA-46 Medical Services

49 2016 Funding and 2017 Advance Appropriations Request The following tables provide an itemized breakout of the obligations by program of the Medical Services appropriation and the Total Medical Care amount. Additional 2016 Appropriation Request Medical Services A 2016 advance appropriation of $47.6 billion for Medical Services was enacted in P.L The 2016 budget requests an additional $1.1 billion to ensure the delivery of high-quality and timely health care services to Veterans and other eligible beneficiaries. There are multiple factors contributing to the additional funding request for Medical Services: The ongoing health care services costs are estimated to increase by $609.5 million over the initial advance appropriation estimate, driven in large part by estimates of the cost of new Hepatitis C drug treatments and updated actuarial trends based on the latest actual data. Long-Term Services and Supports costs are estimated to increase by $188.8 million, above the advance appropriation estimate, reflecting trends in the most recent actual data and the continued investment into non-institutional settings. Ongoing health service programs not projected by the Enrollee Health Care Projection Model are expected to yield a net increase of $229.4 million, driven largely by a $248 million in increase in the Caregivers program due to revised projections of the number of Caregivers, and a $142 million increase in funding for homeless Veteran programs that will allow VA fully support projected utilization in its homeless programs, including the Supportive Services for Veterans Families (SSVF) program and the Housing and Urban Development-VA Supportive Housing program (HUD-VASH). Facility activation costs are estimated to increase by $346.4 million over the initial advance appropriation request; the initial estimate accounted for construction delays that have caused under-execution of activations in recent years. VA has made progress in resolving these issues, and as a result has increased confidence that the additional funding will be required in FY Slightly offsetting these increases is a decrease in projected base appropriations health care costs due to the enactment of the Veterans Choice Act, and a decrease in medical care collections and reimbursements. VA estimates that $452 million in requirements will shift from the regular program to the new Veterans Choice Program in 2016, as Veterans who would otherwise receive care in the VA health care system instead choose to participate in the new Veterans Choice Program. The $1.1 billion in additional funding requested for 2016 will support the following: 217,205 FTE, an increase of 11,423 FTE over the initial advance appropriation estimate, excluding Veterans Choice Act FTE; Inpatient care needs of nearly 613,000 unique patients; 1.7 million readjustment counseling visits for 212,000 Veterans; 12.7 million outpatient visits for recipients of VA mental health care; 2016 Congressional Submission VHA-47

50 A 4.7% increase in institutional long-term services and supports for Veterans, reflecting the tremendous progress VA has made in expanding the availability of services in nursing homes and communities; and A 5.3% increase in non-institutional care as patients turn to these services to help reduce long-term care costs and improve satisfaction; VHA-48 Medical Services

51 Update to the Medical Service 2016 Advance Appropriations Request Excludes Veterans Choice Act (dollars in Thousands) 2016 Advance Current Increase/ Description Approp. Estimate Decrease Health Care Services... $41,105,190 $41,714,694 $609,504 Veterans Choice Program Cost-Shift... ($452,000) ($452,000) Long-Term Services and Supports: Institutional... $4,483,301 $4,563,253 $79,952 Non-Institutional... $1,542,047 $1,650,906 $108,859 Long-Term Services and Supports [Total]... $6,025,348 $6,214,159 $188,811 Other Health Care Programs: CHAMPVA, Spina Bifida, FMP & CWVV... $1,744,061 $1,781,009 $36,948 Caregivers (Title 1)... $302,616 $551,058 $248,442 Indian Health Services (P.L )... $38,649 $28,062 ($10,587) Camp Lejeune - Veterans and Family (P.L ).. $71,906 $19,720 ($52,186) Readjustment Counseling... $204,244 $211,051 $6,807 Other Health Care Programs [Subtotal]... $2,361,476 $2,590,900 $229,424 Ending Veterans Homelessness... $1,214,400 $1,355,946 $141,546 Healthcare Infrastructure Enhancements: VISTA Evolution... $0 $0 $0 Non-Recurring Maintenance... $0 $0 $0 Activations... $96,200 $442,649 $346,449 Healthcare Infrastructure Enhancements [Subtotal]... $96,200 $442,649 $346,449 VA Legislative Proposals... $49,914 $48,347 ($1,567) Obligations [Total]... $50,852,528 $51,914,695 $1,062,167 Funding Availability: Appropriation... $47,603,202 $47,603,202 $0 Trns to North Chicago Demo. Fund... ($192,531) ($195,358) ($2,827) Trns to DoD-VA Health Care Sharing Incentive Fund... ($15,000) ($15,000) $0 Medical Care Collections Fund... $3,252,857 $3,226,548 ($26,309) Reimbursements... $204,000 $171,106 ($32,894) Funding Availability [Total]... $50,852,528 $50,790,498 ($62,030) Annual Appropriation Adjustment... $0 $1,124,197 $1,124, Congressional Submission VHA-49

52 VA Medical Services Obligations by Program Excludes Veterans Choice Act (Dollars in Millions) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate 1/ Estimate Approp. 1/ Request Approp. Decrease Decrease Health Care Services: Ambulatory Care 2/... $19,434 $20,687 $19,463 $22,235 $21,842 $22,890 $2,379 $1,048 New Hepatitis C Treatment... $379 $0 $697 $0 $690 $660 ($7) ($30) Inpatient Care... $8,648 $8,975 $9,043 $9,225 $9,377 $9,723 $334 $346 Rehabilitation Care... $450 $482 $472 $495 $483 $494 $11 $11 Mental Health 3/... $5,070 $5,455 $5,396 $5,661 $5,661 $5,859 $265 $198 Prosthetics... $2,449 $2,577 $2,645 $2,749 $2,842 $3,039 $197 $197 Dental Care... $678 $701 $758 $740 $820 $878 $62 $58 Health Care Services [Total] 4/... $37,108 $38,877 $38,474 $41,105 $41,715 $43,543 $3,241 $1,828 Veterans Choice Program Cost-Shift... ($452) ($733) N/A ($281) Long-Term Services and Supports: VA Community Living Centers (VA CLC)... $2,412 $2,526 $2,438 $2,648 $2,494 $2,616 $56 $122 Community Nursing Home... $717 $745 $805 $769 $840 $903 $35 $63 State Nursing Home... $985 $963 $1,081 $1,001 $1,169 $1,257 $88 $88 State Home Domiciliary... $56 $64 $57 $66 $60 $62 $3 $2 Subtotal... $4,170 $4,298 $4,381 $4,484 $4,563 $4,838 $182 $275 Non-Institutional Care [Total]... $1,482 $1,436 $1,561 $1,542 $1,651 $1,732 $90 $81 Long-Term Services and Supports [Total]... $5,652 $5,734 $5,942 $6,026 $6,214 $6,570 $272 $356 Other Health Care Programs: CHAMPVA, Spina Bifida, FMP, & CWVV... $1,447 $1,610 $1,618 $1,744 $1,781 $1,952 $163 $171 Caregivers (Title 1)... $348 $303 $478 $303 $551 $637 $73 $86 Indian Health Servcies... $15 $39 $18 $39 $28 $28 $10 $0 Camp Lejeune - Veterans and Family... $5 $51 $18 $72 $20 $20 $2 $0 Readjustment Counseling... $185 $204 $206 $204 $211 $211 $5 $0 Other Health Care Programs [Total]... $2,000 $2,207 $2,338 $2,362 $2,591 $2,848 $253 $257 Homeless Veterans Programs: Ending Veterans Homelessness... $1,480 $1,575 $1,407 $1,214 $1,356 $1,356 ($51) $0 Congressional Action: Veterans Choice Act, Sec. 801: Staffing... $854 N/A $854 Veterans Choice Act, Sec. 801: Lease Costs... $0 N/A $0 Veterans Choice Act, Sec. 801: Legionella... $0 N/A $0 Congressional Action [Total]... $854 N/A $854 Healthcare Infrastructure Enhancements: VISTA Evolution... $0 $0 $0 $0 $0 $0 $0 $0 NRM 4/... $0 $0 $0 $0 $0 $0 $0 $0 Activations... $489 $395 $395 $96 $443 $443 $48 $0 Healthcare Infrastructure Enhancements [Total]... $489 $395 $395 $96 $443 $443 ($3) $1,708 VA Legislative Proposals: Total... $0 $46 $38 $50 $48 $48 $10 $0 VA Prior Year Recoveries... $721 N/A $721 Total Obligations... $46,729 $48,834 $48,594 $50,853 $51,915 $55,650 $3,321 $3,735 Note: Dollars may not add due to rounding in this and subsequent charts. 1/ The following initiatives, as previously shown in the 2015 Congressional Submission, are now included within Health Care Services for all columns: Affordable Care Act, VOW to Hire Heroes Act, and Proposed Savings. 2/ Funding for Ending Veterans Homelessness, VISTA Evolution and Activations have been removed from this line and displayed in their respective sections, below, so that the full amount of funding for these programs is displayed. 3/ This displays the full cost of Mental Health, which includes some overlapping obligations with Homeless Veterans Programs. In order to show the full value of Mental Health and Homeless Programs obligations, all Homeless Programs obligations were adjusted from Ambulatory Care. 4/ In prior Congressional Submissions, the obligations for non-recurring maintenance (NRM) were included within Health Care Services. This year, obligations for NRM have been removed from Health Care Services and displayed in the section on Healthcare Infrastructure Enhancements. VHA-50 Medical Services

53 VA Medical Care Obligations by Program Excludes Veterans Choice Act (dollars in millions) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate 1/ Estimate Approp. 1/ Request Approp. Decrease Decrease Health Care Services: Ambulatory Care 2/... $23,542 $24,470 $23,598 $26,222 $26,067 $27,099 $2,469 $1,032 New Hepatitis C Treatment... $379 $0 $697 $0 $690 $660 ($7) ($30) Inpatient Care... $10,806 $11,507 $11,300 $11,827 $11,717 $12,149 $417 $432 Rehabilitation Care... $595 $643 $624 $660 $638 $652 $14 $14 Mental Health 3/... $6,676 $7,178 $7,106 $7,449 $7,455 $7,715 $349 $260 Prosthetics... $2,449 $2,577 $2,645 $2,749 $2,842 $3,039 $197 $197 Dental Care... $888 $922 $992 $973 $1,073 $1,149 $81 $76 Health Care Services [Total] 4/... $45,335 $47,297 $46,962 $49,880 $50,482 $52,463 $3,520 $1,981 Veterans Choice Program Cost-Shift... ($452) ($733) ($452) ($281) Long-Term Services and Supports: VA Community Living Centers (VA CLC)... $3,340 $3,558 $3,376 $3,729 $3,453 $3,622 $77 $169 Community Nursing Home... $721 $753 $810 $777 $845 $908 $35 $63 State Nursing Home... $985 $963 $1,081 $1,001 $1,169 $1,257 $88 $88 State Home Domiciliary... $56 $64 $57 $66 $60 $62 $3 $2 Subtotal... $5,102 $5,338 $5,324 $5,573 $5,527 $5,849 $203 $322 Non-Institutional Care [Total]... $1,721 $1,708 $1,828 $1,837 $1,934 $2,027 $106 $93 Long-Term Services and Supports [Total]... $6,823 $7,046 $7,152 $7,410 $7,461 $7,876 $309 $415 Other Health Care Programs: CHAMPVA, Spina Bifida, FMP, & CWVV... $1,537 $1,716 $1,718 $1,855 $1,884 $2,062 $166 $178 Caregivers (Title 1)... $350 $306 $482 $306 $555 $642 $73 $87 Indian Health Servcies... $15 $39 $18 $39 $28 $28 $10 $0 Camp Lejeune - Veterans and Family... $5 $51 $18 $72 $20 $20 $2 $0 Readjustment Counseling... $213 $238 $238 $238 $243 $243 $5 $0 Other Health Care Programs [Total]... $2,120 $2,350 $2,474 $2,510 $2,730 $2,995 $256 $265 Homeless Veterans Programs: Ending Veterans Homelessness... $1,521 $1,641 $1,445 $1,265 $1,393 $1,393 ($52) $0 Congressional Action: Veterans Choice Act, Sec. 801: Staffing... $870 N/A $870 Veterans Choice Act, Sec. 801: Lease Costs... $121 N/A $121 Veterans Choice Act, Sec. 801: Legionella... $204 N/A $204 Congressional Action [Total]... $1,195 N/A $1,195 Healthcare Infrastructure Enhancements: VISTA Evolution... $74 $123 $68 $208 $160 $208 $92 $48 Non-Recurring Maintenance 4/... $998 $461 $636 $461 $708 $461 $72 ($247) Activations... $659 $534 $548 $130 $598 $598 $50 $0 Healthcare Infrastructure Enhancements [Total]... $1,731 $1,118 $1,252 $799 $1,466 $1,267 $214 ($199) VA Legislative Proposals: Total... $0 $46 $38 $50 $49 $49 $11 $0 VA Prior Year Recoveries... $737 N/A $737 Total Obligations... $57,530 $59,498 $59,323 $61,914 $63,129 $67,242 $3,806 $4,113 Note: Dollars may not add due to rounding in this and subsequent charts. 1/ The following initiatives, as previously shown in the 2015 Congressional Submission, are now included within Health Care Services for all columns: Affordable Care Act, VOW to Hire Heroes Act, and Proposed Savings. 2/ Funding for Ending Veterans Homelessness, VISTA Evolution and Activations have been removed from this line and displayed in their respective sections, below, so that the full amount of funding for these programs is displayed. 3/ This displays the full cost of Mental Health, which includes some overlapping obligations with Homeless Veterans Programs. In order to show the full value of Mental Health and Homeless Programs obligations, all Homeless Programs obligations were adjusted from Ambulatory Care. 4/ In prior Congressional Submissions, the obligations for non-recurring maintenance (NRM) were included within Health Care Services. This year, obligations for NRM have been removed from Health Care Services and displayed in the section on Healthcare Infrastructure Enhancements. Actuarially Modelled Requirements VA uses two actuarial models to support formulation of the majority of the VA health care budget, strategic and capital planning, and assessment of the impact of potential policies and changes in a dynamic health care environment. The two actuarial models are the VA 2016 Congressional Submission VHA-51

54 Enrollee Health Care Projection Model (EHCPM) and the Civilian Health and Medical Program Veterans Administration (CHAMPVA) Model. For more information about the EHCPM please see the chapter on the EHCPM and CHAMPVA model. The following funding tables represent the Medical Service and total Medical Care 2016 funding levels and 2017 advance appropriations request on an obligation basis. Workload estimates can be found in the Summary of Workloads for VA and Non-VA Facilities chart in the Executive Summary Charts chapter. All of the funding levels shown below include both VA and non-va care obligations, but excludes funding provided by the Veterans Choice Act. For more detailed information on non-va care, separately, please see the Selected Program Highlights chapter. Health Care Services: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Health Care Services: Medical Services... $37,108 $38,877 $38,474 $41,105 $41,715 $43,543 $3,241 $1,828 Medical Care Total... $45,335 $47,297 $46,962 $49,880 $50,482 $52,463 $3,520 $1,981 Health Care Services consists of the following types of care. See workload charts in the Executive Summary Charts chapter for additional detail. Ambulatory Care: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Ambulatory Care: Medical Services... $19,434 $20,687 $19,463 $22,235 $21,842 $22,890 $2,379 $1,048 Medical Care Total... $23,542 $24,470 $23,598 $26,222 $26,067 $27,099 $2,469 $1,032 This health service category includes funding for ambulatory care in VA hospital- and community-based clinics. Non-VA care is provided to eligible beneficiaries when VA facilities are not geographically accessible, services are not available at a particular facility, or when care cannot be provided in a timely manner within existing resources. For more details about Ambulatory care, please see the Enrollee Healthcare Projection and CHAMPVA Models chapter Accomplishments Approximately 95 percent (up from 82 percent) of all Patient Aligned Care Team (PACT) teams have received training in basic PACT principles and operations. In 2014, the PACT Demonstration Laboratory Initiative published 43 journal articles related to PACT implementation and processes. Primary Care Services collaborated with Mental Health to increase Primary Care Mental Health Integration (PCMHI) penetration rates 15 percent overall during 2014 (from 5.9 percent to 6.8 percent), and increase rates 101 percent at facilities with low baseline (beginning of 2014) levels of program activity. Future Goals ( ) Publish Patient Centered Management Module (PCMM) Handbook in VHA-52 Medical Services

55 Continue PACT PCMHI implementation with emphasis on chronic disease management and improving team effectiveness. Achieve open access and team based continuity of care in Primary Care. Enhance telehealth presence in rural areas. Implement more rigorous education/training strategies to better standardize PACT Implementation. Pharmacy:* to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Total Medical Care Obligations... $5,824 $6,169 $6,280 $6,490 $6,526 $6,818 $246 $292 # of 30-Day Prescriptions (millions) * Table shows all pharmacy obligations, those included in Ambulatory Care funding and those associated with the cost of the new Hepatitis C Drug treatments. VA s use of medication therapies is a fundamental underpinning of how VA delivers health care today. VA s primary focus is on diagnosis and treatment in an ambulatory environment and home environment basis with institutional care as the modality of last resort Accomplishments Provided outpatient prescription to over 4.8 million Veterans. VA Pharmacies implemented a Veteran Centric prescription label to help improve comprehension and adherence to medication instructions. The label was re-designed based on a research study conducted in collaboration with VA National Center for Patient Safety which included Veteran preferences. VA Consolidated Mail Outpatient Pharmacy (CMOP) ranked highest among mailorder pharmacies including private sector companies for customer satisfaction in J.D. Power and Associates 2014 National Pharmacy Study with a score of 871. This marks the fifth consecutive year that CMOP scored highest in this survey. Created the ability for Veterans to track the delivery of their mail order prescriptions that come from the VHA CMOP via the MyHealtheVet web site, delivering on an innovative idea recognized as the 2013 Securing America s Value and Efficiency (SAVE) Award winning proposal. On a daily basis 3,000-4,000 Veterans utilize this service. Support the VA National Formulary that contains national standardization items within selected therapeutic categories and ensures uniform availability of drug therapies across the nation. Deployment and implementation of the maximum single dose order check as part of the VA Medication Order Check Healthcare Application (MOCHA) to help prevent adverse drug events. Pharmacy Benefits Management (PBM) Services provides comprehensive outpatient mail pharmacy services to 119,500 qualifying beneficiaries of the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) and dispensed 2,716,587 outpatient prescriptions to the beneficiaries through the CMOP Congressional Submission VHA-53

56 VA pharmacy has the VA Learning Opportunities Residency (VALOR) positions nationwide that helps VA Pharmacy recruit future pharmacists. Since 2010, there has been a 43 percent increase in Clinical Pharmacists practicing as non-physician providers. Expansion of the Pharmacists Achieve Results with Medications Documentation (PhARMD) Project to 89 VA facilities with use by over 1500 pharmacist users who documented over 484,000 disease state interventions and an additional 320,000 interventions focused on their role in team based care. These interventions demonstrated the clinical pharmacist s contribution to the use of medications in key chronic disease states such as diabetes, hypertension, hyperlipidemia, pain management, and mental health. Future Goals ( ) VA Pharmacy will continue to promote initiatives and programs to improve the health status of Veterans by encouraging the appropriate use of medications in a comprehensive medical care setting. Implement drug take back programs for Veterans in alignment with the recently published Drug Enforcement Agency rule to reduce the risk of abuse, diversion and overdose Upgrade equipment at MidSouth CMOP to increase quality and efficiency of prescription fulfillment operation by end of Fiscal Year Upgrade equipment at Great Lakes and Leavenworth CMOPs to increase quality and efficiency of prescription fulfillment operation by end of Fiscal Year Designing and executing a data-driven process for tracking and trending the difficult-to-recruit pharmacy leadership vacancies. Continue to support enhancements to MOCHA and the Pharmacy Product System/National Drug File. Support VA facilities ability to achieve better staffing in primary care and other specialty areas with Clinical Pharmacy Specialists. Support an initiative to create and execute an overarching strategy across the VA entitled, Partnering with Veterans and their Medications. National Formulary - VA transitioned from individual medical center formularies to Veterans Integrated Service Networks (VISN) formularies in 1996 and established a VA National Formulary in VA abolished the use of individual medical center formularies in July 2001 and, in February 2009, abolished the use of VISN formularies, leaving only the VA National Formulary as the sole drug formulary authorized for use in VA. VA National Formulary contains national standardization items within selected therapeutic categories and ensures uniform availability of drug therapies across the nation. Pharmacy Benefits Management (PBM) Services - VA established the PBM in the early 1990s to administer the drug benefit across the VA health care system. Where it is clinically feasible, national standardization contracts are awarded within therapeutic categories that represent the greatest opportunity for enhancing cost-effective drug therapy. VHA-54 Medical Services

57 Consolidated Mail Outpatient Pharmacies (CMOP) VA automated and consolidated its prescription fulfillment processes for Veteran outpatients. Prescriptions are filled and mailed to the Veteran s home. CMOPs significantly improve customer service, reduce potential for errors, and improve efficiency by filling large volumes of prescriptions faster with continually improving technologies that require less staff than would be needed at individual VA medical centers. VA currently operates seven of these facilities across the nation and fills approximately 80 percent of all outpatient prescriptions via the CMOPs. VA/DoD Pharmaceutical Procurement VA and DoD continue to convert existing unilateral contracts to joint contracts where clinically appropriate. VA Adverse Drug Event Reporting (VA ADERS) / VA Center for Medication Safety (VAMedSAFE) VA ADERS is a spontaneous web-based passive surveillance reporting system for adverse drug and vaccine events (ADEs). These reports are reported directly to the Food and Drug Administration (FDA) and are analyzed for overall trends and preventable ADEs. VAMedSAFE conducts passive surveillance (VA ADERS), active medication safety surveillance (integrated databases), and national medication safety Medication Use Evaluations and Risk Reduction efforts for certain classes of medication and vaccines. Staff works collaboratively with the FDA on surveillance with an emphasis on the safe use of medications and vaccines in the Veteran population. VA Mobile Pharmacy VA mobile pharmacies provide acute and chronic medications to Veterans and potentially other Americans affected by a natural disaster. VA mobile pharmacies are capable of connecting via satellite to a CMOP which can then dispense prescriptions for delivery to a central location within the disaster zone. Pharmacy Clinical Informatics and Re-engineering VA Pharmacy Informatics and Reengineering program provides business owner oversight of pharmacy development activities to improve and transform health care through information technology. The primary initiative is to replace the Pharmacy VistA system component of VA s Electronic Health Record. One component of this effort is the VA Medication Order Check Healthcare Application (MOCHA). This application provides clinical decision support for drug interactions and became initially operational across all VA medical centers for drug interaction decision support in Maximum Single Dose order checks were deployed to all VA medical centers beginning March 2014 and completing in July MOCHA generates over 1,000 order checks per site per day to help prevent adverse drug events due to incorrect drug dosage, unnecessary therapeutic duplication and potential drug-drug interactions. Minor enhancements to non-dosing order checks are planned to be completed and deployed by March Total Daily Dosage checks are currently being developed and tested. The Pharmacy Enterprise Customization System (PECS) component provides tools to allow customization of Commercial Off the Shelf (COTS) drug database information used in production order checks provided by the Medication Order Check Healthcare 2016 Congressional Submission VHA-55

58 Application (MOCHA) to increase patient safety while reducing false alert fatigue to pharmacists, and improving order checks to use unique VA expert pharmacist knowledge instead of just COTS data. In 2015 PECS 6.0 of PECS will be completed. PECS 6.0 will upgrade VA to FDB latest version of their software version 4.0. In addition 6.0 will also make PECS PIV card compliant as well as make other technical changes to make the system easier to use, and manage. There will also be a number of technical changes. Pharmacy Product System (PPS)/National Drug File Project (PPSN and PPSL), are currently on hold awaiting the contracting process however it expected that these projects will restart in February The PPS/NDF system is the largest open source drug file in the USA. The Pharmacy Product System-National (PPS-N) is a Web-based application that provides the ability to manage pharmacy-specific data across the VA enterprise, ensuring that all facilities are using the same base data for their operations. It allows approved national VA personnel to easily, quickly, and safely manage the VA National Formulary which directs which products (such as medications and supplies) are to be purchased and used by the VA hospital system. There are two major projects for 2015; these include PPS-N 3.0 and PPS-L 1.0 Foundations. PPS-N 3.0 will completely automate the updating of PPS/NDF information at the sites, PPS/NDF updates will occur weekly with the option to do daily updates. This will improve VA ability to respond to clinical and market changes. PPS-N 3.0 will also add support for hazardous waste drugs; length of clinical effect, which will be used to pinpoint duplicate therapy alerts on expired medications, PPS-N 3.0 will allow RxNorm information to be directly updated in PPS daily. PPS-L 1.0 Foundations will take the core functionality from PPS_N and create a foundation for a deployable local system where local site data can be imported into. VHA Pharmacy is actively working on the activation of recently released software to transmit data to State Prescription Drug Monitoring Programs (SPMPs). This program allows VA to share data about controlled substance prescriptions with a database established in most states for the tracking of these medications across all pharmacies from which they are dispensed and all providers that prescribed them. The activation of SPMP transmissions is in a phased schedule, anticipated completion in mid Clinical Pharmacy Program Office The Clinical Pharmacy Program Office was created in 2010 to assist the field in organizing, standardizing, and enhancing clinical pharmacy practice and to help sites navigate the transformational changes occurring within VHA. The primary focus of this program office has been to maximize the utilization of Clinical Pharmacists as non-physician providers with a scope of practice, thus improving care by performing essential medication management services, enhancing medication safety, and significantly improving chronic disease management in our Veteran population. Since the inception of this program office, there has been a 46 percent increase in Clinical Pharmacists practicing as non-physician providers. Additionally, the program office has developed robust and comprehensive data collection tools, including metrics that illustrate both the performance and quality of clinical pharmacy practice in VHA. To assure the competency, consistency and standardization of clinical pharmacy practice, the program office developed comprehensive educational and communication programs focusing on key disease states and promoting expansion of clinical pharmacy practice roles. VHA-56 Medical Services

59 Patient Medication Information Management and Medication Reconciliation Initiative Office - Patient Medication Information and Medication Reconciliation Initiative Office serves to collaborate with program offices, the field, and partner federal healthcare organizations to ensure patients and their caregivers have safe, effective, team based, and patient driven medication reconciliation as part of a larger goal to partner with patients and their medications. For example, The Medication Use Crisis Virtual Conference provided 16 hours credentialed for over 4,000 registrants last year available to VA, DoD, and Indian Health Service. This office has developed patient and staff education resources, operational support, policies, metrics, and collaborative efforts to reduce variation in medication information tools and improve medication information processes. Meds by Mail Program: The Pharmacy Benefits Management Services (PBM) Meds by Mail (MbM) Program is designed to provide comprehensive outpatient mail pharmacy services to qualifying beneficiaries of the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). CHAMPVA beneficiaries are the dependents of permanently and totally disabled veterans, survivors of veterans who died from service-connected conditions or while on active duty, or veterans who at the time of death were rated permanently and totally disabled from a service-connected condition. Additionally, MbM also supports the CHAMPVA Spina Bifida/ Children of Women Vietnam Veterans (CWVV) programs. Under CHAMPVA, VA shares the cost of covered services, including medications, with eligible beneficiaries. The MbM program is a unique benefit that provides cost effective and efficient mail order prescription services in a partnership between PBM, CMOP and the VA Chief Business Office Purchased Care (CBOPC). MbM staff process and manage non-va provider prescriptions including customer service and CMOP distributes medications to CHAMPVA beneficiaries. Prescriptions are dispensed by CMOP then mailed directly to the beneficiary at no cost to the patient and at significant cost avoidance to government. New Hepatitis C Treatment: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease New Hepatitis C Treatment: Medical Services... $379 $0 $697 $0 $690 $660 ($7) ($30) Medical Care Total... $379 $0 $697 $0 $690 $660 ($7) ($30) VA places a high priority on ensuring that all enrolled Veterans who require Hepatitis C treatment have access to the necessary therapies. Hepatitis C is an infectious disease affecting primarily the liver, caused by the Hepatitis C virus (HCV). The infection is often asymptomatic, but chronic infection can lead to scarring of the liver and ultimately to cirrhosis, which is generally apparent after many years. In many cases, those with cirrhosis will go on to develop liver failure, or liver cancer. Approximately 175,000 enrollees are diagnosed with HCV, with at least 30,000 having cirrhosis; the proportion of enrollees with HCV who have cirrhosis has doubled over the last decade. It is estimated that as many as 40,000 enrollees may be infected with the virus but have not yet had this condition diagnosed Congressional Submission VHA-57

60 The Food and Drug Administration approved two new highly-effective drugs Sofosbuvir and Simeprevir that will change the lives of Veterans infected with Hepatitis C. Prior to the introduction of the new high-cost treatment therapies in January 2014 in the VA system, the treatments for Hepatitis C were often ineffective and presented considerable side effects to the user. By contrast, the new treatment options are considerably more effective at curing patients with HCV, present significantly fewer side-effects than earlier options, and are considerably simpler to administer. There are four new treatment therapies: Simeprevir 12 weeks, Sofosbuvir 12 weeks, Sofosbuvir 24 weeks, and Sofosbuvir/Simeprevir 12 weeks. Cure of HCV significantly decreases the risk of progression of disease to cirrhosis, liver failure, liver cancer, and death. As a result, there has been a large increase in demand for the new treatments and subsequent increases in the number of prescribed treatments. Furthermore, given the availability of new anti-viral therapies as well as increases in HCV testing to identify previously undiagnosed enrollees with HCV, VHA may experience an increase in Hepatitis C diagnoses within the enrolled Veteran population. These increased treatments and diagnoses may reduce the number of cases of cirrhosis or liver cancer for enrollees infected with HCV. VA has developed a Hepatitis C projection model to supplement the VA Enrollee Health Care Projection Model. The Hepatitis C model projects both the prevalence of HCV infections in the enrolled Veteran population, as well as the number of newly available treatment therapies prescribed for 2014 through Each modeled treatment is assigned a national average cost per treatment. The cost per treatment, along with the number of projected treatments in each projection year, has been used to develop projected total treatment drug costs for 2015 through The following chart (see Figure A) shows the projected number of enrollees infected with HCV, broken into the following categories: undiagnosed, diagnosed, or cured in 2014 through The actual number of undiagnosed enrollees is not known; in this chart, the maximum estimated number of undiagnosed enrollees, 42,000, is used. The effectiveness of the new HCV treatments is evident in the considerable increase in the projected number of infected enrollees who are treated and cured. VHA-58 Medical Services

61 Figure A The number of total national Hepatitis C treatments per year increased from approximately 2,800 per year in 2011 through 2013, to approximately 5,400 in This growth reflects the additional demand for HCV treatment with the newly available drugs, beginning in the second quarter of fiscal year The total number of annual treatments is expected to grow to nearly 12,000 in 2015 and beyond. The total cost of Hepatitis C treatment increased significantly from 2013 to 2014, due to both the increased treatment rate described above, as well as the significant increase in the average cost per treatment under the new regimens. Following the expected increases in treatments, the associated costs are also projected to increase into 2015 and decrease marginally thereafter through Inpatient Care: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Inpatient Care: Medical Services... $8,648 $8,975 $9,043 $9,225 $9,377 $9,723 $334 $346 Medical Care Total... $10,806 $11,507 $11,300 $11,827 $11,717 $12,149 $417 $432 VA delivers inpatient acute care in its hospitals and through inpatient contract care Accomplishments Partner in the Million Hearts initiative a national initiative to prevent one million heart attacks and strokes by Regularly conducted real time evidence-based appropriateness and continued stay reviews for psychiatry, medicine, and surgery. Flow management for efficiency and appropriate level of care through emergency department enhanced with synergy in bed management system and emergency department information system Congressional Submission VHA-59

62 Bedside Care collaborative prompted best practices in safe transitions and served as the springboard for reducing unexpected admission and readmissions. Surgical collaborative represents balanced protocol to manage efficiency, quality and safety for surgical patients across continuum. Standardization in discharge procedures including medication reconciliation bundled approached know to prevent readmissions. Future Goals ( ) VHA estimates treating 615,275 patients for inpatient care in 2015, 612,966 patients in 2016, and 610,353 patients in The decrease in patients treated is evidence of a shift within the medical profession from inpatient to less costly ambulatory care. Specialty Care Services notes the following Inpatient Care Objectives: o Gap analysis on patient safety issues, including environmental scanning of Federal agencies and private sector. o Identify best discharge practices from VHA, other Federal agencies, and private sector. o Establish shared decision making site for specific decisions for both patients and providers. o Patient and providers will have information they need at the time they need it (connected health). Rehabilitative Care: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Rehabilitation Care: Medical Services... $450 $482 $472 $495 $483 $494 $11 $11 Medical Care Total... $595 $643 $624 $660 $638 $652 $14 $14 Unique Patients Blind Rehabilitation Service... 19,696 20,782 19,168 21,045 18,669 18,199 (499) (470) Spinal Cord Injury... 14,982 15,057 15,272 15,282 15,546 15,823 $274 $277 These services include inpatient and outpatient blind and vision rehabilitation programs, adjustment to blindness counseling, patient and family education, and assistive technology. The mission of Spinal Cord Injury and Disorders (SCI/D) Services is to promote the health, independence, quality of life and productivity of individuals with spinal cord injury and disorders through efficient delivery of acute rehabilitation, psychological, social, vocational, medical and surgical care, professional training, as well as patient and family education. Blind Rehabilitation Service 2014 Accomplishments Partnered with Prosthetic and Sensory Aids Service (PSAS) and the Denver Acquisitions and Logistics Center (DALC) to request proposals for access technology and help desk services for blind Veterans. The outcome of this new partnership with the DALC is to streamline the order process and increase efficiency to better serve the Veteran. VHA-60 Medical Services

63 Partnered with PSAS to deploy practice guidelines for assuring quality assessment and training in access technology and rehabilitation for in-home safety for blind Veterans via community vendors. Accomplished the statutory mandated switch of blind rehabilitation professionals from Title 5 to Hybrid Title 38 hiring authority. This required the development of qualification standards and peer-review standards boarding in partnership with VA and VHA Human Resources. Partnered with PSAS and Office of Administrative and Regulatory Affairs to develop regulations for the provision of blind aids. The drafted regulations are under review. Supported dramatic increase in connected health encounters, and regional memoranda of understanding for tele-rehabilitation between inpatient blind rehabilitation and case managers for blind Veterans. Developed International Classification of Disease (ICD) crosswalk from version 9 to version 10 for vision and blind rehabilitation care. These codes are used by VHA blind rehabilitation professionals to indicate the level of impairment for patients with vision loss. Partnered with Office of Workforce and Management Consulting to roll out blind rehabilitation pre-service scholarships mandated by P.L to assure a vital workforce. Supported Joint Commission accreditation preparedness for all BRS programs involved in providing care in veterans home and eligible for survey under the Home Care standards. Continued supporting the field deployment of a comprehensive set of Event Capture System data products that are linked to specific Current Procedural Terminology codes and Relative Value Units used in all inpatient Blind Rehabilitation Centers. This standardized methodology allows consistent, system wide productivity and workload data capture and monitoring that promotes staff efficiency, enhances patient care and promotes effective stewardship of resources by allowing identification of outlier utilization and costs and provides the ability to conduct in-depth trending and comparison analyses across inpatient programs in BRS. Developed basic presentation about services for blind Veterans that can be presented in VHA medical facilities by a variety of practitioners to stimulate discussion and integration. Partnered with Care Management and Social Work Service to update toolkit developed in 2010 for primary care social workers. Supported deployment and utilization of the Universal Stakeholder Participation and Experience Questionnaires (uspeq) Consumer Experiences Survey. This VACO initiative allows an agency-wide data collection process in VHA for over 380 VA rehabilitation programs (133 of which are BRS field-based programs). In partnership with Office of Productivity, Efficiency, and Staffing, (OPES), and Decision Support Office, refined benchmarks to assist in assessing provider productivity for Rehabilitation Services disciplines. Partnered with Prosthetics and Sensory Aids Service, Eye Care and VHA Driver Rehabilitation for Veterans with Disabilities Program to develop a best practices 2016 Congressional Submission VHA-61

64 document for blind Veteran driver evaluation, training and adaptive automobile support. Continued partnership with DoD Vision Center of Excellence to support Center s mission and goals. Future Goals ( ) Partner with VHA Office of Productivity, Efficiency, and Staffing, and Decision Support Refine benchmarks to assist in assessing provider productivity for Rehabilitation Services disciplines. Develop guidelines and best practices. Include labor mapping examples, from different programs and various BRS position types. Partner with DoD and VHA Patient Care Services to roll out the one mission- one policy-one plan to ensure interagency complex care coordination process across the full spectrum of care, benefits and services for Veterans and Servicemembers. Partner with the Denver Acquisition and Logistics Center, and Prosthetics & Sensory Aids Service to contract with vendors for provision of access technology, peripherals, and provision of helpdesk services for blind Veterans. Deploy uspeq Consumer Experiences Survey to measure and assess Veteran Patient Experience and Satisfaction. In partnership with key VHA staff and Office of the Assistant Deputy Under Secretary for Health for Policy and Planning, BRS will refine new guidance on Catastrophic Disability and legal blindness ICD-10 codes. Revise BRS and BROS Hybrid Title 38 Qualification Standards. Collaborate with VHA Office of Enrollment and Forecasting to build model for projecting / right-sizing in-patient beds and resources needed for Blind Rehabilitation. Revise and enhance discipline-based Preferred Practice Patterns, and deploy information across VHA. Provide updated policy and guidance to the field concerning prosthetic aids for Veterans with visual impairment. Conduct an accessibility review related Veteran VA experience with BRS. The mission of Blind Rehabilitation Service (BRS) is to assist eligible blind and visually impaired Veterans and Servicemembers in developing the skills needed for personal independence and successful reintegration into the community and family environment. BRS is an integrated system of care that includes: 13 inpatient blind rehabilitation centers; 9 outpatient blind rehabilitation clinics; 44 low vision clinics; 161 blindness case managers (called Visual Impairment Services Team (VIST) Coordinators) for the most severely disabled blind Veterans; and 85 Blind Rehabilitation Outpatient Specialists (BROS) who provide care at VA medical facilities and in Veterans homes. BROS are VHA-62 Medical Services

65 assigned to Polytrauma Centers and sites of care to partner for the care of Servicemembers and Veterans whose injuries and disorders include vision loss. Rehabilitation in BRS is interdisciplinary and patient-centered, using integrated plans of care that address the Veterans needs and goals to guide service delivery. Family members, included as members of the team, are provided with education and training that allows them to understand visual impairment and provide support for goals. The specialized blind rehabilitation database provides a mechanism for coordinated system-wide care, management and data analysis. BRS personnel evaluate and determine best practices for cutting-edge technology that provides blind Veterans and Servicemembers with peak performance. BRS programs provide a model of care that extends from the Veteran s home to the local VA care site, regional low vision clinics, and lodger and inpatient training programs. Components of the model include the following. Intermediate and Advanced Low-Vision Clinics When basic low-vision services available at all VA eye clinics are no longer sufficient, intermediate and advanced low-vision clinics provide clinical examinations, a full spectrum of vision-enhancing devices and specialized training in visual perceptual and visual motor skills as well as ergonomic and environmental enhancements. Eye care specialists and blind rehabilitation specialists work together in interdisciplinary teams to ensure that individuals with low vision are provided with technology and techniques to enhance their remaining sight in the performance of daily activities in order to remain independent and active. Vision Impairment Service in Outpatient Rehabilitation (VISOR) Programs VISOR programs provide intense, short-term (about two weeks) outpatient blind rehabilitation. They provide comfortable overnight accommodations for distant patients who require temporary lodging. Those who attend VISOR must be able to perform basic activities of daily living independently, including the ability to selfmedicate. Visual Impairment Services Team (VIST) Coordinators VIST coordinators are case managers who have responsibility for the information, referral, coordination of services, adjustment counseling and education for severely visually impaired Veterans and active duty Servicemembers and their families. Every VA Medical Center is required to provide a Visual Impairment Service Team to assure that severely disabled blind Veterans are providing all benefits to which they are entitled. Blind Rehabilitation Outpatient Specialists (BROS) 2016 Congressional Submission VHA-63

66 BROS are multi-skilled professionals who provide direct blind and vision rehabilitation care. BROS serve Veterans in their homes, VA medical centers or clinics, colleges or universities, work sites, and long-term care environments. Inpatient Blind Rehabilitation Centers (BRC) The inpatient BRCs provide the most intense and in-depth rehabilitation. Comprehensive, individualized blind rehabilitation services are provided in an inpatient VA medical center environment by a multidisciplinary team of rehabilitation specialists that includes not only blindness professions, but also nursing, social work, psychology and optometry. The management of chronic medical conditions is addressed as part of the training regimen as well. Blind rehabilitation specialists guide the individual through a rehabilitation process that leads to adjustment to blindness, new skill development, use of specialized technology, and reorganization of the person s life. New skills and attitudes foster new abilities to contribute to family and community life. VA continually improves access to specialized rehabilitation services for Veterans with visual impairment and blindness. Programs include: Low vision services to maximize remaining vision these programs include access to optical and electronic devices that enhance vision. Orientation and mobility training to assure that Veterans are able to move safely in their environments, are able to way find using orientation techniques and small mobile global positioning systems, and are able to travel safely on public transportation. Enhanced activities of daily living training to assure that Veterans are able to clean and organize their homes, manage medication and healthcare regimens, manage time effectively, shop, cook, dress, manage finances, and provide care for other family members. Cutting edge technology assessment and training for the use of personal computers, tablets and smartphones and their applications, global positioning systems, Braille, speech-output devices, etc. Manual skills training that leads to successful abilities to resume leisure activities, home maintenance, carpentry, car repair and maintenance, etc. Inpatient transitional rehabilitation programs, focusing on independent living and community re-integration. Telehealth assessment, treatment, and monitoring options for Veterans with visual impairment. Partnerships with Recreational Therapy so that Veterans may participate in leisure sports and games, as well as competitive sports. Partnership with Care Management and Social Work Service to assure that PACT social workers identify, counsel and refer Veterans with visual impairment appropriately. Partnerships with Optometry and Ophthalmology to assure that Veterans, whose visual impairment cannot be managed with basic low vision care, are identified and referred for care in BRS programs. VHA-64 Medical Services

67 Partnerships with other programs in VHA national programs to assure standardization in workload reporting, guidance on best practices, devising appropriate medical coding practices, and prosthetic and sensory aids guidelines for emerging technology. BRS also partners with external agencies to ensure that VA provides world-class care for Veterans visual impairment and blindness: VA blind and vision rehabilitation programs are accredited by the Joint Commission and by the Commission on Accreditation of Rehabilitation Facilities (CARF) an internationally recognized standard of excellence for rehabilitation programs. CARF accreditation is mandatory for all VA BRS inpatient centers and outpatient clinics. In collaboration with the DoD Vision Center of Excellence, BRS staff partner to provide early identification and support case managers to coordinate vision and rehabilitation care services for active duty Servicemembers; assess technology gaps for Servicemembers and Veterans with visual impairments and perform a gap analysis for assistive technology. BRS staff members serve on a workgroup for the Academy for Certification of Vision Rehabilitation & Education Professionals (ACVREP) to develop and deploy a certification in Blindness Assistive Technology. BRS and Prosthetics and Sensory Aids Service (PSAS) partner with guide dog training schools to ensure that Veterans who are interested in working with a guide dog are assessed for appropriateness, understand the responsibilities in acquiring and working with a guide dog, and are referred to schools that meet the highest international standards. After referral and procurement, PSAS supports the health and equipment costs of working dog partners. Spinal Cord Injury and Disorders The mission and commitment to Veterans with spinal cord injuries and disorders (SCI/D) is to support and maintain their health, independence, quality of life, and productivity from initial injury or illness through their lifespan Accomplishments Delivered comprehensive services to Veterans and Active Duty Servicemembers (ADSM) including acute rehabilitation, sustaining medical and surgical care, psychosocial care, vocational rehabilitation, comprehensive lifelong primary and preventive healthcare, patient and family training, provision of assistive technologies and durable medical equipment, and long term care. Expanded Telehealth services delivered to Veterans with SCI/D. Between 2013 and 2014, there was a 34 percent increase in clinical video Telehealth (CVT) encounters and a 62 percent increase in CVT to Home encounters Congressional Submission VHA-65

68 Distributed Emergency Preparedness patient education materials to each of 24 SCI/D Centers to support awareness and advance planning for self-management and safety in the event of an emergency. Disseminated multiple year national-level outcomes data to the SCI/D field to summarize outcomes related to inpatient rehabilitation, outpatient rehabilitation, and annual evaluations. Facilitated improved Quality Improvement (QI) coordination throughout the SCI/D System of Care by analyzing current QI methodologies, assessing active QI projects, supporting SCI/D Centers to strengthen QI processes, and facilitating multi-center collaboration for QI initiatives. Organized a national leadership conference for SCI/D Center Chiefs to facilitate faceto-face discussion of SCI/D initiatives and priorities, support system of care strategic planning, and to share best practices for delivering coordinated care to Veterans with SCI/D. Updated internal and external facing SCI/D web sites to support Veterans, VA personnel, and referral sources to access critical materials and resources. Coordinated an innovative three-part educational program for psychologists on the topic of using hypnosis to manage pain in SCI/D. Distance learning technology was utilized to deliver didactic information and support opportunities for providers to practice new techniques. Developed and implemented functional outcomes data collection for locomotion (walking) at 21 of 24 SCI/D Centers. Future Goals ( ) Improve care coordination and increase access to VHA SCI/D specialty care throughout the country for Veterans with SCI/D by strengthening the hub and spokes system of care and the SCI PACT care delivery model, and by expanding the SCI/D Telehealth program. To further support the goal of improving care coordination and access to VHA SCI/D care, (1) develop a standardized method to determine the wait list for SCI/D inpatient services at the SCI/D centers using the non-count Electronic Wait List (EWL) system; (2) develop a centralized admission/transfer coordination process between the SCI/D centers and spoke sites and the Department of Defense (DoD) facilities to improve access and transition for both active duty personnel and Veterans enrolled in SCI/D centers. In collaboration with the Office of Nursing Services (ONS), develop a new and effective nurse staffing methodology for SCI/D to ensure safe, quality inpatient care for Veterans admitted to SCI/D inpatient units, and to provide SCI/D nursing support and expertise to the field to facilitate recruitment and retention of high quality SCI/D nurses. Utilizing the Geographic Information System (GIS) intern program, GIS technology will be used for outreach, to determine the penetration rate of clinical services for each SCI/D Center, and to quantify unique geographical access issues for Veterans with SCI/D. VHA-66 Medical Services

69 Continue to improve the relationship and partnership with the Paralyzed Veterans of America and improve processes and timeliness of the VA response to PVA Site Visit Reports. Establish standard operating procedures for the evaluation, training, and issuance of exoskeleton technologies utilized by Veterans with SCI/D. Develop a new and improved SCI/D outcomes management system that will interface with the Corporate Data Warehouse (CDW) to facilitate quality improvement projects and outreach activities for both the field and the SCI/D national office. Implement solutions for non-institutional care delivery through comprehensive analysis of existing programs, exploration of opportunities to standardize practices, and coordination for consistent Veteran care in the home setting, including the SCI bowel and bladder non VA care program. VA SCI/D system of care is the largest system of care for people with SCI/D in the United States and provides rehabilitation, sustaining medical and surgical care, psychosocial care, vocational rehabilitation, comprehensive lifelong primary and preventive healthcare, patient and family training, assistive technologies and durable medical equipment, and long-term care. Following acute rehabilitation, the majority of symptoms and problems are chronic; therefore, the foundation of the SCI/D System of Care focuses on self-management to maintain function and prevent additional problems. Since living with spinal cord injuries and disorders increases the possibility of other co-morbid problems and loss of function, another underpinning of the VA SCI/D System of Care is to provide close follow-up, preventive health evaluations, early detection and aggressive treatment of new health and psychosocial challenges. The comprehensive, highly specialized, lifelong care provided to Veterans served by the VA SCI/D System of Care is exceptional and unparalleled by private sector healthcare systems. The VA SCI/D System of Care is organized on a Hub and Spokes structure providing continuity of care, delivered to the Veteran with SCI/D both locally and regionally. SCI/D teams are located in regional SCI/D Centers (Hubs) and local SCI/D Patient Aligned Care Teams (SCI/D PACTsS) are located at all other VA medical centers (Spokes). Twenty-four designated SCI/D Centers provide SCI/D primary care and SCI/D specialty care with a full continuum of services, including: medical and surgical stabilization after a new spinal cord injury; acute rehabilitation; ventilator management and weaning; comprehensive healthcare; health promotion; early detection and management of secondary and co-morbid conditions; management and treatment of chronic pain; functional assessments; interventions to optimize independence, economic self-sufficiency, social role participation, and quality of life; respite care; extended and long-term care; and end-of-life care. Five of the SCI/D Centers have designated long term care beds. VA has the only SCI/D system of care in the country where specialists coordinate with a wide network of primary care providers to integrate specialty and primary care. Dedicated SCI/D clinicians at SCI/D Centers utilize virtual technologies to communicate and coordinate specialty care with primary care clinicians throughout the country. Telehealth is also used to support Veterans in their home setting. Telehealth applications include pre-admission 2016 Congressional Submission VHA-67

70 assessment, discharge coordination, post-discharge visits, specialty medical consultations, and rehabilitation therapy services. VA SCI/D System of Care also promotes ongoing educational and research opportunities to support excellent care and improved outcomes for Veterans with SCI/D. Educational activities are directed at Veterans, family members, caregivers, SCI/D providers, policy makers and other stakeholders. Research opportunities in the SCI/D System of Care are unique in that the Hub and Spokes organizational structure supports multicenter studies that are difficult to coordinate elsewhere because spinal cord injuries and disorders are relatively uncommon. There is a long-standing Memorandum of Agreement (MoA) between VA and the Department of Defense to provide specialized care at VA medical facilities for Active Duty Service members who have sustained a spinal cord injury, traumatic brain injury, blindness, or polytrauma injuries. VA SCI/D Centers that provide acute rehabilitation after new onset SCI/D maintain accreditation with the Commission on Accreditation of Rehabilitation Facilities (CARF) and The Joint Commission (TJC) for acute care beds in SCI/D regional centers. Mental Health Care: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Mental Health: Medical Services... $5,070 $5,455 $5,396 $5,661 $5,661 $5,859 $265 $198 Medical Care Total... $6,676 $7,178 $7,106 $7,449 $7,455 $7,715 $349 $260 Mental health services and operations ensure timely access to a range of services, from treatment of a variety of common mental health conditions in primary care to more intensive interventions in specialty mental health programs for more severe and persisting mental health conditions. Specialty services such as evidence-based psychotherapies, intensive outpatient programs, residential rehabilitation treatment, and inpatient care are available to meet the range of Veterans' needs. It is critical for Veterans to get timely access to mental health services and this is further discussed in the Performance Plan Chapter Accomplishments VA provided specialized mental health treatment to more than 1.4 million Veterans. VA completed hiring initiatives that increased the mental health workforce by more than 1,600 new clinical providers and over 960 Peer Specialists and Peer Support Apprentices. An update to 2012 s National Suicide Data Report on Veteran Suicides was released using more complete data from State data reports, a VA internal data collection system, and the Veterans Crisis Line. Related to suicide prevention efforts, gun safety initiatives were increased, including a new gun safety video that was developed in collaboration with the National Sports Shooting Foundation and disseminated throughout the VA system. VHA-68 Medical Services

71 Also, tens of thousands of gun locks were provided to Veterans and family members when requested, no questions asked. A mental health staffing model was implemented, incorporating team-based concepts that require at least one general mental health outpatient team per VA medical center, known as Behavioral Health Interdisciplinary Program (BHIP) teams. Each VA Medical Center hosted a Community Mental Health Summit. This generated mutually-beneficial relationships enhancing mental health care for Veterans and their family members through collaboration between VA and the community. VA established pilot partnerships with 24 community-based mental health and substance use clinics across nine states and seven Veterans Integrated Service Networks (VISNs). PTSD Coach ( which was first deployed as a VA and DoD joint project in 2011, continues to be widely acclaimed and has been downloaded free for iphones and Android smartphones nearly 200,000 times in 88 countries. As of the end of 2014 PTSD Coach Canada and PTSD Coach Australia have been deployed. These efforts integrated language, cultural, and local changes into the existing platform, creating the foundation for the first truly global mobile resource for mental health. More countries will launch versions in VA and DoD efforts in supporting the provision of evidence-based care with mobile apps have continued. As of the beginning of 2015, the suite of apps in this domain include: Prolonged Exposure (PE) Coach for PTSD (released 2012); Cognitive Behavioral Therapy for Insomnia (CBT-i) Coach (released 2013); Acceptance and Commitment Therapy (ACT) Coach for Depression (released 2014); Cognitive Processing Therapy (CPT) Coach for PTSD (released 2014); Stay Quit Coach for smoking cessation (released 2013), and Moving Forward, which teaches problem solving training for Depression (released 2014). During 2014, VA launched its online portal for self-help web-based resources, ( to provide a one stop shopping experience for web-based self-help resources for Veterans and their families. Currently, the following award-winning courses are available: o Moving Forward, ( an educational and life coaching program that teaches Problem Solving skills to help Veterans better handle life s challenges. It is an interactive program based on the principles of Problem Solving Therapy which allows for anonymous, self-paced, 24-hour-a-day access that can be used independently or in conjunction with mental health treatment. o Veteran Parenting ( a course to help parents learn how to address everyday parenting challenges as well as family issues unique to military families. o PTSD Coach Online ( a web-based version of the award winning PTSD Coach, this course is for trauma 2016 Congressional Submission VHA-69

72 survivors, their families or anyone coping with stress. It includes tools to help manage anxiety, anger, sleep problems and more. o Anger & Irritability Management Skills, an educational interactive course on managing anger effectively, to be launched during the first quarter of Veteran Parenting ( Over 1,500 mental health clinicians were trained in one or more evidence-based psychotherapies during In 2013 and 2014, VHA Mental Health Services developed a series of specialized online toolkits for different populations including Veterans seeking employment, Veterans who are attending colleges and universities, and mental health providers who see Veterans in the community o Veterans Employment Toolkit ( a resource that supports Veterans seeking work and that also helps employers support their employees who are Veterans or members of the Reserve or National Guard. o VA Campus Toolkit ( a site where faculty, staff, and administrators can find resources to support student Veterans and learn about their strengths, skills, and needs. o Community Provider Toolkit ( provides information about VA services and resources, understanding military culture and experience, and tools for working with a variety of mental health conditions. In 2014, VHA expanded access to Mental Health Residential Rehabilitation Treatment Programs (MH RRTP) by opening three 40-bed Domiciliary Care for Homeless Veterans (DCHV) programs in San Diego, California, Atlanta, Georgia and Philadelphia, Pennsylvania; a new 29-bed Substance Abuse Residential Rehabilitation Treatment Program (SARRTP) also in San Diego; a new 34-bed General Psychosocial Residential Rehabilitation Treatment Program (PRRTP) in Murfreesboro, Tennessee and a new 8-bed Compensated Work Therapy/Transitional Residence (CWT/TR in Salisbury, North Carolina. At the end of 2014, VHA operated 245 MH RRTP programs with 8,252 beds at 104 VA Medical Centers. Six whiteboards that aim to encourage recognition of PTSD and increase Veteran engagement in and provider provision of evidence-based treatment were released ( These short animated videos combine narration with hand-drawn images and can be easily shared electronically. The PTSD Consultation Program for VA Providers (vaww.ptsd.va.gov/ptsd_consultation_program.asp) which answers questions from any VA provider about PTSD and implementation of evidence-based care, provided 946 consults in 2014 (an increase of 61 percent over 2013). The Program continues to offer VA providers a monthly virtual lecture series, which disseminate the latest research and clinical applications and are often attended by over 400 VA providers. VHA-70 Medical Services

73 Future Goals ( ) Continue full implementation of the VA/DoD Clinical Practice Guideline for Suicide Prevention across VA. The VA/DoD Clinical Practice Guideline will help those within VA best provide care to Veterans who may be at risk for suicide. Develop a gun safety toolkit and advance gun safety initiatives in collaboration with Veterans Service Organizations (VSOs) and firearm associations. Launch the second generation of Mental Health Outcome Oriented Quality Metrics to include measures of patient satisfaction, function, and symptom monitoring as part of the overall strategy to develop a measurement-based system of mental health care. Incorporate innovations in mental health care by providing a clear menu of evidence-based treatment choices, enhancing Primary Care Mental Health Integration in Patient Aligned Care Teams, providing self-care and selfmanagement resources, and fully implementing a patient-centered, recoveryoriented model of care. Expand peer support services into Primary Care through the implementation of 25 pilot sites as per the President s August 2014 Executive Order. Expand the use of Telemental Health services and support the VISNs in their implementation of the Telemental Health Strategic Plan. Work with VA medical centers as they complete all of the items in their After Action Reports from the 2013 Community Mental Health Summits and provide technical support for any additional local summits that are planned. Improve the understanding of military culture among healthcare professionals through the VA/DoD web-based training curriculum, Military Culture: Core Competencies for Healthcare Professionals. The first module was launched in November 2013, and the remaining modules will be available in Work with VISNs and VA Medical Centers to ensure appropriate geographic distribution and availability of residential treatment in order to ensure timely access for men and women Veterans presenting with mental health and substance use disorders. These efforts will incorporate information from new projection models developed in collaboration with the Office of Policy and Planning. Continue to extend the reach of evidence-based care with the release of VetChange, a publically available online self-management program designed for active duty military and Veterans concerned about their drinking and stress-related symptoms. Launch the PTSD Consultation Program for community providers to provide education, training, information, resources, and consultation to health professionals who are treating Veterans with PTSD outside of the VA system with the goal of improving care available to all Veterans with PTSD, regardless of where they access services. Launch an online course to train providers in the use of the Clinician Administered PTSD Scale for DSM-5 (CAPS-5), the gold standard for PTSD assessment and diagnosis. The course will include branching video vignettes that will help learners develop a comprehensive understanding of CAPS-5 administration and scoring. In August 2014, President Obama announced 19 new executive actions that the Departments of Veterans Affairs (VA) and Defense (DoD) are taking to improve the mental health of Servicemembers, Veterans and their families. These new actions build on the actions the Departments have taken in response to the 2016 Congressional Submission VHA-71

74 President s 2012 Executive Order on Servicemembers, Veterans and their families mental health. In response to the Executive Order, VA has increased its mental health staffing, expanded the capacity of the Veterans Crisis Line, and enhanced its partnerships with community mental health providers. DoD is reviewing its mental health outreach programs to prioritize those with the greatest impact; DoD and VA worked to increase suicide prevention awareness and, DoD, VA and the National Institutes of Health jointly developed the National Research Action Plan on military and Veteran s mental health to better coordinate Federal research efforts. These efforts and actions represent the latest in DoD and VA s continued commitment to ensure that this Administration is working to fulfill our promises to Servicemembers, Veterans and their families, and the Departments will continue to look for additional ways to do so in this space, both thorough our work and work with the private sector. Overview of Mental Health Services in VHA: to to 2017 Total Medical Care Obligations 2014 Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Treatment Modality ($000): VA Inpatient Hospital... $1,436,538 $1,483,680 $1,417,904 $1,473,416 $1,386,655 $1,320,305 ($31,249) ($66,350) Contract Inpatient Hospital... $370,958 $406,954 $425,284 $425,578 $480,948 $527,189 $55,664 $46,241 Psychiatric Res. Rehab. Trmt... $326,610 $362,883 $331,064 $368,752 $337,424 $339,523 $6,360 $2,099 Domicilary... $534,864 $529,981 $539,523 $526,499 $550,877 $557,807 $11,354 $6,930 VA Outpatient Clinics... $3,972,627 $4,368,471 $4,355,168 $4,629,856 $4,659,125 $4,927,572 $303,957 $268,447 Non-VA Outpatient... $34,359 $25,631 $37,139 $24,799 $39,988 $42,961 $2,849 $2,973 Treatment Modality [Total]... $6,675,956 $7,177,600 $7,106,082 $7,448,900 $7,455,017 $7,715,357 $348,935 $260,340 Not Included Above: VA-Mental Health in non MH Setting... $193,520 $171,409 $216,702 $180,504 $235,248 $250,085 $18,546 $14,837 Major Characteristics of Program ($000): SMI - PTSD... $358,547 $417,000 $369,515 $435,500 $381,182 $392,898 $11,667 $11,716 SMI - Substance Abuse... $591,284 $640,200 $603,841 $653,300 $612,277 $623,840 $8,436 $11,563 SMI - Other than PTSD & SA... $4,171,387 $4,613,500 $4,482,351 $4,820,066 $4,798,907 $5,144,143 $316,556 $345,236 SMI [Subtotal]... $5,121,218 $5,670,700 $5,455,707 $5,908,866 $5,792,366 $6,160,881 $336,659 $368,515 Suicide Prevention Outreach... $110,445 $132,821 $132,821 $143,680 $143,680 $159,246 $10,859 $15,566 Other Mental Health... $1,444,293 $1,374,079 $1,517,554 $1,396,354 $1,518,971 $1,395,230 $1,417 ($123,741) Mental Health [Total]... $6,675,956 $7,177,600 $7,106,082 $7,448,900 $7,455,017 $7,715,357 $348,935 $260,340 Included Above: OEF/OIF/OND Population Only: SMI - PTSD... $134,862 $141,473 $148,122 $169,816 $161,339 $173,578 $13,217 $12,239 SMI - Substance Abuse... $105,400 $110,699 $120,228 $141,571 $134,959 $148,438 $14,731 $13,479 SMI - Other than PTSD & SA... $636,519 $607,721 $715,278 $753,940 $796,929 $881,641 $81,651 $84,712 SMI [Subtotal]... $876,781 $859,893 $983,628 $1,065,327 $1,093,227 $1,203,657 $109,599 $110,430 Other Mental Health... $213,247 $199,856 $237,400 $242,964 $262,396 $286,902 $24,996 $24,506 OEF/OIF/OND [Total]... $1,090,028 $1,059,749 $1,221,028 $1,308,291 $1,355,623 $1,490,559 $134,595 $134,936 Average Daily Census Acute Psychiatry... 2,634 2,629 2,554 2,468 2,474 2,435 (80) (39) Contract Hospital (Psych) Psy. Residential Rehab... 1,949 1,199 2,048 1,212 2,123 2, Dom. Residential Rehab... 4,463 5,086 4,465 4,908 4,469 4, Average Daily Census [Total]... 9,428 9,216 9,465 8,866 9,487 9, Outpatient Visits/Encounters: VA Care - Mental Health... 11,874,040 11,590,752 12,329,246 12,149,234 12,713,867 13,049, , ,733 Non-VA Care - Mental Health , , , , , ,131 10,462 10,352 Not Included Above: VA - Mental Health in Non-MH Setting , , , ,892 1,056,979 1,157, , ,869 VHA-72 Medical Services

75 Mental Health in VA Central Office has two components: Mental Health Services (MHS) resides in the Office of Patient Care Services and is responsible for providing clinical policies and national guidance for mental health programs, and defines the vision of mental health care for VA. Office of Mental Health Operations (OMHO) in Operations and Management is responsible for ensuring that these policies developed by and with MHS are implemented in order to guide the development, enhancement, and sustainment of mental health programs throughout the VA health care system. MHS and OMHO collaborate to ensure the availability of a range of services, from treatment of a variety of common mental health conditions in primary care to treatment in specialty mental health programs for conditions requiring more specialized intensive intervention, including the most severe and persisting mental health conditions. A continuum of primary and specialty care services including evidence-based psychotherapies, intensive outpatient programs, residential rehabilitation treatment, and inpatient care is available to meet the range of needs that Veterans have. MHS developed the recommendations of the VHA Comprehensive Mental Health Strategic Plan (MHSP), implemented beginning in 2005 and completed in MHS then designed national requirements for mental health programs, reflected in VHA Handbook , Uniform Mental Health Services in VA Medical Centers and Clinics (UMHSH), published in September Further, and more recently, in support of broad VHA, Patient Care Service and VISN Network Operation initiatives, MHS has been actively involved in the development of PACT and has been working collaboratively with the National Center for Prevention to improve and maintain the health of populations of Veterans treated in VA primary and specialty care. All of this work was further enhanced and facilitated by the Department s major initiative to Improve Veterans Mental Health (IVMH) as outlined in VA s FY Strategic Plan Refresh. VA s commitment to IVMH was tracked through the Major Initiative monthly reporting process during 2011 and 2012, and through the routine reporting processes in MHS beginning in OMHO is the operational partner to MHS, with particular responsibility to work directly with the VISNs and medical facilities to monitor and support full implementation of policies defining required mental health services in VA. OMHO is divided into three components: clinical care, evaluation, and technical assistance. Clinical care components are covered in some aspects within this section and include direct oversight of the Therapeutic and Supported Employment Services, the National Clozapine Center, and the Veterans Crisis Line. Two core responsibilities for OMHO include responsibility for the ongoing monitoring of mental health programs and services throughout VA (evaluation), and working with VISNs and facilities to ensure that relevant policy requirements are met and that unnecessary variability between programs is minimized (technical assistance). These two components often overlap and are carefully coordinated within the office. For example, the Technical Assistance component helps to monitor programs through site visits, and the Program Evaluation component provides technical assistance to help VISNs 2016 Congressional Submission VHA-73

76 and facilities respond to analytic findings. These two components are described in greater detail later in this section. The guiding principles/goals of VA mental health services are: Veteran-centric care A recovery/rehabilitation orientation to health care Evidence-based practices in the delivery of care Maximizing access to care across clinical sites of care Decrease stigma associated with mental health treatment Improve the health of Veterans through the PACT Increase use of technology to facilitate care Expand partnerships with other government agencies and communities These concepts are consistent with VA s Core Values: Integrity, Commitment, Advocacy, Respect and Excellence ( I CARE ) and demonstrated in the implementation of the Uniform Mental Health Services in VA Medical Centers and Clinics handbook. The primary actions in the transformation of mental health services designed to meet the goals listed above include: Enhancing the overall capacity of mental health services in VA medical centers and clinics with improvements in both access to services and the continuity of care. Improving the delivery of mental health care by enhancing services for Veterans at community-based outpatient clinics and those living in rural areas. Integrating mental health with primary care and other medical care services. Focusing specialty mental health care and inpatient mental health care on rehabilitation- and recovery-oriented services. Implementing evidence-based treatments with a focus on specific, evidence-based psychotherapy and psychopharmacology. Expanding treatment opportunities for homeless Veterans. Addressing the mental health needs of returning Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans. Preventing suicide. Implementation of the MHSP began the process of transformation, which was codified with the publication of the UMHSH. This document defines requirements for those mental health services that must be available to all Veterans and those that are required to be available in VA medical centers, very large, large, mid-sized, and small community-based outpatient clinics (CBOCs). VA is now well along in implementation of the Handbook. VHA-74 Medical Services

77 As of September 2014, VA medical centers have implemented percent of the Handbook requirements. VA continues to work closely with the Department of Defense (DoD) and the Department of Health and Human Services (HHS) to implement the President s Executive Order (E.O.) 13625, Improve Access to Mental Health Services for Veterans, Service Members, and Military Families, signed on August 31, The executive order reaffirmed the President s commitment to preventing suicide, increasing access to mental health services, and supporting innovative research on relevant mental health conditions. Executive Order strengthens suicide prevention efforts, supports recovery-oriented mental health services through peer counseling, and supports VA in using a variety of recruitment strategies to assist in hiring qualified mental health personnel. In addition, VA is partnering with DoD and HHS to carry out the 2014 Cross Agency Priority Goal (CAP Goal) on Servicemember and Veteran mental health, and 19 new Executive Actions announced by the President in August The CAP Goal focuses on improving access and reducing barriers to mental health care and on supporting innovative research on posttraumatic stress disorder and suicide prevention. The new Executive Actions include activities that will: (1) improving Servicemembers transition from DoD to VA and civilian health care providers; (2) improving access and quality of mental health care at DoD and VA; (3) improving treatments for mental health conditions; (4) raising awareness about mental health and encouraging individuals to seek help; (5) improving patient safety and suicide prevention; and (6) Strengthening community resources for Servicemembers, Veterans and their families. As of June 30, 2014, 4,308 mental health professionals and administrative support have been hired and are providing services to Veterans since the start of VA s Mental Health Hiring Initiative in April Of these, 1,669 mental health providers have been hired specifically as part of the initiative to add at least 1,600 clinical mental health professionals by June 30, In addition, a comprehensive recruitment and hiring plan has been completed that resulted in over 800 peer specialists hired and trained in advance of the executive order s December 31, 2013, deadline, resulting in a total workforce by the end of the first quarter of 2015 of 964 peer staff. These new mental health team members are deployed at every VA medical center and very large CBOC and provide peer support services in a variety of outpatient mental health programs and on inpatient mental health units. VHA has developed and implemented an aggressive recruiting and marketing effort to fill vacancies in mental health care occupations. This effort includes the following actions: working directly with mental health provider associations and training programs, conducting numerous media advertising efforts, developing a professional recruitment contract, and using incentives such as pay flexibilities and loan repayment to promote hiring of mental health professionals. Additionally, VA partners with the National Rural Recruitment and Retention Network for outreach to difficult-to-recruit areas and is partnering with HHS to collaborate on pilots that increase access to underserved areas Congressional Submission VHA-75

78 More specific information is provided on the following pages about a number of VHA s key programs in mental health. The first section below describes programs that are based in specific clinical settings, the second focuses on the needs of specific Veteran patient sub-populations, and the third section provides information on programs that cut across clinical settings and populations to enhance the health and mental health of all Veterans: Mental Health Care Provided in Specific Clinical Settings Mental Health Integrated in Patient Alignment Care Teams (PACTs): The UMHSH requires that integrated mental health services operate in PACTs in primary care clinics in VA medical centers and large CBOCs. Integrated mental health services utilize evidencebased practices that blend together both co-located collaborative care and care management components. The co-located collaborative care component involves one or more mental health professionals who are integral members of the primary care team, providing assessment and psychosocial treatment as needed for a variety of mental health problems, including depression, PTSD, problem drinking, anxiety, and other mental disorders. The care management component is based on the Behavioral Health Laboratory, the Translating Initiatives for Depression into Effective Solutions (TIDES) program, or other evidence-based strategies; it includes monitoring adherence to treatment, ongoing evaluations of treatment outcomes and medication side effects, decision support, patient education and activation, and assistance in referral to specialty mental health services when needed. Integrated mental health services are core components of the PACT model, alongside Health Behavior Coordinators to support Health Promotion/Disease Prevention activities. General Mental Health Services: VA supports the availability of general outpatient mental health services for the broad range of conditions Veterans may experience (such as depression, anxiety, PTSD, psychosis, and other disorders). General mental health outpatient services are available on-site in every medical center and all CBOCs with greater than 1,500 unique Veterans. Smaller CBOCs must develop strategies to ensure such services can be delivered to all eligible Veterans in their patient case load who need such care. VA Telemental Health services are available to supplement services provided by the CBOC staff. For those Veterans whose mental health problems cannot be adequately managed in primary care clinics and general outpatient mental health clinics, an array of specialized programs are available, as detailed below. Intensive, Recovery-Oriented Programs: Day Treatment and Day Hospital programs, which typically provided few rehabilitative services, have been replaced by recoveryoriented Psychosocial Rehabilitation and Recovery Centers (PRRC), which provide individual and group treatments designed to help Veterans learn the life skills, coping skills, and interpersonal skills required for meaningful community integration. Additionally, VA facilities with more than 1,500 Veterans on the National Psychosis Registry must develop a PRRC to meet the needs of these Veterans. As of the end of December 2014, there were 102 VA Central Office-funded, formally designated PRRCs, and others are under development. PRRCs must be accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). Currently, 93 PRRCs are CARFaccredited, all of which received full three-year accreditation. Program evaluation efforts VHA-76 Medical Services

79 in collaboration with the Northeast Program Evaluation Center (NEPEC) have commenced. With the expansion of peer support positions nationwide in 2013 and 2014, in accordance with E.O , the VA Mental Health program requires the use of certified peer specialists in the provision of treatment services. Veterans who are currently confronting a serious mental illness may be more willing to seek treatment and to share their experiences when they share a common bond of duty, honor, and service with the provider. Peers can be found in a wide variety of mental health programs, including inpatient mental health units, PRRCs, Mental Health Residential Rehabilitation Treatment Programs (MH RRTPs), and substance use disorder programs. With at least two certified Peer Specialists at each medical center and at each very large CBOC, this hiring initiative will not only improve existing services to Veterans but will also be a positive employment opportunity for Veterans who have mental health conditions to become successfully employed in meaningful and well-paying jobs. Many newly hired peer support staff are began in apprentice roles and attended certification training paid for by VHA under a contract with the Depression and Bipolar Support Alliance (DBSA). In 2015, peer support will be expanding into Primary Care through the development of 25 pilot sites authorized by an August 2014 Executive Action. Mental Health Intensive Case Management (MHICM) and Rural Access Network for Growth Enhancement (RANGE): MHICM and RANGE programs have been established to provide treatment to Veterans who have a diagnosis of a serious mental illness and need intensive support to avoid or decrease utilization of inpatient mental health services and to support an effective community-based life for these Veterans. These programs are based on the successful, evidence-based Assertive Community Treatment programs. Increasing the incorporation of psychosocial rehabilitation and recovery-oriented values and practices on these teams is a major priority in the coming year. MHICM teams primarily serve urban and suburban Veterans in larger market areas, and RANGE serves Veterans in rural and small market areas. There are 112 MHICM teams serving over 8,000 Veterans with serious mental illness. A newer program, RANGE has expanded MHICM level care to rural areas and areas where the population density has been too sparse to be served by conventional MHICM programs. There are now 37 RANGE programs serving over 900 Veterans. Inpatient Care: Inpatient mental health services are available for Veterans who need this level of care for safety, such as in the case of suicidal or homicidal patients, or stabilization for patients with acute episodes of psychosis or other severe conditions. The Inpatient Mental Health Handbook ( ) was published at the end of 2013, and was designed to fully incorporate recovery-oriented principles and practices into this setting and level of care. Facilities are developing recovery-oriented programming into their inpatient care programs to facilitate seamless programming as patients move through levels of care. This initiative is part of ongoing efforts to improve the care provided in the inpatient mental health setting; reduce lengths of stay, particularly for longer-term hospitalizations; reduce admissions and readmissions; and improve patient engagement in outpatient care. A continuum of care upon discharge is offered to include transition from 2016 Congressional Submission VHA-77

80 inpatient to residential care, MHICM, general or specialty ambulatory services, and other care modalities as appropriate to support safety, stabilization, and recovery. Additionally, facilities are being encouraged to incorporate design elements within their inpatient units to create warm, healing, and safe environments of care that promote patient and staff engagement and interaction. In 2014, VA provided inpatient mental health care to 92,876 patients, with an average daily census (ADC) of 2,634 Veterans. Mental Health Residential Rehabilitation Treatment Programs (MH RRTP): The mission of MH RRTP is to provide state-of-the-art, high-quality 24-hours-per-day, 7 days-perweek (24/7) structured and supervised residential rehabilitation and treatment services for Veterans with complex mental health and substance use disorder treatment needs as well as co-occurring medical conditions and other psychosocial needs including homelessness. MH RRTP identifies and addresses goals of rehabilitation, recovery, health maintenance, improved quality of life, and community integration while providing specific treatment and services for mental health and substance use disorders and homelessness. Currently, VHA operates 245 MH RRTPs at 106 VA medical center facilities with a total of 8,252 operational beds located across all 21 VISNs. This includes programs providing specialized treatment for PTSD (41 programs), substance use disorders (63 programs), and for Veterans who are homeless (48 programs). As an organization, VHA is working diligently to provide a consistently high level of residential rehabilitation and treatment for all Veterans, including those classified as special populations, by continuously aiming to improve and enhance services. As part of this continuous effort, in 2007 the National Leadership Board-Health Systems Committee charged MHS with the task of reviewing the current status of care delivery in MH RRTP in order to improve and enhance services to Veterans. Subsequently, MHS developed a MH RRTP Transformation Plan, which included a full review of all MH RRTPs and the development of a unified VHA MH RRTP Handbook. The Handbook, VHA Handbook , Mental Health Residential Rehabilitation Treatment Programs, established the policies, procedures and reporting requirements for the MH RRTP bed level of care; the current edition was published December 22, In addition, all MH RRTPs are directed to achieve and maintain CARF-accreditation. Population-Specific Approaches to Care Specialized PTSD: PTSD is a mental disorder that can occur following potentially lifethreatening trauma, including combat or Military Sexual Trauma (MST). Symptoms can include reliving the experience through nightmares and flashbacks; increased arousal and difficulty sleeping; and feeling numb, detached, or estranged. These symptoms can be severe and persistent enough to impair daily life, with difficulties that include marital problems, divorce, difficulties in parenting, and occupational instability. PTSD frequently occurs in conjunction with related problems such as depression, substance use disorder, problems with memory and cognition, and other physical and mental health challenges. Although it can be an acute condition, it is often episodic, recurrent, or chronic. Of those who have sought VA health care, slightly more than half of returning OEF/OIF/OND Veterans with a mental health condition have been diagnosed with PTSD, either by itself or in association with another problem. PTSD represents the most VHA-78 Medical Services

81 common, but by no means the only, mental health condition among returning OEF/OIF/OND Veterans. To address the needs of returning Veterans, VA has established post deployment services in most medical centers that provide mental health assessment and treatment services as well as other components of care. Serving Returning Veterans Mental Health (SeRV-MH) Teams are specifically designed to meet the unique needs of returning combat Veterans and work in collaboration with Primary Care Post Deployment Health Clinics to provide care in a setting that minimizes the potential stigma that may be associated with treatment in an identified mental health clinic. To provide a continuum of care to match the needs of Veterans with PTSD, VA maintains an array of treatment sites and services to help Veterans gain mastery over their PTSD symptoms and to improve their social and occupational functioning. VA operates specialized programs for the treatment of PTSD in each of its medical centers. These programs provide a continuum of care, from outpatient PTSD Clinical Teams and specialists through specialized inpatient units, brief-treatment units, and residential rehabilitation treatment programs around the country. Every VA medical center possesses outpatient PTSD specialty capability and Addictions Specialists are associated with these PTSD services. In accordance with the Uniform Mental Health Services in VA Medical Centers and Clinics handbook, PTSD services are also provided in CBOCs. VA s programs are designed to deliver evidence-based treatments including specific forms of behavioral and cognitive-behavioral psychotherapy and pharmacotherapy. For those who experience recurring or persistent symptoms in spite of evidence-based therapies, VA offers a range of recovery-oriented services that focus on improving day-to-day functioning. VA is addressing the need for concurrent and integrated treatment for disorders that commonly co-occur with PTSD, such as substance use disorders and traumatic brain injury. VA consensus conferences based on thorough literature reviews support the efficacy of concurrent treatment of PTSD and these co-occurring disorders, following the guidance of the VA/DoD Clinical Practice Guideline. VA also supports research on new treatments including Complementary and Alternative Medicine approaches and innovative strategies for delivering care. Substance Use Disorders (SUD): Misuse of substances is associated with a variety of adverse effects across the various dimensions of life functioning, including physical health and mental health along with occupational and social functioning. Despite their potential for causing grave harm to individuals with the condition and those near them, substance use disorders are generally treatable with evidence-based psychosocial and pharmacological interventions. Within the Veteran population, unhealthy drinking and other forms of substance misuse occur in forms that vary in frequency and severity. The most common and uncomplicated cases are best identified and treated in primary care and other general medical settings through programs that include screening, brief interventions, collaborative care within those settings and referral to specialty programs as needed. When these problems occur in the presence of other mental health conditions, they can be treated in various mental health clinic settings that provide integrated care for the co-occurring conditions. In recognition of this principle, VA has incorporated substance use disorder treatment 2016 Congressional Submission VHA-79

82 specialists into the PTSD treatment teams in each medical center to facilitate integrated care for both disorders. More severe problems with substance misuse are typically treated in residential or outpatient specialty care programs. Services in the programs vary from intensive residential care or multiple sessions of outpatient treatment several times per week, to less frequent ambulatory care visits. Monitoring response to treatment and sustaining patient improvement following initial stabilization are important components of the continuum of care. Treatment for alcohol and other substance use disorders recognizes the principle that these are often chronic or recurring conditions. For some Veterans, treatment begins with medically-supervised detoxification provided in ambulatory or inpatient settings. However, for care to be effective over the long term, detoxification and initial stabilization must be followed by continuing care using evidence-based psychosocial and/or pharmacological treatments. Evidence-based medication-assisted treatment for opioid dependence, including buprenorphine, has expanded to 167 locations that served at least 10 patients and an additional 139 CBOCs or other locations that had at least some active buprenorphine treatment. Other components of effective treatment for alcohol and other substance use disorders include rehabilitative services focusing on day-to-day functioning and maintenance treatments focusing on preventing relapse. Relapse prevention involves ongoing monitoring for any substance use or emerging relapse risk factors using standardized brief assessments that are available as part of the electronic health record and being implemented in substance use disorder specialty care programs. Services for Veterans with Serious Mental Illness (SMI): VA Mental Health is committed to transforming mental health services to follow a recovery orientation, providing services that will help Veterans with serious mental illness fulfill their personal goals and live meaningful lives in a community of their choice. To that end, Local Recovery Coordinators (LRC) have been deployed at VA facilities throughout the country. They have been instrumental in facilitating the transition of mental health services to a recovery orientation through education of staff and Veterans, the development of peer support programs and through involvement in facility- and VISN-level committees and task forces. LRCs have broadened their reach to include inpatient settings, in order to promote the expansion of recovery-oriented services along the entire continuum of care. In addition, LRCs are the Points of Contact (POC) for a new program designed to re-engage Veterans with serious mental illness in treatment (described below). The transformation to a recovery orientation cannot be accomplished without the involvement of Veterans, their family members, and stakeholder groups. VA Mental Health encourages the development of Veterans Mental Health Councils, operated independently from VHA, to provide input into mental health programming from the Veterans perspective and maintain contact with outside mental health and Veteran constituency groups (e.g., National Alliance on Mental Illness [NAMI], Depression and Bipolar Support Alliance [DBSA], Veterans Service Organizations [VSOs], professional VHA-80 Medical Services

83 organizations) to both solicit and provide information about mental health services for Veterans. Work is a fundamental component of recovery; therefore, VA has significantly expanded its Compensated Work Therapy (CWT) programs. In particular, Supported Employment has been deployed throughout VA facilities and focuses on helping Veterans with serious mental illness find meaningful, competitive work. In addition, partnering with families is an essential component of VA mental health services. Consistent with a recovery philosophy, flexibility is a key principle when involving families in care. Services must be tailored to the Veteran s phase of illness, symptom level, self-sufficiency, family constellation, and preferences. When family services are a necessary part of the Veteran s treatment plan, VA offers a continuum of family services to meet varying needs including family education/training, consultation, and marriage and family counseling. National training programs in several evidence-based practices for marital and family counseling are available for clinicians. In support of Veterans with SMI, the UMHSH requires that clozapine be available to all eligible Veterans. Clozapine is the most efficacious medication available for the treatment of schizophrenia, and it is the only medication proven to reduce the suicidality of patients with schizophrenia. However, there is a one-to-two percent risk of clozapine-induced agranulocytosis that is fatal, if not treated. The FDA has mandated that all patients receiving clozapine enroll in a national clozapine registry to monitor Absolute Granulocyte Counts. The VA National Clozapine Coordinating Center (NCCC) fulfills this FDA mandate in a manner that is safe, provider- and patient-friendly, and cost effective. NCCC also serves as a nationally accessible medical consulting resource for all VA clozapine providers. Women s Mental Health: VHA offers a full continuum of mental health services to women Veterans, including general outpatient, specialty, and inpatient and residential mental health treatment options. Evidence suggests that women Veterans may differ from men in the prevalence and expression of certain mental health disorders, and responses to treatment. VA policy requires that mental health services be provided in a manner that recognizes that gender-specific issues can be important components of care. For example, all VHA facilities must ensure that outpatient and residential programs have environments that can accommodate and support women with safety, privacy, dignity, and respect. Some specialty care programs that target problems such as PTSD, substance use, depression, and homelessness, include women-only services (e.g., women-only groups). Many facilities provide this care through specialized women-only outpatient treatment teams. For those in need of more intense treatment, many facilities offer MH RRTPs and nationally there are women-only programs that specialize in women s care and MSTspecific treatment. Mental Health Services has developed targeted educational resources for VA providers who care for women Veterans: The Women s Mental Health monthly teleconference training series offers didactic seminars on key topics and best practices in the provision of women s mental health services. The Women s Mental Health SharePoint was launched 2016 Congressional Submission VHA-81

84 in 2014 to make up to-date information and treatment resources readily available to VA providers. Also in 2014, Women s Mental Health collaborated with the author of the therapy for women with emotional dysregulation and interpersonal problems to develop and implement an entirely web-based didactic and case conference workshop. Difficulties with emotion regulation and interpersonal relationships are common in cases of chronic and complicated forms of PTSD. Finally, in collaboration with Women s Health Services, a clinical training curriculum on reproductive mental health has been developed. An overview presentation of this curriculum and a clinical case presentation were disseminated to the field in 2014 through the Women s Mental Health teleconference training series. Mental Health Programs for Older Veterans: VHA has implemented several programs designed to promote mental health care access and treatment for older Veterans. These initiatives incorporate innovative and evidence-based mental health care practices, as well as person- and family-centered care approaches. This includes the integration of a fulltime mental health provider on every VA Home-Based Primary Care team, to best meet the mental health needs of homebound Veterans by providing services such as psychotherapy; behavioral interventions for problems such as sleep disturbance, chronic pain, and disability; and prevention-oriented services. VHA has also integrated mental health providers in VA Community Living Centers (CLCs) to provide a full range of assessment and treatment services, with specific focus on promoting the delivery of evidence-based psychosocial services to manage challenging behaviors associated with dementia and mental illness. VA has also completed a pilot initiative to implement Sustained Treatment and Rehabilitation (STAR)-VA, an adapted evidence-based psychosocial intervention for managing challenging behaviors associated with dementia in CLC residents. The evaluation results from the implementation of STAR-VA intervention at 17 CLCs indicate significant reductions in the frequency and severity of challenging dementia-related behaviors, depression, and anxiety symptoms. In light of these positive findings, VA has engaged in broader implementation of STAR-VA in 2014 to double the number of STAR-VA implementation sites. Finally, VA includes special training modules with adaptations and relevant examples for older Veterans in training developed for evidence-based psychotherapies, which have been shown to be very effective in older adults when such adaptations are included. Programs that Cut Across Settings and Populations Mental Health Outreach: VA Mental Health programs engage in numerous, widespread outreach efforts to improve access to care and to reduce the stigma associated with seeking mental health care, as documented in an October 2011 Government Accountability Office (GAO) report titled, VA Mental Health: Number of Veterans Receiving Care, Barriers Faced, and Efforts to Increase Access. These efforts are too numerous to list here, but they include some specific programs deserving special attention: two specific public messaging campaigns, a program to re-engage Veterans with SMI in treatment, and a college campus outreach initiative. The Veterans Crisis Line is a toll-free, confidential resource that connects Veterans in crisis and their families and friends with qualified, caring Department VHA-82 Medical Services

85 of Veterans Affairs (VA) responders. Veterans and their loved ones can call and Press 1, text to , or chat online at to receive free, confidential support 24 hours a day, 7 days a week, 365 days a year, even if they are not registered with VA or enrolled in VA health care. The online chat function and a new texting option reflect efforts to improve access to care for Veterans of all eras of service through alternative modes of communication. In 2014, VA developed and launched its yearly national public information campaign to help promote the Veterans Crisis Line. The campaign, entitled The Power of One, focuses on the idea that one small act (one conversation, one call, one person) can make a significant difference in a Veteran s life. The Suicide Prevention Coordinators also engage in significant outreach efforts within their local communities. Make the Connection is an award-winning, national mental health public awareness campaign that launched in November The goals of the campaign are to reduce the stigma that Veterans and their families associate with seeking mental health care, to educate Veterans and their families about signs and symptoms of mental health issues, to increase awareness of and trust in VA s advances in mental health services, and to promote a positive view of Veterans unique strengths to the American public. Make the Connection utilizes traditional media (radio and television), internet, and social media (e.g. Facebook and YouTube) to reach as many Veterans as possible. At the heart of the campaign is a comprehensive, interactive website ( where Veterans and their friends and families can confidentially and easily connect with information and services that are most relevant to their own experiences and needs. The website features extensive videos of dozens of Veterans who share their personal stories of facing life events, experiences, physical injuries or psychological symptoms and overcoming a wide variety of challenges. To reach as many Veterans as possible with the Veterans Crisis Line (Power of One) and Make the Connection public outreach campaigns, VA is coordinating with communities and partner groups nationwide, including community-based organizations, Veteran Service Organizations, and local health care providers, to let Veterans and their loved ones know that support is available whenever, if ever, they need it. A specific effort focused on increasing awareness of PTSD, About Face ( has also been developed by the National Center for PTSD and fully complements the messages and strategies of Make the Connection. The SMI Re-engagement Program is designed to re-engage in treatment Veterans with serious mental illness who at one time received care from VHA but who have been lost to follow-up care. Based on findings from a project by the Office of the Medical Inspector (OMI), this program utilizes the resources of the Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC) to identify such Veterans with SMI who have been lost to follow-up care. The OMI project documented that such Veterans are at a markedly increased risk of mortality unless reconnected with care. The lists of these Veterans are 2016 Congressional Submission VHA-83

86 disseminated to the Local Recovery Coordinators (LRC) at the facility where the Veteran was last seen, and the LRC attempts to locate the Veterans and re-engage them in treatment. This program was implemented nationally in 2012, with initial efforts targeting those Veterans most at risk for mortality. Subsequent efforts are focusing on re-engaging all Veterans with serious mental illness who have been lost to follow-up care since the end of the OMI project and will expand to identify such Veterans in as close to real time as possible. To date, over 500 Veterans have been successfully returned to care. The Veterans Integration to Academic Leadership (VITAL) Initiative is an outreach partnership between VA and community colleges, colleges, and universities. Veterans bring unique resources to these settings, as well as face a variety of challenges. The purpose of this initiative is to build resilience and leadership in Veterans on campus, facilitate adjustment to and success in academic life, and increase access to high quality health and mental health resources for those Veterans who need them. The goal of the VITAL initiative is to provide support for projects that increase access to Veteran-centric, results oriented, forward-looking services for Veterans on college and university campuses. Suicide Prevention: VA s suicide prevention activities are built upon the principle that prevention requires ready access to high-quality mental health care and other services. This requires outreach, educational, and assessment programs designed to help individuals seek care when needed, and programs designed to address the specific needs of those at high-risk for suicide. The suicide prevention program includes specific outreach activities and clinical programs for addressing high-risk and potentially high-risk patients, including the Veterans Crisis Line (discussed above) and Veterans Chat and Text service; Suicide Prevention Coordinators and their teams in each medical center and large community-based outpatient clinic; the VA National Suicide Prevention Office; the Center of Excellence for Suicide Prevention in Canandaigua, NY; the Mental Illness Research Education and Clinical Center in Denver, CO; the Serious Mental Illness Treatment Resource and Evaluation Center in Ann Arbor, MI; demonstration projects; and national public information campaigns. Enhanced care packages have been developed for those Veterans who have been identified as being high-risk for suicide. In addition, a wide range of tracking and reporting mechanisms have been established, including the joint VA/DoD Suicide Data Repository. Also, the VA/DoD Clinical Practice Guidelines on the Assessment and Management of Patients at Risk for Suicide have been disseminated throughout the VA system to help inform how to best manage Veterans who may be at high risk for suicidal behavior. Evidence-Based Psychotherapies (EBPs): VA is working intensively to make a broad array of EBPs for PTSD, depression, SMI, relationship distress, substance use, and behavioral health conditions (e.g., insomnia and pain) widely available to Veterans who can benefit from them. UMHSH requires that all facilities have the capacity to provide a variety of EBPs. VA is nationally implementing training to ensure an adequate workforce VHA-84 Medical Services

87 able to deliver the following EBPs with full competence: Cognitive Processing Therapy (CPT), Prolonged Exposure Therapy (PE) for PTSD, and Cognitive Behavioral Conjoint Therapy for PTSD; Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy, and Interpersonal Psychotherapy for depression; Behavioral Family Therapy (BFT) for serious psychiatric disorders, Social Skills Training for SMI; Integrative Behavioral Couples Therapy (IBCT) for relationship distress; CBT and Behavioral Couples Therapy for Substance Use, Motivational Enhancement Therapy, CBT, and Contingency Management for substance use disorders; Motivational Interviewing (MI) for promoting motivation and adherence; CBT for insomnia; and CBT for chronic pain. To promote the availability and effective implementation of these therapies, VA has established national competency-based staff training programs that have provided training to more than 7,500 VA staff in the delivery of one or more EBPs. Program evaluation components that have been incorporated into each of these programs show that the training in and implementation of these therapies have resulted in significant, positive outcomes for therapists and patients. Furthermore, VA has designated a Local EBP Coordinator at each medical center to promote local systems and administrative infrastructures to facilitate the implementation of these therapies, which typically require minute weekly sessions over the course of approximately weeks. The Local EBP Coordinator Program has been implemented throughout the system and has helped to increase the availability of evidence-based psychotherapies at the local level. For example, all facilities now provide CPT and PE for PTSD, whereas just five years ago, relatively few facilities had EBP for PTSD available. VA sees significant potential to extend the reach of these therapies, especially to Veterans residing in rural and frontier communities, by utilizing telehealth modalities (such as clinical video teleconferencing) so that providers and Veterans can meet synchronously across distances. In , VA placed more than 100 evidence-based PTSD psychotherapy providers at targeted sites to deliver CPT and PE telemental health services, where needed. In addition, to augment the delivery of these services provided by local staff, 3 regional pilot clinics have been established to enable further delivery of these services across VISN boundaries. The number of telehealth psychotherapy encounters to Veterans with PTSD has doubled since In 2015, VHA will continue to expand its efforts to implement EBPs and to evaluate the impact of the training in and delivery of these therapies. In addition, VHA will closely monitor the availability and delivery of these services throughout the system through specialized EBP documentation templates that will be nationally incorporated into VA s electronic health record system. Furthermore, VHA will implement mechanisms and resources for sustaining and expanding providers EBP skills. Military Sexual Trauma: VA defines MST in accordance with U.S. law as sexual assault or repeated, threatening sexual harassment experienced by a Veteran while on active duty, active duty for training, or inactive duty training. Among Veterans receiving VA health care, approximately one in four women and one in a hundred men report experiences of sexual trauma during their military service. A broad range of mental health diagnoses exists among Veteran users of VA health care services who screened positive for MST including PTSD and other anxiety disorders, depressive disorders, bipolar disorders, drug and alcohol disorders and schizophrenia and psychoses. MST survivors may also struggle 2016 Congressional Submission VHA-85

88 with chronic physical health problems, difficulties in relationships, and increased risk of unemployment or homelessness. VHA has policies and services in place to assist the recovery of Veterans who experienced MST. All Veterans seen in VHA must be screened for MST, and all health care for mental and physical health conditions related to MST is provided free of charge. Receipt of free MST-related services is entirely separate from the disability compensation process through VBA; service connection (VA disability compensation) is not required. Veterans may be able to receive this free MST-related care even if they are not eligible for other VA care. Every VHA facility provides outpatient care for conditions related to MST. For Veterans who need more intense treatment and support, there are also programs that offer specialized sexual trauma treatment in VA residential or inpatient settings. VHA has established an organizational structure that provides oversight of MST-related services at the facility, regional, and national level. Every facility must have a designated MST Coordinator who serves as the point of contact for MST-related issues, including staff education and training, monitoring of MST-related screening, referral, and treatment, and outreach to Veterans. Each VISN has an MST POC to monitor and ensure national and VISN-level policies related to MST are implemented within the VISN. At the national level, MHS created the MST Support Team to monitor screening and treatment related to MST, oversee and expand MST-related education and training, promote best practices in the field, and develop policy recommendations. To continue to improve VHA s MST-related services, a VHA Directive establishing a one-time mandatory training requirement on MST for all VHA mental health providers and primary care providers was issued in January This training requirement complements pre-existing and ongoing training opportunities provided by the MST Support Team, including webinar trainings on MST-related topics that are available to all interested VA staff, and an annual conference focused on MST-related clinical care and program development. VHA is also collaborating with VBA to develop new trainings and initiatives for VBA staff that rate MST disability claims and VHA staff involved in the Compensation & Pension exam process. Family Services: Substance Abuse and Mental Health Services Administration (SAMHSA), in HHS, has defined one of its mental health recovery principles as Recovery is supported through relationship and social networks." In accordance with this principle, partnering with families is an essential component of VA mental health services. Consistent with a recovery philosophy, flexibility is a key principle when involving families in care. Services must be tailored to the Veteran s phase of illness, symptom level, self-sufficiency, family constellation, and preferences. When family services are a necessary part of the Veteran s treatment plan, VA offers a continuum of family services to meet varying needs including family education/training, family consultation, and marriage and family counseling. National training programs in several evidence-based practices for marital and family counseling are available for clinicians. While some of these are specific to diagnosis (for example, Behavioral Couples Therapy for Substance Use) others are cross-diagnostic (for example, Integrative Behavioral VHA-86 Medical Services

89 Couples Therapy for relationship distress). Couples therapy trainings are augmented with instruction on supporting Veterans successful parenting, identifying and managing interpersonal violence, and working with same sex couples. Additionally an online Veteran parenting website ( is now available to help Veterans (re)connect with their children and provide strategies and tools for effective parenting. VA has collaborated with the National Alliance on Mental Illness (NAMI) through a Memorandum of Understanding (MOU) to offer the family peer-led Family-to-Family Education Program at VAs throughout the country. VA also has an active monthly training program for clinicians on family issues and interventions of particular relevance to Veterans and has developed a family services website as a resource for VA providers. Specialized Mental Health Centers of Excellence: Specialized Mental Health Centers of Excellence (MH CoEs), which include the National Center for PTSD (NCPTSD); 10 Mental Illness Research, Education and Clinical Centers (MIRECCs); three specialized Centers created to address the mental health needs of Veterans returning from the wars in Iraq and Afghanistan; and the Center for Integrated Healthcare are essential components of VA s response to meeting the mental health needs of Veterans. All of the MH CoEs have a singular mission: to improve the health and well-being of Veterans through world class, cutting-edge science, education and support of clinical care. Because mental illness is not a single disorder and includes multiple complex conditions that differ considerably in terms of symptoms, causes, prevalence, course, prognosis, and treatment, each Center focuses on a specific mental illness or illnesses across the spectrum of Veteran mental health. The centers are designed to be incubators for new investigators, new clinicians, new methods of treatment, new ways of educating staff and patients, and new ways of delivering care. The MH CoEs not only leverage regional and local VA expertise but also pull in clinical, research and educational expertise from academic affiliates and across other centers, making it possible for a single site to conduct research and educational activities across the spectrum of basic and clinical domains that is necessary to fully address a given disorder. Research by the MH CoEs has had a profound effect on enhancing the understanding and treatment of mental illness in Veterans. The concentrated expertise at each center informs and strengthens clinical care, research, and education tools that are essential to improving Veteran mental health. Because of its particular prominence, additional information specifically on the NCPTSD follows. Program Evaluation Centers: OMHO includes three Program Evaluation Centers that serve its needs as well as those of MHS: the NEPEC in West Haven, CT; Program Evaluation Resource Center (PERC) in Palo Alto, CA; and the Serious Mental Illness Treatment Resource and Education Center (SMITREC) in Ann Arbor, MI. Each of the Centers represents a source of expertise in specific aspects of mental health. Briefly, NEPEC has expertise in areas such as inpatient and residential care, mental health rehabilitation, mental health services for homeless Veterans, and ambulatory care in mental health specialty services. PERC has expertise in substance use disorders, including treatment provided in inpatient, residential, intensive outpatient, and general ambulatory settings. SMITREC has expertise in psychosis and depression, suicide prevention, services for the elderly, and the integration of mental health with primary care Congressional Submission VHA-87

90 The three Centers collaborated extensively throughout 2011 to develop a Mental Health Dashboard and Report Card, which was completed at the end of 2011, and they continue to work together to update and maintain it as a part of a comprehensive Mental Health Information System. The dashboard provides an overview while the Report Card provides greater detail about the performance of each VISN and medical center in three domains: the Department s major transformation or T21 initiatives, overall implementation of the UMHSH, and the implementation of Handbook requirements in specific program areas. The Program Evaluation Centers are currently working with the Veterans Services Support Center (VSSC) to disseminate this tool. Other components of the Mental Health Information System maintained by the Program Evaluation Centers include a Basic Data Set for Mental Health Programs and Population (under development), designed to provide patient-level data to support program planning in both central office and the field; registries of mental health patient (sub)/populations; directories of specialized mental health programs; recurring reports on specific programs; and periodic issue briefs. Through these activities and products, contributions to technical assistance, and their availability for consultation and the conduct of analyses whenever requested, the Program Evaluation Centers are key resources for VA s mental health programs, both in VA Central Office and the field. Informatics: The Mental Health Informatics group within VHA Mental Health Services works closely with the Office of Information and Technology (OI&T), VHA Office of Informatics and Analytics (OIA), and other VHA program offices to design and implement technology tools that support the transformation of mental health services. For example, this includes the development of a variety of new products and resources for the My HealtheVet website, such as the My Recovery Plan component, and a number of selfassessment tools information resources. Particular emphasis is placed on providing tools for clinicians to support the delivery of evidence-based services; development of patient facing tools to support patient-centered care and preventative interventions; and on improving the monitoring of patient outcomes to support continuous improvement in care delivery. Technical Assistance: OMHO also provides technical assistance to facilities and VISNs regarding the delivery of quality mental health care to Veterans. Its role is to assist the VHA system with strategic action planning and implementation of policies to improve access to clinical services, integrate and execute new/revised clinical services with other components of the health care organization, and monitor the integrity, quality and value of mental health services. Technical assistance is provided as a collaborative consultative service when facilities or VISNs request or require assistance in specific areas identified as being in need of improvement via the Mental Health Dashboard. OMHO staff review the Dashboard monthly to monitor performance related to the UMHSH domain areas. The OMHO technical assistance team members are professionally trained consultants and facilitators who work with internal and external experts in mental health services across the spectrum. Examples of technical assistance include data analysis and interpretation, consultation, mentoring, connection with Subject Matter Experts (SMEs) and/or relevant program VHA-88 Medical Services

91 materials, and training. Technical Assistance can be accomplished through telephone calls, video-teleconference, and/or site visits. OMHO provides technical assistance in conjunction with the OMHO Program Evaluation Centers, MHS, National PC-MHI Office, National PC-MHI Program Evaluation Office, Office of Geriatric and Extended Care, and other PCS offices. National Center for Post-Traumatic Stress Disorder (Amounts included in total Mental Health) to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Obligations... $17 $18 $18 $19 $19 $19 $1 $0 National Center for Post-Traumatic Stress Disorder (PTSD) is dedicated to the advancement of the clinical care and social welfare of America s Veterans through research, education, and training in the science, diagnosis, and treatment of PTSD and stress-related disorders. The Center was created in response to a Congressional mandate (P.L , 98 Stat (1984)) to address the needs of Veterans with military-related posttraumatic stress disorder. The mandate called for a center of excellence that would set the agenda for research and education on PTSD without direct responsibility for patient care. The Center also was mandated to serve as a resource center for information about PTSD research and education for VA and other Federal and non-federal organizations. The Center currently consists of seven divisions located at VA facilities, with headquarters in White River Junction, VT. Other divisions are located in Boston, MA; West Haven, CT; Palo Alto, CA; and Honolulu, HI. The National Center for PTSD is an integral component of Mental Health Services within Patient Care Services in VHA. Research: The National Center for PTSD helps improve patient care through its strong commitment to research into the prevention, causes, assessment, and treatment of traumatic stress disorders. Each of the Center's divisions has its own area of specialization, giving researchers access to different types of expertise across many geographical areas of the country. Besides its own staff, the Center has built strong collaborative relationships with institutions and agencies from VA, other branches of government, the health care community, and academia, giving researchers a vast array of affiliates and partners for research activities. These activities are enriched by constant contact with clinicians who are directly involved in patient care, giving the research activities a uniquely real-world perspective. As a result, the Center specializes in translating basic findings into clinically relevant techniques and studying how best to implement evidence-based practices into care. A leader in basic neurobiological research on PTSD, the Center recently received funding to create the nation s first brain tissue repository, or brain bank, dedicated to researching the physical impact of stress, trauma and PTSD on brain tissue. The National Center, in partnership with the STRONG STAR Consortium at the University of Texas Health Science Center at San Antonio, was awarded $45 million for the Consortium to Alleviate PTSD (CAP) to advance PTSD care for service members and Veterans. CAP will provide an array of cutting-edge clinical treatment 2016 Congressional Submission VHA-89

92 trials and biological studies, including efforts to learn more about the biology/physiology of PTSD development and treatment response to inform diagnosis, prediction of disease outcome, and new or improved treatment methods. The Center leads the field in the development of state-of-the art assessment measures for PTSD. These include the Clinician Administered PTSD Scale (CAPS; the gold standard for assessing PTSD), the Primary Care-PTSD screen (used in VA and DoD to screen for PTSD), and the PTSD Checklist (the most widely-used measure of PTSD symptom severity). The Center recently updated these instruments to align with newly developed PTSD diagnostic criteria (DSM-5). Center research has also led to innovations in PTSD treatment, including the VA national rollouts of Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), validation of telehealth delivered care, and the 2010 revision of the VA/DoD PTSD Practice Guideline for PTSD. The Center is currently leading a $10 million groundbreaking study that will compare PE and CPT. The study, which will involve 900 Veterans at 17 sites across the country will help VA leadership, clinicians, and Veterans in making informed choices about the delivery of PTSD care in VA, and will also be broadly relevant to the scientific and clinical communities outside VA. Education and Training: The National Center for PTSD brings current research and clinical knowledge from the field to Veterans, their families, the general public, VA and community clinicians, military leaders, and others. Information is efficiently disseminated through the Center s award-winning website ( publications, online resources, as well as nationwide trainings. Examples of specific initiatives include: The VA PTSD Mentoring Program, established in 2008, provides support to PTSD Program Directors and PTSD Specialists via a network of PTSD Mentors who help to disseminate best administrative and clinical practices to improve the delivery of evidence based PTSD treatment in VA. The VA PTSD Consultation Program was established in 2011 to provide expert resources and consultation about the assessment and treatment of Veterans with PTSD to providers who are not a part of VA PTSD specialty care. The Consultation Program also hosts a monthly PTSD clinical lecture series available to any VA staff. The PTSD Resource Center is the world's largest collection of literature on traumatic stress, with more than 3,000 book volumes and 41,000 journal articles. The Resource Center s Published International Literature on Traumatic Stress (PILOTS) Database now includes 53,000 records with materials in 30 languages. Continuing online education for providers includes PTSD 101, a web-based curriculum of expert lectures on timely and relevant issues related to PTSD and trauma in an on-demand format. Online education offerings now also include longer advanced courses (e.g., Skills Training in Affective and Interpersonal Regulation, anger management). The Center also produced the Iraq War Clinician Guide to help providers treat returning Service members, and, with the National Child Traumatic Stress Network, developed Psychological First Aid, to help with VHA-90 Medical Services

93 mental health needs in the immediate aftermath of a disaster. The Clinician s Trauma Update-Online, an electronic newsletter published 6 times a year, provides summaries of articles from professional journals that have relevance for clinicians, with emphasis on articles on the assessment and treatment of Veterans. A second regular publication, the PTSD Research Quarterly, provides expert reviews of the scientific literature on specific topics and is intended primarily for researchers and scientists. Online educational courses for Veterans, their families, and the public, include Understanding PTSD, Understanding PTSD Treatment, and the Returning from the War Zone Guides. AboutFace, an online video collection of Veterans talking about living with PTSD and how getting into treatment turned their lives around, also includes a family member section and videos of clinicians discussing PTSD treatment. PTSD Coach, VA s first mobile phone application, was developed by the Center with DoD s National Center for Telehealth and Technology and released in The app offers users self-assessment, coping skills, and resources. Other apps include PTSD Family Coach and apps that support the delivery of PE, CPT, and CBT for Insomnia. Mobile phone applications provide a way to assist individuals wherever they are, whenever they need support. PTSD Coach Online, released in 2013, extends the reach of the PTSD Coach app to desktop users and consists of a suite of 17 tools designed to help people cope with sleep problems, trauma reminders, anxiety and other symptoms that can develop after trauma. In 2014, the Center developed a series of six Whiteboards, short animated videos that combine narration with hand-drawn images, to encourage recognition of PTSD and increase engagement in and provision of evidence-based treatment. The Center utilizes diverse web-based communication strategies to disseminate information and its resources. One vehicle is the PTSD Monthly Update, an electronic newsletter sent to over 133,000 subscribers highlighting Center fact web pages and products on a particular topic. The Center also maintains a strong social media presence, with over 18,000 Twitter followers and a Facebook page with over 83,000 fans. Prosthetics Care: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Prosthetics: Medical Services... $2,449 $2,577 $2,645 $2,749 $2,842 $3,039 $197 $197 Medical Care Total... $2,449 $2,577 $2,645 $2,749 $2,842 $3,039 $197 $197 Prosthetic and Sensory Aids Service (PSAS) is an integrated delivery system designed to provide medically prescribed prosthetic and sensory aids, medical devices, assistive aids, repairs and services to eligible Veterans to maximize their independence and enhance their quality of life. Although the term prosthetic device may suggest images of artificial limbs, it actually refers to any device that supports or replaces loss of a body part or function and includes a full range of equipment and services for Veterans. This includes but is not limited to, artificial limbs, hearing aids, speech communication aids, home oxygen, orthopedic footwear, orthopedic braces and supports, cosmetic restorations, breast 2016 Congressional Submission VHA-91

94 prostheses, wigs; items that improve accessibility such as ramps and vehicle modifications, wheelchairs and mobility aids; and devices surgically placed in the Veteran, such as stents, joint replacements, and pacemakers. These items are provided from prescription through procurement, delivery, training, replacement, and when necessary, repair Accomplishments VHA PSAS provided 17.5 million medical items and services to over three million Veterans. Partnered with Veterans Benefits Administration, General Counsel, and VHA Regulatory and Administrative Affairs to publish final Home Improvement and Structural Alterations regulations. Collaborated with VHA Office of Enrollment and Forecasting to build model for projecting/right-sizing resources for the procurement of Glasses/Contacts, Hearing Aids, Surgical Implants, Cardiothoracic Surgical Implants, Medical Equipment & Supplies, Home Telehealth Devices, Oxygen, Respiratory Equipment, Wheelchairs, Orthotics, Prosthetics Artificial Limbs, Blind Aids and VA Specialized Products and Services. Finalized Access regulations for Service Dogs. First time key VHA directives were developed and published that clarify the authority and responsibilities for administering the annual $2.5 billion Prosthetic and Sensory Aids Specific Purpose Budget, and define VA policy for procurement of medical devices above the micro-purchase level ($3,000). The Procurement Acquisition Lead Time Tool was developed and implemented to provide real-time tracking of critical patient specific prosthetic devices from prescription to acquisition, resulting in significant overall reduction in procurement times. Successful development of a PSAS Dashboard displaying Key Performance Indicators in the areas of: Timeliness, Policy/Operational Audits, Staffing Levels, Contract Utilization, Purchasing Agent Efficiencies and Inventory Management. Future Goals ( ) Support the Strategic Analytics for Improvement and Learning (SAIL) Value model by developing a measure under the Access domain related to the timeliness of providing prosthetic devices below the micro-purchase level. Increase the percentage of prosthetic procurements below the micro-purchase level completed in five days or less by 1 percent in 2015 based on EOFY 2014 actuals. Support VA implementation of the Choice Act and Purchased Community Care Contract with regard to provision of prosthetic and sensory aid items and services. Develop a PSAS Dashboard displaying Key Performance Indicators over next 2 years ( ), and in 2015 deploy and track Key Performance Indicators for this project. Continue to refine and develop processes, policies and guidance that produce more accurate analyses and modeling to project resource requirements, and provide stringent fiscal accountability for the PSAS budget. VHA-92 Medical Services

95 Continue to stay abreast of emerging technologies and prosthetic devices, and incorporate into VA provision of devices and services in support of clinical plans that enable Veterans to function independently. Dental Care: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Dental Care: Medical Services... $678 $701 $758 $740 $820 $878 $62 $58 Medical Care Total... $888 $922 $992 $973 $1,073 $1,149 $81 $76 The mission of VA Dentistry is to provide improved oral health outcomes for eligible Veterans. Eligibility for dental care is defined by statute and is provided in accordance with the provisions of existing law and VA regulations. The scope of care is determined by the Veteran s dental classification. VA Dentistry strives to be the benchmark of excellence and value in oral health care by providing exemplary services that are both patient centered and evidence based Accomplishments Provided dental care for over 450,000 Veterans, most of whom are now eligible for lifelong comprehensive dental care due to their service-connected medical conditions. Over 92 percent of comprehensive care dental patients have been teamed with a primary dental care provider to oversee and coordinate their care needs. Improved Veteran access to their dental care teams by implementing Secure Messaging in 97 percent of VAMC Dental Clinics. One hundred twenty one VHA facilities coordinated dental care services for 19,201 homeless Veterans, the highest number of Veterans served since the inception of the homeless dental care initiative. Studies show those receiving dental care had a 30 percent increase in completing their homeless rehabilitation program, 15 percent increase in obtaining permanent housing and 14 percent increase in employment/stable financial status. Improved dental patient satisfaction scores were achieved as a result of action plans developed using attributable effects from the ongoing Dental Patient Satisfaction Survey. Future Goals ( ) Develop a dental care delivery model that defines the right physical plant infrastructure to efficiently meet the forecasted demand for dental care utilizing a contemporary dental clinic design guide and data driven space planning criteria. Identify and deploy TeleDentistry sites with the execution of training and procurement of appropriate equipment through Improve the Veteran s access to care, together with better health outcomes, by maintaining national dental quality indicators that focus on population health management metrics promoting access to prevention and improved oral health. Manage the complexities of dental laboratory technology to ensure provision of prostheses in a timely, technically accurate manner to facilitate efficient restoration of Veteran oral health and function Congressional Submission VHA-93

96 Negotiate a new contract to continue to leverage results of the Dental Patient Satisfaction Survey to optimize dental service processes based on the needs and preferences of Veterans. Ensure a strategically skilled dental workforce by delivering educational opportunities that promote state of the art, evidence-based dental care. Veterans Choice Program Cost-Shift: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Veterans Choice Program Cost-Shift: Medical Services... ($452) ($733) N/A ($281) Medical Care Total... ($452) ($733) N/A ($281) The Veterans Choice Program (VCP) may provide a measure of short-term relief from the pressure of escalating health care requirements as some current patients in the VA system elect to receive their care through the program. The 2016 and 2017 requests for Medical Services appropriations assume that some Veterans who would otherwise receive care in the VA health care system will now receive that care through the VCP, instead. This introduces a shift of health care costs from the discretionary program to the new mandatory source of funding in the Veterans Choice Fund, thereby reducing the discretionary appropriations request by the same amount. The assumed cost shift is $452 million in 2016 and $733 million in These estimates are highly dependent on the number of Veterans who choose to participate in the VCP; to the extent that participation is higher or lower than anticipated, VA will realize more or less of a cost shift. The cost shift does not impact VA s planned use of the $5 billion in mandatory funding that was appropriated under Section 801 of the Veterans Choice Act. VA anticipates that its experience with the Veterans Choice Program in 2015 will be used to inform the 2017 budget process and the final 2017 funding requirements Long-Term Services and Supports: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Long-Term Services and Supports: Medical Services... $5,652 $5,734 $5,942 $6,026 $6,214 $6,570 $272 $356 Medical Care Total... $6,823 $7,046 $7,152 $7,410 $7,461 $7,876 $309 $415 VA offers a spectrum of Long Term Services and Supports (LTSS) and a specialty in geriatric services to Veterans enrolled in its health care system. The spectrum of long term services and supports includes home and community based services (HCBS); hospice and palliative care; nursing home and domiciliary care; and, programs of geriatric innovations and ambulatory and inpatient geriatrics, dementia management. All VA medical centers provide HCBS for Veterans of all ages. This patient-focused approach supports Veterans who wish to live safely at home in their own communities for as long as possible. In addition, Veterans receive nursing home and domiciliary care through one of four venues: VA Community Living Centers (CLCs); Community Nursing Homes (CNH); State Veterans Nursing Homes; and State Veterans Home Domiciliaries. The LTSS 2016 estimate has increased by $51.1 million above the advance appropriation level, reflecting trends in the most recent actual data and the continued investment into non-institutional settings. Aging and the changes in the Priority Level 1a population are VHA-94 Medical Services

97 significant drivers of projected expenditure increases for LTSS. VA is mandated by law to provide continuing care nursing home services to Priority 1a enrollees. Additionally, World War II enrollees are in the age bands (greater than age 75) that are the highest users of LTSS and are driving the recent and near-term annual growth in LTSS expenditure requirements. For more details about LTSS, please see the Enrollee Healthcare Projection and CHAMPVA Models chapter Congressional Submission VHA-95

98 Total Medical Care Obligations Institutional: Obligations ($000) 2014 Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease VA Community Living Centers... $3,339,924 $3,558,288 $3,375,853 $3,729,201 $3,453,246 $3,621,640 $77,393 $168,394 Community Nursing Home... $720,907 $752,800 $809,522 $776,600 $844,863 $907,986 $35,341 $63,123 State Home Nursing... $984,945 $963,100 $1,081,134 $1,001,000 $1,169,306 $1,257,334 $88,172 $88,028 Subtotal (VA CLC, CNH, SNH)... $5,045,776 $5,274,188 $5,266,509 $5,506,801 $5,467,415 $5,786,960 $200,906 $319,545 State Home Domiciliary... $56,278 $63,900 $57,117 $65,800 $59,543 $61,537 $2,426 $1,994 Total Institutional... $5,102,054 $5,338,088 $5,323,626 $5,572,601 $5,526,958 $5,848,497 $203,332 $321,539 Average Daily Census VA Community Living Centers... 9,469 9,079 9,213 8,779 8,944 8,759 (269) (185) Community Nursing Home... 7,772 7,918 8,113 8,177 8,417 8, State Home Nursing... 19,829 19,774 19,980 19,817 20,070 20, Subtotal... 37,070 36,771 37,306 36,773 37,431 37, State Home Domiciliary... 3,576 3,926 3,561 3,991 3,539 3,527 (22) (12) Total Institutional... 40,646 40,697 40,867 40,764 40,970 41, Per Diem Costs VA Community Living Centers... $ $1, $1, $1, $1, $1, $51.01 $77.90 Community Nursing Home... $ $ $ $ $ $ $0.88 $9.21 State Home Nursing... $ $ $ $ $ $ $10.94 $10.57 State Home Domiciliary... $43.12 $44.59 $43.94 $45.05 $45.97 $47.80 $2.03 $1.83 Denominator VA Community Living Centers (1) Community Nursing Home (1) State Home Nursing (1) State Home Domiciliary (1) Institutional: Obligations ($000) 2014 Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease VA Community Living Centers... $3,339,924 $3,558,288 $3,375,853 $3,729,201 $3,453,246 $3,621,640 $77,393 $168,394 Community Nursing Home... $720,907 $752,800 $809,522 $776,600 $844,863 $907,986 $35,341 $63,123 State Home Nursing... $984,945 $963,100 $1,081,134 $1,001,000 $1,169,306 $1,257,334 $88,172 $88,028 Subtotal (VA CLC, CNH, SNH)... $5,045,776 $5,274,188 $5,266,509 $5,506,801 $5,467,415 $5,786,960 $200,906 $319,545 State Home Domiciliary... $56,278 $63,900 $57,117 $65,800 $59,543 $61,537 $2,426 $1,994 Total Institutional... $5,102,054 $5,338,088 $5,323,626 $5,572,601 $5,526,958 $5,848,497 $203,332 $321,539 Average Daily Census VA Community Living Centers... 9,469 9,079 9,213 8,779 8,944 8,759 (269) (185) Community Nursing Home... 7,772 7,918 8,113 8,177 8,417 8, State Home Nursing... 19,829 19,774 19,980 19,817 20,070 20, Subtotal... 37,070 36,771 37,306 36,773 37,431 37, State Home Domiciliary... 3,576 3,926 3,561 3,991 3,539 3,527 (22) (12) Total Institutional... 40,646 40,697 40,867 40,764 40,970 41, Per Diem Costs VA Community Living Centers... $ $1, $1, $1, $1, $1, $51.01 $77.90 Community Nursing Home... $ $ $ $ $ $ $0.88 $9.21 State Home Nursing... $ $ $ $ $ $ $10.94 $10.57 State Home Domiciliary... $43.12 $44.59 $43.94 $45.05 $45.97 $47.80 $2.03 $1.83 Denominator VA Community Living Centers (1) Community Nursing Home (1) State Home Nursing (1) State Home Domiciliary (1) VHA-96 Medical Services

99 Non-Institutional: Obligations ($000) 2014 Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease VA Adult Day Health Care... $14,594 $15,700 $14,575 $16,000 $14,769 $15,283 $194 $514 State Adult Day Health Care... $2,807 $800 $1,094 $1,600 $1,203 $1,312 $109 $109 Community Adult Day Health Care... $65,965 $67,400 $74,573 $71,900 $78,853 $84,693 $4,280 $5,840 Home-Based Primary Care... $577,116 $626,900 $709,654 $692,900 $766,653 $799,753 $56,999 $33,100 Other Home Based Prgs: Home Respite Care... $30,934 $29,700 $31,483 $30,900 $32,812 $35,092 $1,329 $2,280 Purchased Skilled Home Care... $273,267 $202,000 $222,985 $209,600 $228,929 $239,481 $5,944 $10,552 Hospice Care... $76,903 $76,300 $77,117 $78,300 $78,283 $80,987 $1,166 $2,704 Homemaker/Hm. Hlth. Aide Prgs... $429,253 $409,700 $445,613 $442,200 $473,469 $499,695 $27,856 $26,226 Spinal Cord Injury Home Care... $9,877 $11,300 $9,388 $11,700 $9,407 $9,685 $19 $278 Home Telehealth... $217,356 $246,027 $219,692 $259,047 $227,529 $239,104 $7,837 $11,575 Community Residential Care... $22,507 $22,200 $21,567 $22,700 $21,648 $22,080 $81 $432 Total Non-Institutional... $1,720,579 $1,708,027 $1,827,741 $1,836,847 $1,933,555 $2,027,165 $105,814 $93,610 Total Long-Term Care... $6,822,633 $7,046,115 $7,151,367 $7,409,448 $7,460,513 $7,875,662 $309,146 $415,149 Clinic Stops (VA Care)/Procedures (Purchased LTC) VA Adult Day Health Care , , , , , , State Adult Day Health Care (ADC) Community Adult Day Health Care , , , , , ,130 7,791 10,624 Home-Based Primary Care... 1,218,453 1,290,328 1,302,002 1,341,585 1,391,421 1,413,182 89,419 21,761 Other Home Based Prgs: Home Respite Care , , , , , ,666 8,442 11,968 Purchased Skilled Home Care... 1,709,022 1,594,786 1,734,002 1,593,748 1,754,413 1,780,289 20,411 25,876 Hospice Care , , , , , , ,386 Homemaker/Hm. Hlth. Aide Prgs... 7,574,605 7,079,340 7,652,801 7,315,096 8,013,269 8,203, , ,462 Spinal Cord Injury Home Care... 20,235 20,485 20,093 20,637 19,916 19,964 (177) 48 Home Telehealth (Participation Months)... 1,162,606 1,268,896 1,197,645 1,391,137 1,227,005 1,255,389 29,360 28,384 Community Residential Care... 70,182 64,259 69,118 61,737 67,867 66,606 (1,251) (1,261) Cost Per Clinic Stop/Procedure VA Adult Day Health Care... $ $ $ $ $ $ $1.22 $3.05 State Adult Day Health Care... $ $79.68 $ $ $ $ $1.90 $4.52 Community Adult Day Health Care... $76.48 $73.16 $83.26 $74.98 $87.27 $92.65 $4.02 $5.37 Home-Based Primary Care... $ $ $ $ $ $ $5.94 $14.94 Other Home Based Prgs: Home Respite Care... $ $94.39 $ $95.22 $ $ $1.49 $3.17 Purchased Skilled Home Care... $ $ $ $ $ $ $1.89 $4.03 Hospice Care... $ $ $ $ $ $ $2.91 $6.20 Homemaker/Hm. Hlth. Aide Prgs... $56.67 $57.87 $58.23 $60.45 $59.09 $60.91 $0.86 $1.83 Spinal Cord Injury Home Care... $ $ $ $ $ $ $5.11 $12.79 Home Telehealth... $ $ $ $ $ $ $2.00 $5.03 Community Residential Care... $ $ $ $ $ $ $6.95 $12.52 Denominator State Adult Day Health Care (1) 2016 Congressional Submission VHA-97

100 Institutional Long-Term Care Average Daily Census: 2014 Actual Budget Current Advance Revised Estimate Estimate Approp. Request Advance Increase / Increase / Approp. Decrease Decrease Length of Stay Short Stay VA Community Living Centers... 2,418 2,449 2,404 2,439 2,384 2,370 (20) (14) Community Nursing Home... 1,416 1,450 1,500 1,515 1,577 1, State Home Nursing ,035 1, Subtotal... 4,754 4,422 4,884 4,428 4,996 5, Long Stay VA Community Living Centers... 7,051 6,630 6,809 6,340 6,560 6,389 (249) (171) Community Nursing Home... 6,356 6,468 6,613 6,662 6,840 7, State Home Nursing... 18,909 19,251 19,000 19,343 19,035 19, Subtotal... 32,316 32,349 32,422 32,345 32,435 32, Total... 37,070 36,771 37,306 36,773 37,431 37, Age Age < 65 VA Community Living Centers... 2,126 1,769 1,838 1,473 1,556 1,297 (282) (259) Community Nursing Home... 1,412 1,259 1,278 1,125 1,148 1,036 (130) (112) State Home Nursing... 1,327 1,123 1, ,115 1,022 (105) (93) Subtotal... 4,865 4,151 4,336 3,571 3,819 3,355 (517) (464) Age VA Community Living Centers... 5,192 5,279 5,349 5,396 5,488 5, Community Nursing Home... 4,165 4,515 4,603 4,894 5,006 5, State Home Nursing... 9,199 8,844 9,206 8,708 9,189 9,235 (17) 46 Subtotal... 18,556 18,638 19,158 18,998 19,683 20, Age > 84 VA Community Living Centers... 2,151 2,031 2,026 1,910 1,900 1,796 (126) (104) Community Nursing Home... 2,195 2,144 2,232 2,158 2,263 2, State Home Nursing... 9,303 9,807 9,554 10,136 9,766 10, Subtotal... 13,649 13,982 13,812 14,204 13,929 14, Total... 37,070 36,771 37,306 36,773 37,431 37, Eligibility Priority 1A VA Community Living Centers... 4,663 5,759 4,648 5,999 4,622 4,634 (26) 12 Community Nursing Home... 5,598 6,662 5,932 6,945 6,237 6, State Home Nursing... 2,202 2,961 2,540 3,364 2,854 3, Subtotal... 12,463 15,382 13,120 16,308 13,713 14, Service-connected VA Community Living Centers... 1, , ,841 1,788 (71) (53) Community Nursing Home... 1, , ,287 1,236 (64) (51) State Home Nursing... 3,880 3,344 3,945 3,260 3,996 4, Subtotal... 7,272 4,642 7,208 4,185 7,124 7,096 (84) (28) Non-service-connected VA Community Living Centers... 2,825 2,536 2,653 2,330 2,481 2,337 (172) (144) Community Nursing Home State Home Nursing... 13,747 13,469 13,495 13,193 13,220 13,048 (275) (172) Subtotal... 17,335 16,747 16,978 16,280 16,594 16,346 (384) (248) Total... 37,070 36,771 37,306 36,773 37,431 37, VHA-98 Medical Services

101 Institutional Long-Term Care Obligations: 2014 Actual Budget Current Advance Revised Estimate Estimate Approp. Request Advance Increase / Increase / Approp. Decrease Decrease Length of Stay Short Stay VA Community Living Centers... $1,007,643 $1,129,899 $1,041,508 $1,193,540 $1,086,793 $1,156,264 $45,285 $69,471 Community Nursing Home... $141,308 $153,602 $161,023 $170,217 $170,208 $185,159 $9,185 $14,951 State Home Nursing... $48,105 $27,229 $55,843 $26,188 $63,494 $75,796 $7,651 $12,302 Subtotal... $1,197,056 $1,310,730 $1,258,374 $1,389,945 $1,320,495 $1,417,219 $62,121 $96,724 Long Stay VA Community Living Centers... $2,332,281 $2,397,588 $2,334,345 $2,431,574 $2,366,453 $2,465,376 $32,108 $98,923 Community Nursing Home... $579,599 $622,598 $648,499 $680,125 $674,655 $722,827 $26,156 $48,172 State Home Nursing... $936,840 $943,272 $1,025,291 $1,005,157 $1,105,812 $1,181,538 $80,521 $75,726 Subtotal... $3,848,720 $3,963,458 $4,008,135 $4,116,856 $4,146,920 $4,369,741 $138,785 $222,821 Total... $5,045,776 $5,274,188 $5,266,509 $5,506,801 $5,467,415 $5,786,960 $200,906 $319,545 Age Age < 65 VA Community Living Centers... $791,559 $723,186 $824,539 $640,630 $869,277 $939,433 $44,738 $70,156 Community Nursing Home... $140,099 $131,890 $164,777 $125,211 $179,335 $200,201 $14,558 $20,866 State Home Nursing... $66,092 $56,296 $83,503 $51,830 $100,859 $119,009 $17,356 $18,150 Subtotal... $997,750 $911,372 $1,072,819 $817,671 $1,149,471 $1,258,643 $76,652 $109,172 Age VA Community Living Centers... $1,831,314 $2,050,280 $1,847,397 $2,227,408 $1,885,929 $1,973,789 $38,532 $87,860 Community Nursing Home... $389,162 $444,769 $413,239 $512,507 $407,767 $414,371 ($5,472) $6,604 State Home Nursing... $457,725 $439,185 $505,008 $459,749 $549,821 $594,844 $44,813 $45,023 Subtotal... $2,678,201 $2,934,234 $2,765,644 $3,199,664 $2,843,517 $2,983,004 $77,873 $139,487 Age > 84 VA Community Living Centers... $717,051 $748,531 $703,917 $748,123 $698,040 $708,418 ($5,877) $10,378 Community Nursing Home... $191,646 $200,839 $231,506 $214,923 $257,761 $293,414 $26,255 $35,653 State Home Nursing... $461,128 $479,212 $492,623 $526,420 $518,626 $543,481 $26,003 $24,855 Subtotal... $1,369,825 $1,428,582 $1,428,046 $1,489,466 $1,474,427 $1,545,313 $46,381 $70,886 Total... $5,045,776 $5,274,188 $5,266,509 $5,506,801 $5,467,415 $5,786,960 $200,906 $319,545 Eligibility Priority 1A VA Community Living Centers... $1,582,843 $2,149,058 $1,771,091 $2,381,987 $1,998,130 $2,302,457 $227,039 $304,327 Community Nursing Home... $520,444 $654,034 $600,325 $725,676 $640,598 $701,350 $40,273 $60,752 State Home Nursing... $118,441 $155,159 $156,935 $187,106 $196,317 $237,999 $39,382 $41,682 Subtotal... $2,221,728 $2,958,251 $2,528,351 $3,294,769 $2,835,045 $3,241,806 $306,694 $406,761 Service-connected VA Community Living Centers... $699,896 $555,909 $564,003 $319,262 $420,766 $267,983 ($143,237) ($152,783) Community Nursing Home... $127,229 $90,855 $127,202 $83,560 $118,913 $115,115 ($8,289) ($3,798) State Home Nursing... $192,234 $294,507 $205,828 $286,393 $215,699 $224,940 $9,871 $9,241 Subtotal... $1,019,359 $941,271 $897,033 $689,215 $755,378 $608,038 ($141,655) ($147,340) Non-service-connected VA Community Living Centers... $1,057,185 $808,407 $1,040,759 $869,747 $1,034,350 $1,051,200 ($6,409) $16,850 Community Nursing Home... $73,234 $58,457 $81,995 $69,912 $85,352 $91,521 $3,357 $6,169 State Home Nursing... $674,270 $507,802 $718,371 $583,158 $757,290 $794,395 $38,919 $37,105 Subtotal... $1,804,689 $1,374,666 $1,841,125 $1,522,817 $1,876,992 $1,937,116 $35,867 $60,124 Total... $5,045,776 $5,274,188 $5,266,509 $5,506,801 $5,467,415 $5,786,960 $200,906 $319, Congressional Submission VHA-99

102 Institutional Long-Term Care Per Diems: 2014 Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease Length of Stay Short Stay VA Community Living Centers... $1, $1, $1, $1, $1, $1, $58.59 $91.10 Community Nursing Home... $ $ $ $ $ $ $0.79 $9.96 State Home Nursing... $ $ $ $ $ $ $11.50 $11.09 $0.00 $0.00 Long Stay VA Community Living Centers... $ $ $ $1, $ $1, $46.36 $71.57 Community Nursing Home... $ $ $ $ $ $ $0.82 $8.96 State Home Nursing... $ $ $ $ $ $ $10.88 $10.49 Age Age < 65 VA Community Living Centers... $1, $1, $1, $1, $1, $1, $ $ Community Nursing Home... $ $ $ $ $ $ $73.57 $ State Home Nursing... $ $ $ $ $ $ $59.63 $71.88 Age VA Community Living Centers... $ $1, $ $1, $ $ ($7.30) $15.48 Community Nursing Home... $ $ $ $ $ $ ($23.41) ($13.45) State Home Nursing... $ $ $ $ $ $ $13.19 $12.99 Age > 84 VA Community Living Centers... $ $1, $ $1, $1, $1, $51.90 $76.87 Community Nursing Home... $ $ $ $ $ $ $27.04 $36.64 State Home Nursing... $ $ $ $ $ $ $3.83 $3.28 Eligibility Priority 1A VA Community Living Centers... $ $1, $1, $1, $1, $1, $ $ Community Nursing Home... $ $ $ $ $ $ $3.36 $11.44 State Home Nursing... $ $ $ $ $ $ $18.67 $17.62 Service-connected VA Community Living Centers... $ $1, $ $1, $ $ ($183.70) ($213.84) Community Nursing Home... $ $ $ $ $ $ ($5.51) $2.72 State Home Nursing... $ $ $ $ $ $ $4.54 $3.86 Non-service-connected VA Community Living Centers... $1, $ $1, $1, $1, $1, $64.31 $93.25 Community Nursing Home... $ $ $ $ $ $ ($9.51) ($0.23) State Home Nursing... $ $ $ $ $ $ $10.67 $10.29 Home and Community Based Services (HCBS): HCBS programs have grown out of the philosophy that: (1) a home or community setting is the desired location to deliver LTSS; and (2) placement in a nursing home should be reserved for situations in which Veterans cannot receive the care they need or can no longer safely be cared for at home. Veterans prefer HCBS care because it enables them to live at home with a higher quality of life than is normally possible in an institution. Within VA, HCBS programs include home-based primary care, purchased skilled home health care, spinal cord injury home care, adult day health care, homemaker and home health aide services, Veteran-directed home- and community-based services, home respite care, home hospice care, community residential care, medical foster home and home telehealth. Hospice and Palliative Care (HPC): HPC represents a continuum of comfort-oriented and supportive services provided in the home, community, outpatient, or inpatient settings for persons with advanced life-limiting disease. The mission of the VA HPC program is to honor Veterans preferences for care at the end of life. VA must offer to provide or purchase hospice and palliative care that VA determines an enrolled Veteran needs (38 VHA-100 Medical Services

103 Code of Federal Regulations and 17.38). These services include but are not limited to: advance care planning, symptom management, inpatient palliative care, collaboration with community hospice providers, and access to home hospice care at VA expense. To effectively deliver these services, VA has embarked on a Comprehensive End of Life Care Initiative to ensure reliable access to quality end of life care through enhanced palliative care staffing and leadership, expansion of the number of HPC inpatient units, specialized Veteran-specific training, promotion of Hospice-Veteran Partnerships, and implementation of a quality program that links quality indicators to care interventions. Nursing Home and Domiciliary Care: Institutional LTSS are provided for Veterans whose health care needs cannot be met in the home or on an outpatient basis because they require a level of skilled treatment or assessment which can best be provided in an institutional setting. Institutional services may be long term, (i.e., for life), or may be short term for rehabilitation or recovery from an acute condition. Short-term institutional respite care is also available to temporarily relieve caregivers who look after Veterans in the home. VA's nursing home and domiciliary care programs include VA operated CLCs, CNHs, and State Veterans Home programs. While all three programs provide nursing home care, each program has its own particular features. VA re-structured its own program to reflect the Department s commitment to the culture change movement in nursing homes and to enhance Veteran choice. VA CLCs are hospital-based and provide an extensive level of nursing home care supported by an array of clinical specialties at the host hospital. VA purchases care through the CNH program. These homes provide a broad range of nursing home care and have the advantage of being offered in many local communities throughout the Nation, enabling a Veteran to receive care near his/her home and family. VA s CLCs and selected CNHs specialize in treating Veterans with post-acute needs, thus reducing hospital days. The State Veterans Nursing Home program provides a broad range of nursing home care and is characterized by a joint cost-sharing agreement between VA, the Veteran, and the state. Geriatric Programming: Older Veterans with multiple medical, functional or psychosocial problems and those with particular geriatric problems receive assessment and development of multidimensional plan of care from an interdisciplinary team of VA health professionals. A small percentage of the frail elderly Veterans receive primary care in special Patient-Aligned Care Teams, or PACTs, also called Geri PACT, (formerly termed Geriatric Primary Care) where their more complex cases and involved medical histories can receive in-depth attention. Care for Veterans with Alzheimer's or other dementia is provided throughout the full range of VA health care services, which includes, but is not limited to, geriatrics and extended care services. Caregiver support is an essential part of all of these services Congressional Submission VHA-101

104 Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) and Other Dependent Programs: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease CHAMPVA, Spina Bifida, FMP, & CWVV: Medical Services... $1,447 $1,610 $1,618 $1,744 $1,781 $1,952 $163 $171 Medical Care Total... $1,537 $1,716 $1,718 $1,855 $1,884 $2,062 $166 $178 The Veterans Health Care Expansion Act of 1973, P.L , authorized VA to provide a health benefits program that shares the cost of medical supplies and services with eligible beneficiaries. The Veterans' Survivor Benefits Improvements Act of 2001, P.L , extended CHAMPVA benefits, as a secondary payer to Medicare, to CHAMPVA beneficiaries over age 65. To be eligible for CHAMPVA benefits, the beneficiary must be the spouse or child of a Veteran who has a total and permanent service-connected disability, or the widowed spouse or child of a Veteran who: (a) died as a result of a service-connected disability; or (b) had a total, permanent disability resulting from a service-connected condition at the time of death; or (c) died on active duty and in all cases the family member is not eligible for medical benefits under the Department of Defense (DoD) TRICARE Program. CHAMPVA by law is a secondary payer to other health insurance plans to include Medicare. CHAMPVA assumes primary payer status for Medicaid, Indian Health Service, and State Victims of Crime Compensation Programs to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Obligations ($000) CHAMPVA... $1,388,370 $1,544,766 $1,557,683 $1,673,250 $1,714,390 $1,878,900 $156,707 $164,510 Foreign Medical Program (includes Foreign C&P Exams)... $27,685 $33,589 $26,205 $36,830 $28,187 $31,280 $1,982 $3,093 Spina Bifida Program... $30,801 $31,852 $34,382 $33,781 $38,232 $42,216 $3,850 $3,984 Children of Women Vietnam Vets... $0 $200 $200 $200 $200 $200 $0 $0 Subtotal... $1,446,856 $1,610,407 $1,618,470 $1,744,061 $1,781,009 $1,952,596 $162,539 $171,587 Operating Expense: Administrative... $84,305 $100,506 $93,686 $105,059 $97,123 $103,300 $3,437 $6,177 Facilities... $5,881 $5,479 $5,479 $5,750 $5,750 $6,034 $271 $284 Total... $1,537,042 $1,716,392 $1,717,635 $1,854,870 $1,883,882 $2,061,930 $166,247 $178,048 The Veterans Caregivers and Veterans Omnibus Health Services Act of 2010, P.L , section 102, further expanded CHAMPVA to include primary family caregivers of certain seriously injured Veterans. Eligible primary family caregivers are authorized to receive health care benefits through the existing CHAMPVA Program when the primary family caregiver has no other health care coverage (including Medicare and Medicaid). In addition to CHAMPVA, other VA purchased care programs also include the Foreign Medical Program (FMP), Spina Bifida Health Care Benefits Program, and Children of Women Vietnam Veterans Health Care Benefits Program (CWVV). Foreign Medical Program (FMP): The Foreign Medical Program is a health care benefits program for United States Veterans with VA-rated service-connected conditions that are residing or traveling abroad, excluding the Philippines where the VA Outpatient Clinic has jurisdiction of the health care services. Under FMP, VA assumes payment responsibility for certain necessary medical services associated with the treatment of Veterans service-connected conditions, with certain exclusions. VHA-102 Medical Services

105 Spina Bifida Health Care Program: Under the Departments of Veterans Affairs and Housing and Urban Development, and Independent Agencies Appropriations Act of 1997, P.L , section 421, VA administers the Spina Bifida Health Care Benefits Program for birth children of Vietnam Veterans diagnosed with spina bifida (excluding spina bifida occulta). Additionally, the Veterans Benefit Act of 2003, P.L , section 102, authorized birth children with spina bifida of certain Veterans who served in Korea to be eligible for care under this program. Prior to October 10, 2008, the program provided reimbursement only for medical services associated with spina bifida; however, under the Veterans Mental Health and Other Care Improvements Act of 2008, P.L , the program provides reimbursement for comprehensive medical care. Children of Women Vietnam Veterans Health Care Benefits Program (CWVV): Under the Veterans Benefits and Health Care Improvement Act of 2000, P.L , section 401, VA administers the CWVV Program for children with certain birth defects born to women Vietnam Veterans. CWVV Program provides reimbursement only for covered birth defects. Existing Non-Modeled Requirements Non-modeled activities and programs are those that are not projected by either the EHCPM or the CHAMPVA Model. These include state-based long-term care programs, readjustment counseling, programs recently enacted, and medical care programs and services not captured by the EHCPM, expansions to Homeless Veterans Programs, and care provided to non-veterans patients. Caregivers: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Caregivers (Title 1): Medical Services... $348 $303 $478 $303 $551 $637 $73 $86 Medical Care Total... $350 $306 $482 $306 $555 $642 $73 $87 The Caregivers and Veterans Omnibus Health Services Act of 2010, signed into law by President Obama on May 5, 2010, allows VA to provide an unprecedented level of benefits to family caregivers of Veterans ( Family Caregivers ). The Caregiver Law (P.L , Title 1, Caregiver Support) directly benefits Family Caregivers by establishing a comprehensive National Caregiver Support Program with a prevention and wellness focus that includes the use of evidence-based training and support services for Family Caregivers. The 2016 estimated obligation increase from the advance appropriation level is primarily driven by an increase in the number of anticipated Caregivers, from 22,468 to 24,049. The increased is based on the most recent data trend. P.L establishes additional services and supports for Family Caregivers of eligible post 9/11 Veterans seriously injured in the line of duty under the Program of Comprehensive Assistance for Family Caregivers. Additional services and supports include a stipend paid directly to the Family Caregiver, enrollment in VA s Civilian 2016 Congressional Submission VHA-103

106 Health and Medical Program (CHAMPVA) if the Family Caregiver is not already eligible under a health care plan, an expanded respite benefit, and mental health treatment. VA has partnered with Easter Seals Disability Services to provide comprehensive Family Caregiver training for eligible Family Caregivers. Training is available for Family Caregivers in traditional classroom settings, in a workbook format, and in an online format. More than 20,000 Caregivers have been trained since the program s inception in May Caregiver Support Coordinators at each VA medical center serve as the clinical experts on Caregiver issues and are knowledgeable of both VA and non-va support services and benefits available for Veterans of all eras and their Family Caregivers. Caregiver Support Coordinators can also assist eligible Post 9/11 Veterans and their Caregivers in applying for additional services. VA established a National Caregiver Support Line ( ) on February 1, 2011, at the Medical Center located in Canandaigua, NY. This support line is available to respond to inquiries about the Caregiver services, as well as serve as a resource and referral center for Caregivers, Veterans and others seeking Caregiver information; provide referrals to local VA Medical Center Caregiver Support Coordinators and VA/community resources; and provide emotional support. As of September 30, 2014, VA s Caregiver Support Line, has received approximately 150,000 calls, averaging over 150 calls per day. The calls received are from Family Caregivers of Veterans of all eras Accomplishments VA s Caregiver Support Program has been accepting applications for the Program of Comprehensive Assistance for Family Caregiver since May 9, In fiscal year 2014, 19,124 Primary Family Caregivers were approved for the program with 4,804 Primary Family Caregivers who did not previously have health insurance covered under VA s Civilian Health and Medical Program (CHAMPVA). Caregiver Education and Training: Prior to approval for the Program of Comprehensive Assistance, Caregivers complete a Caregiver Core Curriculum developed in partnership with Easter Seals Disability Services which may be completed on-line, via workbook/dvd or in a classroom setting. In fiscal year 2014, additional optional training opportunities in collaboration with Easter Seals were developed and deployed in the form of 4 Caregiver Self-Care Courses. The courses were made available to Caregivers of all era Veterans participating in the Caregiver Support Program: Managing Stress, Effective Communications/Problem Solving, Taking Care of Yourself and Utilizing Technology. Approximately 9,000 Caregivers participated in education and training opportunities during Caregiver Support Coordinators: Caregiver Support Coordinators (CSCs) stationed at each VA medical center serve as the clinical experts on Caregiver issues and are knowledgeable of both VA and non-va support services and benefits available for Veterans and their Family Caregivers. As of the end of 2014, VHA-104 Medical Services

107 VA funded 267 CSC positions allowing for expanded support to a growing number of Family Caregivers of Veterans from all eras across the nation. VA s Caregiver Support Line ( ): The Support Line, staffed by licensed social workers, responded to more than 52,000 calls in fiscal year 2014 and continues to average 150+ calls per day. Building Better Caregivers TM (BBC): VA partnered with the National Council on Aging (NCoA) to offer BBC to Family Caregivers of Veterans of all eras beginning in January BBC is an evidence-based, interactive web-based workshop designed to provide Family Caregivers with support, teach problem solving, and provide Family Caregivers with additional skills. In 2014, more than 1,500 Family Caregivers were referred to BBC. Future Goals ( ) In addition to continuing current Programs and Services described in 2014 accomplishments above, VA is committed to the following goals for : Caregiver Education and Training: Explore ways to make Caregiver education and training available on mobile devices such as tablets. Explore opportunities to engage Caregivers in Live remote training opportunities around special topics of interest. Partnered Evaluation Center: Support the Partnership Evaluation Center, in collaboration with VA s Quality Enhancement Research Initiative (QUERI), to support the evaluation of program components under the Caregivers and Veterans Omnibus Health Services Act of Caregiver Support Line: Expand the role of the Caregiver Support Line (CSL) through the implementation of monthly telephonic educational calls offered for Family Caregivers nationwide. Respite: Enhance partnerships with other parts of VHA, such as Geriatrics and Extended Care and Voluntary Services, as well as other governmental and nongovernmental organizations to expand respite options for Family Caregivers of Veterans through development of innovative programming and training of staff. Caregiver Peer Support: Expand opportunities for Caregiver support through ongoing collaboration with Joining Forces, Department of Defense, the Elizabeth Dole Foundation, and other community partners through establishing both local and web-based opportunities to connect Caregivers of Veterans and Servicemembers to one another. Indian Health Services (P.L ): to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Indian Health Servcies: Medical Services... $15 $39 $18 $39 $28 $28 $10 $0 Medical Care Total... $15 $39 $18 $39 $28 $28 $10 $0 Consistent with the Administration s goal to increase access to care for Veterans and with the Affordable Care Act, VA and the Indian Health Service (IHS) signed the VA- IHS National Reimbursement Agreement in December This Agreement facilitates reimbursement by VA to IHS for direct health care services provided to eligible American Indian and Alaska Native (AI/AN) Veterans in IHS facilities. The 2016 Congressional Submission VHA-105

108 Agreement also paves the way for future agreements negotiated between VA and tribal health programs, in addition to those already in existence. This VA-IHS national agreement created the basis for individual agreements with interested and appropriate tribal health programs. Each interested tribe can initiate contact with VHA and VHA Chief Business Office in turns will provide the necessary paper work and guidance for the tribe to pursue the agreement. Agreements with tribes will reimburse them for direct care provided to eligible AI/AN Veterans Accomplishments: By July 2014, VA and IHS completed 83 implementation plans establishing the claims processing and payment procedures at 108 healthcare facilities. Additionally, as of September 2014, VA and Tribal health programs (THP) signed 61 individual reimbursement agreements for each tribally-run healthcare facility. IHS and THP facilities with completed reimbursement agreements can now receive reimbursement for direct care services provided to eligible AI/AN Veterans. In 2014, VA reimbursed approximately $11.2 million for direct care services to both IHS and THPs. Future Goals ( ): VA and IHS will continue to work closely to accomplish the goals set in the 2010 Memorandum of Understanding (MOU) to establish coordination, collaboration, and resource-sharing. Focus support to the MOU Workgroup 6 goals to increase availability of services, in accordance with law, by the development of payment and reimbursement policies and mechanisms to: o Support care delivered to eligible AI/AN Veterans served at VA and IHS. o Facilitate the sharing and coordination of services, training, contracts, and sharing agreements, sharing of staff, and development of health information technology and improved coordination of care as specified elsewhere in this agreement. Workgroup 6 is the workgroup responsible for the implementation portion of the overall VA, IHS MOU which led to the signature of the national reimbursement agreement in This responsibility includes facilitating the establishment of implementation plans with appropriate IHS facilities and individual reimbursement agreements with interested and appropriate tribal health facilities (under the tribal health program). In addition to facilitating the agreements, the work group is responsible for estimating/forecasting budgets to cover the reimbursement, establishing reimbursement mechanisms/procedures to include information technology enhancements that will allow the reimbursement for care and other implementation related responsibilities. Continue to coordinate with the VA Office of Tribal Government Relations and Office of Rural Health to conduct outreach and communication targeted to the THPs. This will increase the number of THP Reimbursement Agreements in VHA-106 Medical Services

109 Camp Lejeune Veterans and Family (P.L ): to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Camp Lejeune - Veterans and Family: Medical Services... $5 $51 $18 $72 $20 $20 $2 $0 Medical Care Total... $5 $51 $18 $72 $20 $20 $2 $0 The Honoring America s Veterans and Caring for Camp Lejeune Families Act of 2012 (P.L ) extended eligibility for VA hospital care and medical services for 15 specified illnesses and conditions to certain Veterans who were stationed at Camp Lejeune, North Carolina, for at least 30 days between 1957 and Family members of such Veterans who resided, or were in utero, at Camp Lejeune for at least 30 days during that period are eligible for reimbursement of hospital care and medical services for the same specified illness and conditions, and VA is the payer of last resort. Hospital care and medical services may only be furnished to family members to the extent and in the amount provided in advance in appropriations Acts for such purpose. In addition, VA may only provide reimbursement for such hospital care and medical services provided to a family member after all other claims and remedies against third parties for such care and services have been exhausted. The Consolidated and Further Continuing Appropriations Act of 2015 (Public Law ), which was signed on December 16, 2014, increased the Camp Lejeune exposure period back from January 1, 1957 to August 1, VA began providing care to Camp Lejeune Veterans on August 6, 2012, the day the initial law was enacted, and published regulations supporting implementation of this statutory requirement on September 11, VA began enrolling and reimbursing family members for medical care related to treatment of the Camp Lejeune conditions on October 24, 2014, 30 days after the family member interim final rule was published in the Federal Register and became effective. Qualified family members with at least 30 days of Camp Lejeune residency from may receive reimbursement for treatment received up to two years prior to the date on their eligibility determination. For family members with at least 30 days of Camp Lejeune residency from August 1, 1953 December 31, 1956, VA may only provide claims reimbursement for covered treatment received on or after December 16, VA may not reimburse family members for Camp Lejeune related care prior to March 26, 2013, the date when Congress provided funding to Camp Lejeune Family Member Program. The Fiscal Year (FY) 2016 estimate reflects revised estimates for the Veteran population and cost per Veteran, based on actual FY 2014 experience. This reduced the overall cost for the Veteran portion of the program. The FY 2016 estimate for the Family Member population reflects a revision to the estimate for the Family Member population based on revised estimates from the United States Marine Corps. (USMC), as well as revised methodology for the impacted population. The medical cost methodology was also revised to account for costs by specific illness instead of one average cost for all illnesses. In FY 2016, all VA staff needed to support the Camp Lejeune Program are expected to be on board. This includes 10 administrative staff and 3 medical providers (who are paid under medical services dollars) Congressional Submission VHA-107

110 2014 Accomplishments Veteran Care: In response to the law, VA began providing care to Camp Lejeune Veterans on the day the law was enacted, August 6, To support implementation of this statutory requirement, the final regulation for Camp Lejeune Veterans was published on September 24, VA is making necessary process and system enhancements to enroll and provide health care for eligible Veterans. As of September 30, 2014, VA has provided health care to 2,447 Camp Lejeune Veterans, of which 1,231 have been treated specifically for a Camp Lejeune condition. As of November 13, 2014, 13,880 Veterans have been accepted into the CL Program. The Camp Lejeune Family Member Program launched on October 24, As of December 31, 2014, VA has accepted 76 family members into the Camp Lejeune Family Member Care: To support family members for medical care directly related to treatment of the 15 covered medical conditions listed in the law, VA published an interim final regulation and began reimbursing family members in FY As required by law, VA is the last payer of medical claims related to the 15 Camp Lejeune conditions, and family members must exhaust all other health insurance coverage (if any exists) prior to submitting a claim for coverage under this program. To implement care for Camp Lejeune family members, VA developed clinical guidelines for the fifteen medical conditions, created processes for reviewing applications and reimbursing family members, and implemented technology to support these processes. Program Outreach: VA developed a comprehensive outreach strategy to identify and educate Veterans and their family members about the Camp Lejeune program. VA is using numerous communication channels to reach out to these key stakeholders, including websites, social media, handouts, stakeholder briefings, call centers, and traditional media. Briefings and information papers have been provided to members of the Camp Lejeune Community Action Panel, concerned Veterans and their family members, Veterans Service Organizations, congressional staff, and the media. Interagency Collaboration VA has been working closely with DoD, specifically, USMC, to ensure the successful implementation of the Camp Lejeune Program. In December 2014, USMC distributed a mailing to over 230,000 Veterans, family members and other interested parties, which included information about the Camp Lejeune treatment authority along with a Camp Lejeune-specific Fact Sheet from VA. Veteran and family member Camp Lejeune inquiries increased as a result of the mailing. Further, DoD is supplying digitized housing records and rosters to help validate that service members were on Camp Lejeune during the covered time period. VHA-108 Medical Services

111 Future Goals ( ) VA is making significant progress in providing Veteran care and implementing the Camp Lejeune family member program. VA s future goals include: Reimburse family members for care related to the 15 conditions. Enhance VA systems to automate program enrollment, eligibility and family member claims processing. Expand outreach efforts to continue to educate Veterans and family members about the Camp Lejeune program. Readjustment Counseling: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Readjustment Counseling: Medical Services... $185 $204 $206 $204 $211 $211 $5 $0 Medical Care Total... $213 $238 $238 $238 $243 $243 $5 $0 This funding is required to provide readjustment counseling services at VA Vet Centers. Vet Centers are community-based counseling centers, within Readjustment Counseling Service (RCS), that provide a wide range of social and psychological services to include: professional readjustment counseling to Veterans and Servicemembers who have served in a combat zone or area of hostility, counseling to those who experienced a military sexual trauma, bereavement counseling for families who experience an active duty death, substance abuse assessments and referral, medical referral, VBA benefits explanation and referral, and employment counseling. Services are also extended to the family members of eligible individuals for issues related to military service when found to aid readjustment of the Veteran or Servicemember. Furthermore, this program facilitates community outreach and the brokering of services with community agencies that link Veterans with other needed VA and non-va services. A core value of the Vet Center program is to promote access to care by helping Veterans, Servicemembers, and families overcome barriers that impede them from using those services. For example, all Vet Centers maintain scheduled non-traditional hours to provide services, such as on evenings and weekends to to Budget Current Advance Revised Advance Increase/ Increase/ Total Medical Care Obligations Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Obligations ($000)... $212,966 $237,544 $237, $243,843 $243,843 $6,299 $0 Visits (000)... 1,589 1,637 1, ,680 1, Unique Patients (RCS Only)... 71,765 74,636 74, ,577 78,338 1,941 1,761 Total Patients* , , , , , ,874 Mobile Vet Centers Number of Vet Centers RCS is authorized a total of 2,208 FTE in 300 Vet Centers, 80 Mobile Vet Centers, and the Vet Center Combat Call Center. These Vet Centers are located in all 50 states, American Samoa, the District of Columbia, Guam, and Puerto Rico. Additionally, the Secretary authorized a qualified family counselor at every Vet Center. In 2014, RCS provided over 201,400 Veterans and families with over 1.59 million visits at these locations. To extend the geographical reach of Vet Center services, RCS has implemented initiatives to ensure that Veterans have access to care including the creation of the outreach specialist position, the Mobile Vet Center program, and the Vet Center Combat Veteran Call Center. Following the onset of the conflicts in Afghanistan and Iraq, the Vet Center program was authorized to hire 100 OEF/OIF/OND Veteran Outreach Specialists 2016 Congressional Submission VHA-109

112 to proactively contact their fellow returning Veterans at military demobilization sites, including National Guard and Reserve locations, and in the community. They also provide training and information to VA staff, other Federal agencies, and community agencies regarding both Vet Center services and the OEF/OIF/OND experience. Additionally, they develop and maintain working relationships with a network of service provision agencies and individuals in all areas relevant to returning OEF/OIF/OND Servicemembers and their families. To facilitate access to services for Veterans in 2014, RCS utilized 80 Mobile Vet Centers (MVC) across the country. The placement of the vehicles is designed to cover a national network of designated Veterans Service Areas (VSAs) that collectively cover every county in the continental United States. MVCs are used to provide early access to returning combat Veterans via outreach to a variety of military and community events and are based within close proximity to major active duty military installations and demobilization sites. The vehicles are also extending Vet Center access to more rural communities that are isolated from existing VA services. Other services available through this program can include health care enrollment, preventive care health screenings, and relief effort participation during states of emergency. The vehicles include private counseling space to be used at events where confidentiality is a challenge (i.e., Post Deployment Health Re-Assessment events). The vehicles also have been maximized for multi-use applications by adding portable exam tables and litters that can be configured within the existing private counseling areas to provide the aforementioned health care or disaster relief capabilities respectfully. Each MVC is equipped with a state-of-the-art satellite communications package that includes access to all VA systems (Computerized Patient Record System, MyHealthE Vet), video tele-conferencing/telehealth (fully encrypted), and connectivity to emergency response systems (Emergency Management Strategic Health Care Group). RCS has also established the Vet Center Combat Call Center (877-WAR-Vets) where combat Veterans and family members can call at any time to talk confidentially to combat Veterans or family members of combat Veterans (trained Vet Center counselors) regarding any readjustment issues related to their military service or transition home. This also includes providing information and referral to other VA services and benefits. The Call Center is the product of VA leveraging technology to condense a national system of toll free numbers into a single modern center located in Denver, CO. The Call Center staff has the state of the art capability to provide warm handoffs to both the VA National Crisis Hotline and the VA Primary Care Triage Hotline (located in Dayton, OH) when medical care is needed. In 2014, the Vet Center Combat Call Center took over 43,900 calls from Veterans, their families, and concerned citizens. With the enactment of the Caregivers and Veterans Omnibus Health Services Act of 2010 (P.L ) and the National Defense Authorization Act of 2013 (P.L ), the RCS program was given the authority to extend services to current members of the Armed Forces, including Federally-activated members of the National Guard and Reserve, who served in any combat zone or area of hostility. The regulatory process is complete with the final rule promulgated on October 17, The NDAA also extended RCS VHA-110 Medical Services

113 eligibility to Veterans and Servicemembers who deal directly with the casualties of war but are not located in the combat zone, such as those that provide emergency medicine or mortuary affairs, and the crews who operate unmanned aerial vehicles in support of combat operations. Vet Centers have begun to provide these services. Ending Veterans Homelessness: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Homeless Veterans Programs: Medical Services... $1,480 $1,575 $1,407 $1,214 $1,356 $1,356 ($51) $0 Medical Care Total... $1,521 $1,641 $1,445 $1,265 $1,393 $1,393 ($52) $0 Between 2010 and 2014, VA and its partners have reduced the estimated number of homeless Veterans by 33 percent. Data collected during the annual Point in Time (PIT) Count, conducted on a single night in January shows there were 49,933 homeless Veterans in America, a decline of 24,837 since This includes a nearly 43 percent drop in the number of unsheltered Veterans sleeping on the street. The Administration has vowed to end Veterans homelessness by the end of Our goal is a systematic end to homelessness, which means there are no Veterans sleeping on our streets and every Veteran has access to permanent housing. Should Veterans become or be at-risk of becoming homeless, we will have the capacity to quickly connect them to the help they need to achieve housing stability. The ultimate goal is that all Veterans have permanent, sustainable housing with access to high-quality health care and other supportive services. In 2014, over 367,790 homeless or at-risk Veterans (including formerly homeless Veterans) accessed services and nearly 260,000 received services through the VHA specialized homeless programs. As a result, more than 71,500 homeless and at-risk Veterans obtained permanent housing through VA specialized homeless programs in VA is committed to preventing and ending homelessness among Veterans and is poised to assist homeless and at-risk Veterans through the provision of a comprehensive continuum of care that includes Outreach/Education, Prevention, Treatment, Income/Employment/Benefits, and Housing/Supportive Services provided in collaboration with Federal, state, local governments and community partners. The VA Agency Priority Goal became, and continues to be, a primary initiative of the Department and was incorporated into VA s Transformational Initiatives, where it is referred to as Ending Veteran Homelessness (EVH). The efforts are integrated Department-wide and include the support of the National Cemetery Administration (NCA) and the Veterans Benefits Administration (VBA). The administration of VA s clinical homeless programs are aligned within VHA, Office of the Deputy Under Secretary for Operations and Management, which is accountable for the budget execution of VHA s Homeless Veterans Programs, and for the provision of clinical intervention and treatment services for homeless and at-risk Veterans. VBA, NCA, and the Office of Asset Enterprise Management (OAEM) are collaborative partners in the EVH initiative that operate within their respective budgets -- separate from VHA s Homeless Veteran Programs -- and are accountable to their own leadership for their performance Congressional Submission VHA-111

114 VA is positioned to assist homeless and at-risk Veterans in achieving their optimal level of functioning and quality of life through the provision of a comprehensive continuum of care that addresses the psychosocial factors surrounding homelessness while building the capacity of available residential, rehabilitative, transitional, and permanent housing. The continuum of care includes both prevention and treatment services. These services include, but are not limited to, primary and specialty medical care; mental health and substance use disorder treatment; case management; outreach; vocational rehabilitation/employment services; housing support; and coordination of related services with VBA and NCA. This continuum includes VA Medical Centers (VAMCs), Public Housing Authorities, and Continuums of Care, as well as community partners. The intent is for every eligible Veteran to have access to a safe, stable environment, and that there will be sufficient capacity so that all Veterans willing to accept services will be able to leave the streets and enter shelter/housing in order to stabilize and begin rebuilding their lives. Since the inception of the EVH transformational initiative, VA has not only expanded existing programs and developed new programs, but has increased efforts to: develop partnerships with Federal and state agencies, Veterans Service Organizations (VSOs), national advocacy groups, and community-based providers; enhance outreach efforts to agencies, as well as to individual Veterans; increase data collection and reporting methods by working closely with Federal agencies and local continuums of care; and develop new methods to explore evidence-based research and test best practice models. Additionally, VA has made unprecedented efforts to promote the services available to Veterans who are homeless or might become homeless through its comprehensive approach to outreach (media and boots on the ground ), the implementation of an at-risk clinical reminder in VAMC outpatient settings, and continued interaction and collaboration with public and private sector partners. VHA-112 Medical Services

115 Program Descriptions and Highlights This budget will support the Agency Priority Goal (APG) to end Veteran homelessness by the end of 2015 by emphasizing rescue and prevention - rescue for those who are on the streets or in shelters today, and prevention for those at risk of homelessness from starting that downward spiral Total Medical Care Obligations ($000) 2014 Acutal Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease Homeless Veterans Treatment Costs... $4,799,108 $5,782,060 $5,038,828 $6,397,595 $5,269,667 $5,496,909 $230,839 $227,242 Programs to Assist Homeless Veterans: Permanent Housing/Supportive Services HUD-VASH case management - Initiative 1/... $248,276 $321,000 $321,000 $182,500 $321,000 $321,000 $0 $0 HUD-VASH - Sustainment 2/... $92,530 $52,668 $52,668 $54,670 $52,668 $52,668 $0 $0 Subtotal... $340,806 $373,668 $373,668 $237,170 $373,668 $373,668 $0 $0 Transitional Housing Grant & Per Diem 1/... $214,468 $214,990 $214,990 $145,000 $171,094 $171,094 ($43,896) $0 Grant & Per Diem Liaisons 1/... $29,820 $37,863 $35,010 $25,000 $30,000 $30,000 ($5,010) $0 Other - Sustainment 2/... $46,835 $35,561 $35,561 $36,912 $35,561 $35,561 $0 $0 Health Care for Homeless Vets (HCHV) 1/... $139,714 $155,000 $157,853 $122,500 $155,000 $155,000 ($2,853) $0 Subtotal... $430,837 $443,414 $443,414 $329,412 $391,655 $391,655 ($51,759) $0 Prevention Services Supportive Services Low Income Vets & Families 1/... $299,902 $500,000 $300,000 $375,000 $300,000 $300,000 $0 $0 National Call Center for Homeless Veterans (NCCHV) 1/... $4,464 $5,568 $5,568 $5,568 $5,568 $5,568 $0 $0 Justice Outreach Homelessness Prevention - Initiative 1/... $24,594 $35,224 $35,224 $32,152 $35,224 $35,224 $0 $0 Justice Outreach Homelessness Prevention - Sustainment 2/... $4,173 $3,155 $3,155 $3,275 $3,155 $3,155 $0 $0 Subtotal... $333,133 $543,947 $343,947 $415,995 $343,947 $343,947 $0 $0 Treatment Domiciliary Care for Homeless Vets - Sustainment 2/... $233,989 $183,362 $183,362 $190,328 $183,362 $183,362 $0 $0 Domiciliary Care for Homeless Vets - Initiative 1/... $12,269 $0 $0 $0 $0 $0 $0 $0 Telephone/Homeless Chronicallly Mentally Ill - Sustainment 2/... $33,074 $13,194 $13,194 $13,696 $13,194 $13,194 $0 $0 Substance Abuse/Mental Health Enhancement 1/... $4,020 $0 $0 $0 $0 $0 $0 $0 Expansion of Homeless Dental Initiative 1/... $8,426 $0 $0 $0 $0 $0 $0 $0 Subtotal... $291,778 $196,556 $196,556 $204,024 $196,556 $196,556 $0 $0 Employment/Job Training Homeless Veterans Supported Employment Program 1/... $17,112 $15,000 $0 $10,000 $0 $0 $0 $0 Homeless Veterans Community Employment Program 1/... $4,174 $0 $15,000 $0 $15,000 $15,000 $0 $0 Homeless Ther. Empl, CWT & CWT/TR - Sustainment 2/... $91,055 $60,565 $60,565 $62,867 $60,565 $60,565 $0 $0 Subtotal... $112,341 $75,565 $75,565 $72,867 $75,565 $75,565 $0 $0 Administrative Getting to Zero... $532 $532 $532 $532 $532 $532 $0 $0 Supportive Services Low Income Vets & Families Admin... $7,647 $4,860 $8,619 $4,000 $8,619 $8,619 $0 $0 National Homeless Registry... $3,709 $2,458 $2,458 $1,000 $2,458 $2,458 $0 $0 Subtotal... $11,888 $7,850 $11,609 $5,532 $11,609 $11,609 $0 $0 VA Require Total Obligations (Grand Total)... $1,520,783 $1,641,000 $1,444,759 $1,265,000 $1,393,000 $1,393,000 ($51,759) $0 Specific Purpose total... $1,019,127 $1,292,495 $1,096,254 $903,252 $1,044,495 $1,044,495 ($51,759) $0 General Purpose total... $501,656 $348,505 $348,505 $361,748 $348,505 $348,505 $0 $0 1/ Initiative funding reflects Specific Purpose funds allocated to the program by VA Central Office. 2/ Sustainment funding reflects General Purpose funds distributed through the Veterans Equitable Resource Allocation (VERA) process and allocated to the program. Housing and Urban Development-VA Supportive Housing (HUD-VASH) case management: HUD-VASH is the Nation s largest supportive permanent housing program. HUD-VASH funding will provide resources for HUD-VASH case management, Housing First pilot programs and Homeless Veteran Patient Aligned Care Teams (H-PACTs) in VA expects to hire additional staff in 2015, based on issuance of additional vouchers by HUD. HUD-VASH is a collaborative effort, combining HUD Section 8 Housing Choice rental assistance vouchers with VA s provision of intensive case management services. HUD- VASH targets the most vulnerable and chronically homeless Veterans who require intensive case management and supportive services to sustain housing. These Veterans 2016 Congressional Submission VHA-113

116 often have severe, persistent physical and mental health conditions as well as substance use disorders. This program ends homelessness for Veterans by providing permanent housing through HUD s vouchers with VA case management and supportive services that promote and maintain recovery and housing stability. The primary goal of HUD-VASH is to move Veterans and their families out of homelessness and into stable permanent housing, and then to provide the supports needed to sustain the Veteran and their family in their housing. During 2014, the HUD-VASH program continued to implement a multi-disciplinary team approach to meet the complex case management needs of participating Veterans through provision of a full range of medical, mental health and employment services to Veterans within their communities and, most frequently, in their homes. This ensures access to care in community settings, where Veterans are most likely to engage in services, and provides the support needed to ensure housing stability. In 2014, the HUD-VASH program funded 446 additional positions in various disciplines, including Peer Supports, Employment Specialists, Occupational Therapists, Psychiatrists, Nurses, and Housing Specialists. This furthered VHA s goal of using 2014 funding to more fully support implementation of Housing First principles by creating greater diversity among the existing teams. At the end of 2014, 51,913 unique Veterans were housed in HUD-VASH, a 15 percent increase from the 45,153 reported in At the end of 2015, VA projects that more than 63,000 total Veterans will be housed through the HUD-VASH program. Housing First: In 2014, VHA continued implementation of the evidence-based practice, Housing First. The Housing First model prioritizes housing and assists the Veteran with access to healthcare and other supports that promote housing stabilization and improved quality of life. What differentiates a Housing First approach from other strategies to end homelessness is that there is an immediate and primary focus on helping the homeless Veteran to quickly access and sustain permanent housing. Housing First is a model that promotes rapid access and dispenses with trying to determine who is "housing ready" or demanding treatment prior to housing. Treatment and other support services are wrapped around the Veteran as he/she obtains and maintains permanent housing. Housing First approaches target and place the most needy, most vulnerable Veterans into permanent housing directly from streets, shelters and emergency housing unless there is a need for acute medical intervention. Housing First Programs, initially developed in 2012, were continued in 2013 and 2014 to serve chronically homeless Veterans, targeting unsheltered Veterans living on the streets. During 2014, VA and HUD continued to provide technical assistance to Housing First sites through conference calls and site visits. Lessons learned from this initiative led VA to promote the principles and key components of Housing First as organizational policy. The implementation and dissemination model utilized by VA continues to serve as a prototype for HUD and VA to promote larger community adoption of Housing First. H-PACTs: This initiative was implemented in 50 facilities, including 21 of 25 cities targeted by the United States Interagency Council on Homelessness (USICH) as high priority cities, with the goal of providing integrated, coordinated, and comprehensive clinical and primary care in conjunction with homeless services. These 25 cities, and the VHA-114 Medical Services

117 VA facilities within them, serve approximately 70 percent of all homeless Veterans nationally. This initiative currently has 14,600 enrolled Veterans and has substantially reduced emergency and inpatient levels of care while facilitating earlier exits from homelessness. Grant and Per Diem (GPD) Program: Under authority of the Veterans Benefits, Health Care, and Information Technology Act, P.L , through the Homeless Providers GPD Program, VA awards grants to community-based agencies to create transitional housing programs and offer per diem payments to GPD funded organizations. These per diem payments help offset the operational costs of the program. These grants promote the development and provision of supportive housing and/or supportive services with the goal of helping homeless Veterans achieve residential stability, increase their skill levels and/or income, and realize greater self-determination. The GPD Program has more than 650 funded projects and over 15,000 beds nationwide; the average length of stay for a homeless Veteran in the GPD program is 6 months. In 2014, 45,185 unique Veterans were served in GPD programs and approximately 45,000 homeless Veterans will receive services in GPD in The projected reduction is based upon the continued drop in the number of homeless Veterans and reduction of underutilized beds based on reduced demand for these services. However, overall per diem costs for the program are anticipated to gradually rise overall for operational programs as the nightly cost for per diem increases in the community. Even though the demand for GPD transitional housing beds is expected to decrease over time, the program still plays a vital role in the continuum of homeless services; providing supportive services to those Veterans who would otherwise be among the unsheltered homeless population, and ultimately transitioning to permanent housing. It is estimated that approximately 10,725 Veterans would exit GPD programs with permanent housing with the proposed budget of $171 million in Health Care for Homeless Veterans (HCHV): HCHV provides outreach and case management, as well as contract residential services (CRS), which target homeless Veterans transitioning from literal street homelessness, those being discharged from institutions, and Veterans who recently became homeless and require safe and stable living arrangements while they seek permanent housing. Each of the program elements has been impacted by an increased demand for services and program expansion. In 2014, 185,949 unique Veterans were served through HCHV, an almost 27 percent increase from the 146,545 reported in Based on increased demand for services, there has been an expansion in both size and scope of service delivery across programs and initiatives supported through the HCHV program. It is anticipated that HCHV core programs (outreach, case management, and CRS) will provide services to an estimated 196,590 homeless Veterans in Community Resource and Referral Centers (CRRCs): Established in strategically selected locations to provide services in a one-stop environment, CRRCs enable enhanced access to services, especially for chronic homeless, newly homeless, women, women with children, and other hard to reach populations. CRRCs are a model 2016 Congressional Submission VHA-115

118 development program administered through the National Center on Homelessness among Veterans with funding support made available through HCHV. There are a total of 30 CRRCs nationwide (one is locally funded). During 2011, 15 CRRCs were funded (New York, Philadelphia, DC, Atlanta, Cleveland, Akron, Detroit, Chicago, Des Moines, Phoenix, Denver, Portland, San Francisco, Las Vegas, and Omaha). In 2012 New Orleans was added to the original 15 CRRCs. In 2013, an additional 14 CRRC sites were added: West Haven, Houston, Ft Worth, Puget Sound, Long Beach, Baltimore, Durham, Salisbury, Charleston, Jacksonville, Huntington, Minneapolis (VISN funded), Milwaukee, and Dallas. In 2014, over 20,000 homeless, or at risk Veterans received services in the CRRCs. It is expected that CRRCs will record at least 30,000 Veteran visits in these facilities in CRRC programs partner with SSVF grantees, HPACTS, and other VA and non-va service providers in their area and are considered a link to community permanency and a pathway out of homelessness for Veterans. Contract Residential Services (CRS): VA contracts with community partners to provide emergency housing and residential treatment beds. The demand for this residential bed capacity has grown steadily since the start of the EVH initiative, with 4,061 currently operational beds, representing a 472 percent increase in bed capacity since 2009 and an almost 13 percent increase from 2013 levels. Funding has been prioritized to ensure that every VAMC has the capacity to offer bridge housing, services that are targeted to and prioritized for homeless Veterans who are transitioning from literal street homelessness. A no wrong door approach to ending Veteran homelessness includes availability of these community-based, emergency housing options as an entry point for Veterans in need and supports VA s commitment to house all unsheltered homeless Veterans. The average length of stay for a homeless Veteran receiving CRS services is 73 days. In 2014, 15,696 unique Veterans were served, a 16 percent increase from the 13,524 reported in In 2014, 6,547 Veterans exited HCHV CRS programs to permanent housing and 25 percent experienced an increase in income. At discharge, 37 percent of Veterans were receiving or had pending application for VA benefits and 29 percent for non-va benefits. Service linkages with VA and non-va providers where established for the majority of Veterans following discharge: 81 percent for alcohol treatment, 81 percent for drug treatment, 91 percent for mental health treatment, and 96 percent for medical treatment. Low Demand/Safe Havens (LDSH): LDSH is a 24-hour per day/7-days per week community-based early recovery model of supportive housing that serves hard-to-reach homeless Veterans with severe mental illness who have been unable to participate in traditional treatment and supportive services. Four LDSH sites were funded as pilot programs in 2012 as development projects under the NCHAV with funding support made available through HCHV. Outcomes of fidelity reviews conducted by NCHAV warranted expansion of the model program to include an additional 18 sites in 2013 for chronically homeless Veterans with concurrent mental illness and substance use disorders. In 2014, LDSH programs served 972 Veterans, including both males and females. Forty-one percent left the Safe Haven to move into permanent housing and 33 percent experienced VHA-116 Medical Services

119 an increase in income during their time in the program. At discharge, 43 percent of Veterans were receiving or had pending application for VA benefits and 35 percent for non-va benefits. Service linkages with VA and non-va providers where established for the majority of Veterans following discharge: 59 percent for alcohol treatment, 56 percent for drug treatment, 66 percent for mental health treatment, and 90 percent for medical treatment. Case Management: The complex and multiple needs of our Veterans have resulted in a growing need for ongoing clinical case management for homeless Veterans in communitybased settings. This includes Veterans entering the health care system as well as those who have completed programs, reside in permanent housing, and are in need of aftercare services to prevent falling back into homelessness. Program staff members also provide case management and other related services to non-va community housing programs. To meet this need, more than 200 additional case management staff positions were funded in Increased access to case management services ensures that a larger segment of these community-based permanent housing slots can be made available to homeless Veterans, thereby making access to permanent housing more available to Veterans currently on the streets and in need of this service to acquire and maintain stable housing. Supportive Services for Veteran Families (SSVF): At-risk Veterans benefit from early interventions to avoid homelessness for themselves and their families. VA used the authority mandated in the Veterans Mental Health and Other Care Improvements Act of 2008, P.L , and authority provided in other legislation to establish the SSVF program. VA provides resources through the SSVF program to provide supportive services to very low-income Veteran families. Funds are granted to private non-profit organizations and consumer cooperatives that will assist very low-income Veterans and their families by providing a range of supportive services designed to promote housing stability. Services provided to these Veteran families were highly effective. In its first three years of operations (2012 through 2014), SSVF served over 200,000 Veterans and their family members with 85 percent exiting SSVF into permanent housing. FY 2014, SSVF expanded services to all 50 states, Puerto Rico, the District of Columbia, and the Virgin Islands and exceeded expectations by serving 130,000 participants. Of those served, 27,452 were dependent children, 11,397 were women (15 percent of Veterans served), and 8,283 Veteran participants were OEF/OIF/OND (11 percent of Veterans served). In its second year of operations, SSVF placed 84 percent of all those served in permanent housing while increasing average incomes 8.3 percent in the 90 days that the average participant stayed in the program. National Call Center for Homeless Veterans (NCCHV): The NCCHV began full operation in March The purpose of the NCCHV is to provide homeless Veterans and Veterans at-risk of homelessness with timely and coordinated access to VA and community services, and to disseminate information to concerned family members and non-va providers about all the programs and services available to assist these Veterans. Additional full-time equivalents were funded in 2013, based on the growth in call volumes in 2013; funding in 2014 has been adjusted accordingly to support this growth and these 2016 Congressional Submission VHA-117

120 funds will also be needed to sustain operations in The NCCHV addressed 112,076 callers in 2014 and provided information and referral to approximately 73,880 Veterans and other interested parties. The NCCHV is a national vehicle for VA to respond to Veterans and community providers, assisting them in connecting to local VA and community resources that provide prevention services to Veterans or assist Veterans in exiting homelessness. Justice Outreach Homelessness Prevention Initiative/Veterans Justice Outreach (VJO) Program: The VJO program, formally launched in 2009, aims to prevent homelessness by providing outreach and linkage to VA services for Veterans at early stages of the justice system, including Veterans courts, drug courts, and mental health courts, and Veterans in local, county, and city jails. At least one VJO Specialist is located at each VAMC and works with local justice system partners to facilitate access and adherence to treatment for justice-involved Veterans. The number of Veteran-focused court programs (including Veterans Treatment Courts), community-based entities and one of the three functions of the VJO outreach, increased nationally from 111 in 2011 to 266 in 2014, an increase of 140 percent. Due to significantly increased community demand for VA outreach services to Veterans in jails and courts not yet served, VA added 75 VJO Specialist positions in 2014, and plans to add 10 positions in VJO Specialists served 41,680 justice-involved Veterans in 2014, and are expected to serve 55,000 in VJO funding will also support Health Care for Reentry Veterans (HCRV), a program designed to address the community reentry needs of incarcerated Veterans. HCRV's goals are to prevent homelessness, reduce the impact of medical, psychiatric, and substance abuse problems upon community readjustment, and decrease the likelihood of reincarceration for those leaving prison. In 2014, 16,786 reentry Veterans were provided services through HCRV. Homeless Veteran Community Employment Services: Homeless and at-risk Veterans need access to employment opportunities to support their housing needs, improve the quality of their lives, and assist in their community reintegration efforts. The Homeless Veteran Supported Employment Program (HVSEP) was a collaborative effort between the VHA Homeless and Compensated Work Therapy Programs, which concluded on September 30, In 2014, approximately 45% (1,850) of the Veterans discharged from HVSEP were competitively employed. This represents a 3% increase over 2013 rates. Beginning in 2014, funding was provided to hire approximately 160 Community Employment Coordinators (CECs). CECs will receive site-specific training and mentoring in order to increase the emphasis of competitive employment as a strategy to assist homeless Veterans in obtaining and maintaining permanent stable housing and to improve competitive employment outcomes among homeless Veterans. In addition to providing direct employment services, these new staff will function as community liaisons to all providers of employment placement and support services both within medical centers and in the community; provide training and guidance to homeless program staff on resources that enhance and result in competitive employment outcomes for Veterans who are homeless; and will function as local data systems managers for reporting referrals and VHA-118 Medical Services

121 outcomes. Competitive employment rates among Veterans exiting homeless residential programs will increase by five percent by the end of 2015, with incremental increases on an annual basis thereafter. For 2015, VA has a $15 million budget to support 160 Community Employment Coordinators. HVCES is the only employment program within VHA specifically targeting homeless Veterans. National Homeless Registry: The National Homeless Registry was established in 2012 and is a culmination of various data sources housed in a data cube. This data cube includes selected data on all Veterans who have received homeless services across VHA since 2005 and is linked with other sources of homelessness information, such as the Homeless Operations, Management, and Evaluation System (HOMES), HUD s Homelessness Management Information System, and VHA s Computerized Patient Record System. The Registry allows facilities to drill down to individual Veterans, determine their current housing status, and link them to any future healthcare appointments or VBA claims. By accessing the Veteran profile in the Registry, a provider can determine every VHA facility across the country where a Veteran has accessed services. To date, there are over 800,000 Veterans listed in their Registry. As part of the development of the Registry, HOMES, activated in April 2011, was created to track Veteran demographics, case management services, and treatment outcomes for homeless and at-risk Veterans who are served by VA s homeless programs. Getting to Zero: Getting to Zero provides salary support for dedicated staff within VA s Office of Public and Intergovernmental Affairs to develop, disseminate, and measure the effectiveness of VA s homeless Veteran outreach campaign. VA administers the comprehensive national homeless outreach campaign, to include major media events, to increase awareness of VA services for homeless and at risk Veterans. Strategic communications is an important component in reiterating VA s goal to all stakeholders in order to educate and informing other agencies who would align their efforts with VA in order to end homelessness among Veterans. Veterans Choice Act: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Veterans Access, Choice, and Accountability Act Staffing (P.L ): Medical Services... $854 N/A $854 Medical Care Total... $1,195 N/A $1,195 The 2017 request includes amounts necessary to fund the recurring costs from Section 801 of the Veterans Choice Act: $121 million for recurring lease costs. $204 million for legionella prevention and oversight project costs. $870 million for recurring personnel costs. Additional details can be found in the Veterans Choice Act chapter. VISTA Evolution: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease VISTA Evolution: Medical Services... $0 $0 $0 $0 $0 $0 $0 $0 Medical Care Total... $74 $123 $68 $208 $160 $208 $92 $ Congressional Submission VHA-119

122 See the Selected Program highlights for a detailed description of this program. Activations: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Activations: Medical Services... $489 $395 $395 $96 $443 $443 $48 $0 Medical Care Total... $659 $534 $548 $130 $598 $598 $50 $0 Facility activations provide non-recurring (equipment and supplies) and recurring (additional personnel) costs associated with the activation of completed construction of new or replacement medical care facilities. Resources include assumed rates for medical equipment and furniture reuse based on the facility type (renovation, replacement, or new). VA s activation plans are sensitive to delays in construction schedules and lease awards. VA has recently taken steps to identify and more closely monitor the activations of new facilities and leases to assure that projects stay on schedule, which will promote better synchronization of budgetary resources with program needs. Legislative Proposals: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease VA Legislative Proposals: Medical Services... $0 $46 $38 $50 $48 $48 $10 $0 Medical Care Total... $0 $46 $38 $50 $49 $49 $11 $0 See the Proposed Legislation chapter for a detailed description of these proposals. Prior Year Recoveries: to to 2017 Description 2014 Budget Current Advance Revised Advance Increase/ Increase/ (Dollars in Millions) Actual Estimate Estimate Approp. Request Approp. Decrease Decrease VA Prior Year Recoveries: Medical Services... $721 N/A $721 Medical Care Total... $737 N/A $737 This is an accounting change to record prior year recoveries as required by federal accounting policy under OMB Circular No. A-11 guidance and is being reflected for the first time in the 2017 Budget request. This is a technical change that does not affect the actual resource levels provide for Veterans services, only how they are accounted for. VA has modified its financial accounting system to be able to accurately monitor and record recoveries. VHA-120 Medical Services

123 Medical Services Program Resource Data Unique Patients 1/ to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Priorities ,658,956 4,729,341 4,795,656 4,827,386 4,918,891 5,028, , ,705 Priorities ,296,770 1,289,199 1,284,526 1,279,950 1,273,262 1,263,289 (11,264) (9,973) Subtotal Veterans... 5,955,725 6,018,540 6,080,182 6,107,336 6,192,154 6,291, ,972 99,731 Non-Veterans 2/ , , , , , ,601 11,239 9,366 Total Unique Patients. 6,632,735 6,741,933 6,772,178 6,844,729 6,895,389 7,004, , ,097 Unique Enrollees 3/ Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Priorities ,759,379 6,908,717 6,912,450 7,038,596 7,056,268 7,180, , ,367 Priorities ,319,236 2,378,575 2,323,837 2,397,197 2,326,337 2,323,770 2,500 (2,567) Total Enrollees... 9,078,615 9,287,292 9,236,287 9,435,793 9,382,605 9,504, , ,800 Users as a Percent of Enrollees Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Priorities % 68.5% 69.4% 68.6% 69.7% 70.0% 0.3% 0.3% Priorities % 54.2% 55.3% 53.4% 54.7% 54.4% -0.6% -0.3% Total Enrollees % 64.8% 65.8% 64.7% 66.0% 66.2% 0.2% 0.2% 1/ Unique patients are uniquely identified individuals treated by VA or whose treatment is paid for by VA. 2/ Non-Veterans include active duty military and reserve, spousal collateral, consultations and instruction, CHAMPVA workload, reimbursable reimbursable workload with affiliates, humanitarian care, and employees receiving preventive occupational immunizations such as Hepatitis A&B and flu vaccinations. 3/ Similar to unique patients, the count of unique enrollees represents the count of Veterans enrolled for Veterans health care sometime during the course of the year Congressional Submission VHA-121

124 Summary of Workloads for VA and Non-VA Facilities to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Outpatient Visits (000): Ambulatory Care: Staff... 79,626 81,138 82,251 83,084 84,564 86,628 2,313 2,064 Fee... 14,169 14,470 14,549 14,795 14,965 15, Subtotal... 93,795 95,608 96,800 97,879 99, ,965 2,729 2,436 Readjustment Counseling: Visits... 1,589 1,637 1,637 1,702 1,680 1, Grand Total... 95,384 97,245 98,437 99, , ,685 2,772 2,476 Patients Treated: Inpatient Care , , , , , ,353 (2,309) (2,613) Rehabilitation Care... 16,234 16,249 16,234 16,323 16,234 16, Mental Health Care Total , , , , , , Acute Psychiatry... 92,876 93,445 91,291 92,161 89,200 87,694 (2,091) (1,506) Contract Hospital (Psych)... 19,926 18,267 20,734 18,933 22,796 24,160 2,062 1,364 Psy Residential Rehab... 17,518 10,246 18,072 11,304 18,326 18, Dom Residential Rehab... 24,423 33,325 24,599 33,472 24,910 25, Long-Term Care: Institutional , , , , , ,455 2,548 2,179 Subacute Care... 1,910 2,013 1,685 1,942 1,516 1,351 (169) (165) Inpatient Facilities, Total , , , , , , (223) Average Daily Census: Inpatient Care... 8,882 8,590 8,866 8,522 8,920 9, Rehabilitation Care... 1,166 1,146 1,169 1,138 1,163 1,171 (6) 8 Mental Health Care Total... 9,428 9,108 9,465 8,866 9,487 9, Acute Psychiatry... 2,634 2,549 2,554 2,468 2,474 2,435 (80) (39) Contract Hospital (Psych) Psy Residential Rehab... 1,949 1,207 2,048 1,212 2,123 2, Dom Residential Rehab... 4,463 5,062 4,465 4,908 4,469 4, Long-Term Care: Institutional... 40,646 40,697 40,867 40,764 40,970 41, Subacute Care (5) (3) Inpatient Facilities, Total... 60,208 59,602 60,447 59,342 60,615 61, Length of Stay: Inpatient Care Rehabilitation Care (0.1) 0.1 Mental Health Care Long-Term Care: Institutional (2.1) (1.5) Subacute Care Dental Procedures (000)... 4,292 4,529 4,590 4,645 4,783 4, CHAMPVA/FMP/Spina Bifida: Outpatient Workloads (000)... 14,207 14,710 14,913 15,816 15,655 16, VHA-122 Medical Services

125 to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Advance Appropriation... $43,557,000 $45,015,527 $45,015,527 $47,603,202 $47,603,202 $51,673,000 $2,587,675 $4,069,798 Mandatory Appropriation (P.L )... $5,000,000 $0 $0 $0 $0 $0 $0 $0 Annual Appropriation Adjustment... $40,000 $367,885 $209,189 $0 $1,124,197 $0 $915,008 ($1,124,197) Subtotal Appropriation Request... $48,597,000 $45,383,412 $45,224,716 $47,603,202 $48,727,399 $51,673,000 $3,502,683 $2,945,601 Rescissions, P.L (From Unobligated Balances)... ($179,000) $0 $0 $0 $0 $0 $0 $0 Rescission, P.L $0 $0 ($28,830) $0 $0 $0 $28,830 $0 Net Appropriations... $48,418,000 $45,383,412 $45,195,886 $47,603,202 $48,727,399 $51,673,000 $3,531,513 $2,945,601 Transfers: To North Chicago Demo. Fund... ($176,831) ($187,433) ($190,185) ($192,531) ($195,358) ($200,172) ($5,173) ($4,814) To DoD-VA Hlth Care Svcs Incentive Fund... ($15,000) ($15,000) ($15,000) ($15,000) ($15,000) ($15,000) $0 $0 To Med. Services from Med. Support and Compliance... $59,830 $0 $0 $0 $0 $0 $0 $0 Subtotal Transfers... ($132,001) ($202,433) ($205,185) ($207,531) ($210,358) ($215,172) ($5,173) ($4,814) Collections... $3,068,584 $3,048,303 $3,204,266 $3,252,857 $3,226,548 $3,299,954 $22,282 $73,406 Total Budget Authority... $51,354,583 $48,229,282 $48,194,967 $50,648,528 $51,743,589 $54,757,782 $3,548,622 $3,014,193 Reimbursements... $150,840 $199,000 $171,106 $204,000 $171,106 $171,106 $0 $0 Adjustments to Obligations: Unobligated Balance (SOY): Veterans Access - PL , Section $0 $0 $5,000,000 $0 $1,572,900 $0 ($3,427,100) ($1,572,900) No-Year... $417,931 $405,000 $168,252 $0 $0 $0 ($168,252) $0 H1N1 No-Year (P.L )... $279 $500 $113 $0 $0 $0 ($113) $ Emergency Supplemental (P.L ) (No-Yr)... $1,313 $0 $6 $0 $0 $0 ($6) $0 Hurricane Sandy (P.L )... $9,962 $0 $0 $0 $0 $0 $0 $0 2-Year... $25,137 $0 $59,739 $0 $0 $0 ($59,739) $0 Subtotal... $454,622 $405,500 $5,228,110 $0 $1,572,900 $0 ($3,655,210) ($1,572,900) Transfer of Unobligated Balance, PL , Section $0 $0 ($2,686,900) $0 $0 $0 $2,686,900 $0 Unobligated Balance (EOY): Veterans Access - PL , Section ($5,000,000) $0 ($1,572,900) $0 $0 $0 $1,572,900 $0 No-Year... ($168,252) $0 $0 $0 $0 $0 $0 $0 H1N1 No-Year (P.L )... ($113) $0 $0 $0 $0 $0 $0 $ Emergency Supplemental (P.L ) (No-Yr)... ($6) $0 $0 $0 $0 $0 $0 $0 Hurricane Sandy (P.L )... $0 $0 $0 $0 $0 $0 $0 $0 2-Year... ($59,739) $0 $0 $0 $0 $0 $0 $0 Subtotal... ($5,228,110) $0 ($1,572,900) $0 $0 $0 $1,572,900 $0 Prior Year Recoveries... $0 $0 $0 $0 $0 $721,190 $0 $721,190 Change in Unobligated Balance (Non-Add)... ($4,773,488) $405,500 $3,655,210 $0 $1,572,900 $0 ($2,082,310) ($1,572,900) Lapse... ($3,387) $0 $0 $0 $0 $0 $0 Obligations... $46,728,548 $48,833,782 $49,334,383 $50,852,528 $53,487,595 $55,650,078 $4,153,212 $2,162,483 Less: Veterans Choice Act, Sec. 801, Obligations... $0 $0 ($740,200) $0 ($1,572,900) $0 ($832,700) $1,572,900 Obligations Excluding Veterans Choice Act... $46,728,548 $48,833,782 $48,594,183 $50,852,528 $51,914,695 $55,650,078 $3,320,512 $3,735, Congressional Submission VHA-123

126 FTE by Type Medical Services Excludes Veterans Choice Act to to Budget Current Advance Revised Advance Increase/ Increase/ Account Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Physicians... 18,550 18,420 19,572 18,646 19,943 21, ,838 Dentists... 1,004 1,014 1,088 1,026 1,108 1, Registered Nurses... 49,458 49,763 51,812 50,373 52,800 54, ,523 LP Nurse/LV Nurse/Nurse Assistant. 24,338 24,558 24,837 24,859 25,323 26, Non-Physician Providers... 12,482 12,328 13,385 12,479 13,634 14, ,129 Health Technicians/Allied Health... 62,607 61,759 64,328 62,516 65,643 68,427 1,315 2,784 Wage Board/Purchase & Hire... 5,432 5,537 5,538 5,605 5,647 5, All Other... 31,132 29,911 32,419 30,278 33,107 35, ,181 Total , , , , , ,485 4,226 10,280 Medical Services Employment Summary, FTE by Grade (Excludes Veterans Choice Act) 2015 to to Increase/ Increase/ GS Grade or Title 38 Actual Estimate Estimate Estimate Decrease Decrease SES Title ,899 83,008 84,654 88,662 1,646 4, or higher ,049 8,362 8,528 8, ,097 13,607 13,877 14, ,152 15,742 16,054 16, ,181 2,266 2,311 2, ,235 9,594 9,785 10, ,291 5,497 5,606 5, ,520 9,890 10,087 10, ,956 29,044 29,620 31, , ,837 24,764 25,256 26, , ,692 3,836 3,912 4, Wage Board... 5,410 5,620 5,732 6, Total Number of FTE , , , ,485 4,226 10,280 VHA-124 Medical Services

127 Obligations by Object Medical Services (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease 10 Personnel Compensation and Benefits: Physicians... $5,219,472 $5,355,200 $5,666,300 $5,606,500 $5,975,300 $6,763,800 $309,000 $788,500 Dentists... $238,247 $247,400 $263,900 $257,500 $276,300 $285,400 $12,400 $9,100 Registered Nurses... $5,834,827 $5,929,500 $6,227,000 $6,146,300 $6,508,500 $6,859,500 $281,500 $351,000 LP Nurse/LV Nurse/Nurse Assistant... $1,582,389 $1,639,600 $1,643,000 $1,699,200 $1,716,400 $1,812,000 $73,400 $95,600 Non-Physician Providers... $1,725,341 $1,740,300 $1,883,800 $1,804,000 $1,966,900 $2,176,200 $83,100 $209,300 Health Technicians/Allied Health... $5,815,656 $5,865,300 $6,068,600 $6,066,800 $6,331,900 $6,728,900 $263,300 $397,000 Wage Board/Purchase & Hire... $302,572 $314,400 $313,600 $325,700 $327,500 $336,000 $13,900 $8,500 All Other 1/... $2,035,457 $1,992,000 $2,157,500 $2,064,000 $2,258,700 $2,457,100 $101,200 $198,400 Permanent Change of Station... $3,970 $2,700 $4,100 $2,800 $4,100 $4,200 $0 $100 Employee Compensation Pay... $153,372 $152,600 $156,500 $155,700 $159,700 $162,900 $3,200 $3,200 Subtotal... $22,911,303 $23,239,000 $24,384,300 $24,128,500 $25,525,300 $27,586,047 $1,141,000 $2,060, Travel & Transportation of Persons: Employee... $35,773 $38,800 $44,700 $38,800 $55,900 $69,900 $11,200 $14,000 Beneficiary... $837,569 $968,600 $873,300 $1,007,400 $908,200 $944,500 $34,900 $36,300 Other... $29,352 $27,900 $33,700 $28,500 $38,700 $44,400 $5,000 $5,700 Subtotal... $902,694 $1,035,300 $951,700 $1,074,700 $1,002,800 $1,058,800 $51,100 $56, Transportation of Things... $15,230 $15,600 $18,100 $16,800 $21,500 $25,500 $3,400 $4, Rent, Communications, and Utilities: Rental of Equipment... $117,696 $152,100 $132,000 $168,400 $148,000 $166,000 $16,000 $18,000 Communications... $250,879 $248,600 $274,000 $264,700 $299,200 $326,800 $25,200 $27,600 Utilities... $648 $0 $0 $0 $0 $0 $0 $0 GSA Rent... ($2) $0 $0 $0 $0 $0 $0 $0 Other Real Property Rental... $905 $0 $0 $0 $0 $0 $0 $0 Subtotal... $370,126 $400,700 $406,000 $433,100 $447,200 $492,800 $41,200 $45, Printing & Reproduction:... $9,023 $23,700 $9,200 $24,200 $9,400 $9,600 $200 $ Other Contractual Services: Non-VA Outpatient Dental Care 2/... $137,655 $146,300 $163,300 $160,200 $193,700 $229,800 $30,400 $36,100 Medical and Nursing Non-VA Care 3/... $1,770,453 $2,149,500 $1,862,000 $2,317,300 $1,958,300 $2,059,500 $96,300 $101,200 Repairs to Furniture/Equipment... $214,641 $205,600 $220,000 $212,300 $225,500 $231,100 $5,500 $5,600 Maintenance & Repair Contract Services... $27,435 $39,400 $28,100 $42,400 $28,800 $29,500 $700 $700 Non-VA Hospital Care 4/... $1,900,885 $2,429,800 $2,081,800 $2,757,200 $2,280,000 $2,497,100 $198,200 $217,100 Community Nursing Homes... $676,129 $787,100 $759,300 $811,900 $792,400 $851,600 $33,100 $59,200 Repairs to Prosthetic Appliances... $227,975 $250,200 $259,800 $270,700 $279,100 $298,500 $19,300 $19,400 Home Oxygen... $165,642 $201,600 $191,200 $218,200 $205,400 $219,700 $14,200 $14,300 Personal Services Contracts... $79,503 $103,700 $81,500 $105,800 $83,500 $85,600 $2,000 $2,100 House Staff Disbursing Agreement... $607,861 $672,200 $630,800 $711,600 $654,600 $679,300 $23,800 $24,700 Scarce Medical Specialists... $145,033 $178,100 $148,700 $185,000 $152,400 $156,200 $3,700 $3, Congressional Submission VHA-125

128 Obligations by Object Medical Services (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease 25 Other Contractual Services (continued) Other Medical Contract Services... $3,160,922 $3,862,982 $2,516,283 $3,665,728 $3,474,495 $4,219,731 $958,212 $745,236 Administrative Contract Services... $563,567 $691,300 $604,000 $711,500 $647,400 $693,900 $43,400 $46,500 Training Contract Services... $39,952 $42,000 $41,000 $42,800 $42,000 $43,100 $1,000 $1,100 CHAMPVA... $1,141,793 $1,157,800 $1,258,400 $1,251,200 $1,378,100 $1,508,300 $119,700 $130,200 Subtotal... $10,859,446 $12,917,582 $10,846,183 $13,463,828 $12,395,695 $13,802,931 $1,549,512 $1,407, Supplies & Materials: Provisions... $117,373 $121,500 $121,000 $125,300 $124,800 $128,700 $3,800 $3,900 Drugs & Medicines... $4,948,431 $4,697,200 $5,335,300 $4,941,600 $5,544,700 $5,792,500 $209,400 $247,800 Blood & Blood Products... $64,463 $82,400 $69,500 $86,700 $72,200 $75,500 $2,700 $3,300 Medical/Dental Supplies... $1,396,704 $1,578,800 $1,468,900 $1,684,400 $1,544,800 $1,624,600 $75,900 $79,800 Operating Supplies... $142,658 $145,300 $151,400 $150,900 $160,700 $170,500 $9,300 $9,800 Maintenance & Repair Supplies... $26,226 $0 $0 $0 $0 $0 $0 $0 Other Supplies... $112,860 $108,300 $115,700 $110,500 $118,600 $121,600 $2,900 $3,000 Prosthetic Appliances... $2,001,294 $2,279,900 $2,163,800 $2,467,300 $2,324,800 $2,486,200 $161,000 $161,400 Home Respiratory Therapy... $37,456 $52,600 $49,100 $56,900 $52,700 $56,400 $3,600 $3,700 Subtotal... $8,847,465 $9,066,000 $9,474,700 $9,623,600 $9,943,300 $10,456,000 $468,600 $512, Equipment... $1,226,639 $474,000 $863,300 $387,600 $879,300 $438,800 $16,000 ($440,500) 32 Lands & Structures: Non-Recurring Maintenance... $46 $0 $0 $0 $0 $0 $0 $0 All Other Lands & Structures... $2,375 $0 $0 $0 $0 $0 $0 $0 Subtotal... $2,421 $0 $0 $0 $0 $0 $0 $0 41 Grants, Subsidies & Contributions: State Home... $1,072,732 $946,900 $1,130,000 $985,200 $1,220,000 $1,309,400 $90,000 $89,400 Grants 5/... $511,469 $715,000 $510,700 $715,000 $470,200 $470,200 ($40,500) $0 Subtotal... $1,584,201 $1,661,900 $1,640,700 $1,700,200 $1,690,200 $1,779,600 $49,500 $89, Imputed Interest... $0 $0 $0 $0 $0 $0 $0 $0 Total, Obligations... $46,728,548 $48,833,782 $48,594,183 $50,852,528 $51,914,695 $55,650,078 $3,320,512 $3,735,383 1/ All Other category includes personnel such as medical support assistance, administrative support clerks, administrative specialists, secretaries, social science aid & technicians, administrative officer, purchasing agents, chaplains, management and program analysts, health systems specialists, and other staff that are necessary for the effective operations of VHA medical services. 2/ Formerly known as Medical & Nursing Fees. No change in methodology. 3/ Formerly known as Outpatient Dental Fees. No change in methodology. 4/ Formerly known as Contract Hospital. No change in methodology. 5/ Formerly known as Homeless Programs revised to Grants to better represent all grants, not just grants associated with VA's Homeless programs. No change in methodology. VHA-126 Medical Services

129 Fiscal Year 2014 Actuals Medical Services - All Other (Excludes Veterans Choice Act) Description Obligations ($000) FTE VA Medical Centers & Other Field Activities.. $2,034,434 31,130 VHA Central Office... $984 2 Veteran Integrated Service Networks... $39 0 Total... $2,035,457 31,132 Fiscal Year 2014 Actuals Medical Services - Administrative Contract Services (Excludes Veterans Choice Act) Obligations Description ($000) VA Medical Centers & Other Field Activities.. $435,082 VHA Central Office... $123,426 Veteran Integrated Service Networks... $5,059 Total... $563, Congressional Submission VHA-127

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131 Medical Support and Compliance Medical Support and Compliance Appropriation B i l l i o n s $7.000 $0.000 $5.983 $5.880 $5.874 $6.144 $6.214 $ Actual 2015 Budget Estimate 2015 Current Estimate 2016 Adv. Approp Revised Request 2017 Adv. Approp. Medical Support & Compliance Net Appropriation (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Advance Appropriation... $6,033,000 $5,879,700 $5,879,700 $6,144,000 $6,144,000 $6,524,000 $264,300 $380,000 Annual Appropriation Adjustment... $0 $0 $0 $0 $69,961 $0 $69,961 ($69,961) Subtotal Appropriation Request... $6,033,000 $5,879,700 $5,879,700 $6,144,000 $6,213,961 $6,524,000 $334,261 $310,039 Rescissions, P.L (From Medical Support & Compliance)... ($50,000) $0 $0 $0 $0 $0 $0 $0 Rescission, P.L $0 $0 ($5,609) $0 $0 $0 $5,609 $0 Net Appropriations... $5,983,000 $5,879,700 $5,874,091 $6,144,000 $6,213,961 $6,524,000 $339,870 $310,039 Appropriation Language For necessary expenses in the administration of the medical, hospital, nursing home, domiciliary, construction, supply, and research activities, as authorized by law; administrative expenses in support of capital policy activities; and administrative and legal expenses of the Department for collecting and recovering amounts owed the Department as authorized under chapter 17 of title 38, United States Code, and the Federal Medical Care Recovery Act (42 U.S.C. 2651et seq.); $69,961,000, which shall be 2016 Congressional Submission VHA-129

132 in addition to funds previously appropriated under this heading that became available on October 1, 2015; and, in addition, [$6,144,000,000]$6,524,000,000, plus reimbursements, shall become available on October 1, [2015]2016, and shall remain available until September 30, [2016]2017: Provided, That, of the amount made available on October 1, 2016, under this heading, $100,000,000 shall remain available until September 30, (Military Construction and Veterans Affairs, and Related Agencies Appropriations Act, 2015.) Appropriation Transfers See Appropriation Transfers & Supplementals Chapter for a detailed explanation of the appropriation transfers that affect the Medical Support and Compliance appropriation Funding and 2017 Advance Appropriations Request The Medical Support and Compliance appropriation finances the supporting structures that underlie VHA s ability to deliver high quality health care services to our veterans. Over 68 percent of the FY 2016 total funding for this appropriation is designated for VA Medical Centers, VISNs & Other Field Activities, 21 percent of the funding is designated for National Consolidated Activities and the remaining 11 percent is designated for VHA Central Office. This funding ensures that leadership management teams are in place to govern, provide appropriate oversight for quality of care for our Veterans, essential security services are provided, needed supplies and medications are ordered, health care provider vacancies are filled, financial services and oversight are provide, required medical equipment is procured and patient encounters are appropriately recorded. Details of these critical functions are detailed in the following paragraphs. VHA-130 Medical Support and Compliance

133 2016 Annual Appropriation Adjustment Update to the 2016 Advance Appropriation Request Medical Support & Compliance (Excludes Veterans Choice Act) (dollars in thousands) 2016 Advance Revised Increase/ Description Approp. Request Decrease VA Medical Centers, VISNs & Other Field Activities: VAMCs and Other Field Activities... $3,949,339 $4,054,488 $105,149 VISN Headquarters... $303,339 $188,703 ($114,636) Subtotal... $4,252,678 $4,243,191 ($9,487) VHA Central Office: VHA Central Office... $638,329 $675,703 $37,374 Subtotal... $638,329 $675,703 $37,374 National Consolidated Activities: Consolidated Patient Account Centers... $311,303 $305,000 ($6,303) Office of Informatics and Analytics... $270,259 $255,000 ($15,259) Chief Business Office Purchased Care... $227,479 $265,000 $37,521 Employee Education Service Center... $72,287 $73,703 $1,416 VHA Service Center... $255,964 $268,000 $12,036 Health Resource Center... $51,356 $52,703 $1,347 Health Eligibility Center... $49,110 $49,000 ($110) Consolidated Mail Outpatient Pharmacies... $16,847 $17,000 $153 National Center for Patient Safety... $7,453 $6,000 ($1,453) Subtotal... $1,262,058 $1,291,406 $29,348 Obligations [Total]... $6,153,065 $6,210,300 $57,235 Funding Availability: Appropriation... $6,144,000 $6,144,000 $0 Trns to North Chicago Demo. Fund... ($26,935) ($27,332) ($397) Reimbursements... $36,000 $23,671 ($12,329) Funding Availability [Total]... $6,153,065 $6,140,339 ($12,726) Annual Appropriation Adjustment... $0 $69,961 $69, Congressional Submission VHA-131

134 Additional 2016 Appropriation Request Medical Support and Compliance A 2016 advance appropriation of $6.1 billion for Medical Support and Compliance was enacted in P.L The 2016 budget requests an additional $70.0 million to support the management, security, and administration of VA s health care system. The additional funding is required primarily to support an increased staffing level, as well as travel and transportation. From the 2016 advance appropriation, personnel compensation and benefits costs are expected to increase by $283.7 million to support 54,020 total FTEs, which is an additional 5,006 FTEs over the level in the 2016 advance request. Part of the cost increase is attributable to a change in the proposed pay raise from 1 percent to 1.3 percent. However, the majority of the funding increase is due to additional staffing requirements for field activities at the VA Medical Centers and VISNs. The additional positions are being added to the Medical Centers and VISNs to support and fulfill the Secretary s vision of becoming a more Veteran-centric organization and to be able to provide top-level customer service in a more efficient manner to our Veterans; as a result, some of the positions we are increasing are: Personnel Management Specialist, Police, Contract Administrator, Voucher Examiner, Claims Assistant, Emergency Management Series, Medical Records Clerk/Technician, Health Systems Specialist, Administrative Officer, Security Clerical & Assistance. These personnel are in direct support of VA s objective to manage and improve VA operations to deliver seamless and integrated support. These personnel will support healthcare workers in order to deliver the healthcare services that our Veterans expect. In addition, travel and transportation costs are expected to increase by $32.2 million over the 2016 advance appropriation in order to increase support for employee training, collaboration, and oversight. Offsetting these increases are decreases of nearly $275 million in contractual services; rental of equipment and communications; and equipment. Below, the funding represents total obligations in 2016 and Program Resources (Excludes Veterans Choice Act) $6.210 billion in 2016 $6.520 billion in 2017 In an effort to provide better visibility into the spending under this appropriation, VA is providing additional detail on obligations by the categories below. Obligations in this account finance activities at the VHA National Consolidated Activities and VHA Central Office; however, most of the resources support activities at VA Medical Centers and other VA field offices that provide or help administer direct patient care. The charts below reflect VA s actuals for 2014, current plan for 2015, revised request for 2016, and 2017 estimate. VHA-132 Medical Support and Compliance

135 Summary of Obligations by Functional Area Medical Support and Compliance (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease VA Medical Centers, VISNs & Other Field Activities: VAMCs and Other Field Activities... $3,876,407 $3,771,578 $3,849,062 $3,949,339 $4,054,488 $4,299,428 $205,426 $244,940 VISN Headquarters... $180,856 $297,100 $179,686 $303,339 $188,703 $194,364 $9,017 $5,661 Subtotal... $4,057,263 $4,068,678 $4,028,748 $4,252,678 $4,243,191 $4,493,792 $214,443 $250,601 VHA Central Office: VHA Central Office... $656,630 $625,200 $655,686 $638,329 $675,703 $695,974 $20,017 $20,271 Subtotal... $656,630 $625,200 $655,686 $638,329 $675,703 $695,974 $20,017 $20,271 National Consolidated Activities: Consolidated Patient Account Centers... $291,958 $304,900 $290,000 $311,303 $305,000 $314,150 $15,000 $9,150 Office of Informatics and Analytics... $244,422 $264,700 $242,000 $270,259 $255,000 $262,650 $13,000 $7,650 Chief Business Office Purchased Care 1/... $253,927 $222,800 $252,000 $227,479 $265,000 $272,950 $13,000 $7,950 Employee Education Service Center... $71,363 $70,800 $70,686 $72,287 $73,703 $75,914 $3,017 $2,211 VHA Service Center... $257,316 $250,700 $255,000 $255,964 $268,000 $276,040 $13,000 $8,040 Health Resource Center... $51,225 $50,300 $50,686 $51,356 $52,703 $54,284 $2,017 $1,581 Health Eligibility Center... $47,196 $48,100 $47,000 $49,110 $49,000 $50,470 $2,000 $1,470 Consolidated Mail Outpatient Pharmacies... $16,358 $16,500 $16,000 $16,847 $17,000 $17,510 $1,000 $510 National Center for Patient Safety... $6,323 $7,300 $6,000 $7,453 $6,000 $6,180 $0 $180 Subtotal... $1,240,088 $1,236,100 $1,229,372 $1,262,058 $1,291,406 $1,330,148 $62,034 $38,742 Total... $5,953,981 $5,929,978 $5,913,806 $6,153,065 $6,210,300 $6,519,914 $296,494 $309,614 1/ Previously Health Administration Center 2016 Congressional Submission VHA-133

136 Fiscal Year 2014 Actuals Medical Support and Compliance (Excludes Veterans Choice Act) Pay & All Description Benefits 2/ Capital 3/ Other 4/ Total FTE VA Medical Centers, VISNs & Other Field Activities: VAMCs and Other Field Activities... $3,240,901 $44,253 $591,253 $3,876,407 37,882 VISN Headquarters... $158,728 $472 $21,656 $180,856 1,108 Subtotal... $3,399,629 $44,725 $612,909 $4,057,263 38,990 VHA Central Office: VHA Central Office... $248,226 $855 $407,549 $656,630 1,742 Subtotal... $248,226 $855 $407,549 $656,630 1,742 National Consolidated Activities: Consolidated Patient Account Centers... $245,539 $99 $46,320 $291,958 3,682 Office of Informatics and Analytics... $93,329 $6 $151,087 $244, Chief Business Office Purchased Care 1/... $96,905 $107 $156,915 $253,927 1,095 Employee Education Service Center... $39,429 $783 $31,151 $71, VHA Service Center... $239,275 $358 $17,683 $257,316 2,535 Health Resource Center... $48,238 $669 $2,318 $51, Health Eligibility Center... $26,674 $47 $20,475 $47, Consolidated Mail Outpatient Pharmacies... $14,786 $18 $1,554 $16, National Center for Patient Safety... $5,854 $21 $448 $6, Subtotal... $810,029 $2,108 $427,951 $1,240,088 9,591 Total... $4,457,884 $47,688 $1,448,409 $5,953,981 50,323 1/ Previously Health Administration Center 2/ Pay Benefits = 10 Personnel Compensation and Benefits. 3/ Capital = 31 Equipment and 32 Lands and Structures. 4/ All Other = 31 Travel & Transportation of Persons; 22 Transportation of Things; 23 Rent, Communications & Utilities; 24 Printing & Reproduction; 25 Other Contractual Services; and 26 Supplies & Materials VA Medical Centers, VISNs & Other Field Activities VA Medical Centers and Other Field Activities to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Obligations ($000)... $3,876,407 $3,771,578 $3,849,062 $3,949,339 $4,054,488 $4,299,428 $205,426 $244,940 Funding in this account for VA Medical Centers and other field activities supports the management, operation, oversight, security, and administration of the VA s health care system. This includes medical center management teams (Director, Chief of Staff, Chief Medical Officer, and Chief Nurse), medical center support functions (quality of care oversight, security services, legal services, billing and coding activities, acquisition, procurement, and logistics activities), human resource management, logistics and supply chain management, and financial management. Of the many functions required to operate VHA facilities, one essential function is revenue generation. This begins at the medical VHA-134 Medical Support and Compliance

137 centers and clinics with the verification of insurance and the coding of inpatient and outpatient encounters. Veteran Integrated Service Networks (VISN) Headquarters to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Obligations ($000)... $180,856 $297,100 $179,686 $303,339 $188,703 $194,364 $9,017 $5,661 These funds provide the necessary resources for the 21 VISN offices that provide regional support, management and oversight to the medical centers, clinics and other field activities within their regions. This includes but is not limited to network leadership teams (Network Director, Deputy Network Director, Chief Financial Officer, Chief Medical Officer, and Chief Information Officer) and clinical and administrative functional leads that are centrally located to provide leadership to those programs within each VISN. Each VISN office is responsible for coordinating the delivery of health care to Veterans by leveraging and integrating operations at all of the VA health care facilities within the VISN. VHA Central Office to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Obligations ($000)... $656,630 $625,200 $655,686 $638,329 $675,703 $695,974 $20,017 $20,271 VHA Central Office (VHACO) is the headquarters for one of the world s largest integrated health care systems. With a medical care budget of more than $59 billion, VHA in 2015 anticipates employing nearly 290,000 personnel 1, including hospitals, clinics, nursing homes, domiciliaries, and Readjustment Counseling Centers. In addition, VHA is the Nation s largest provider of graduate medical education and a major contributor to medical research. Over nine million Veterans are enrolled in VA s health care system. VHACO is led by the Under Secretary for Health whose office serves as the Department s central coordination point for the establishment or implementation of policies, practices, management and operational activities of VHA. This must be done in order to most effectively carry out the mission of Honoring America's Veterans by providing exceptional health care that improves their health and well-being. VHACO provides the strategic, policy and operational leadership that coordinates and governs VHA activities including development of strategic direction, deployment and measurement of performance, accountability, and transparency of decision making. VHACO assures organizational oversight to the vision, values and mission of VHA, and alignment with the strategic direction and goals of the administration and department. In addition to the Office of the Under Secretary for Health, which includes the VHA Chief of Staff, Office of Research Oversight, the Office of the Medical Inspector, and Readjustment Counseling Services, VHACO also includes the Principal Deputy Under 1 Excludes Veterans Choice Act Congressional Submission VHA-135

138 Secretary for Health, the Deputy Under Secretary for Health for Operations and Management, and the Deputy Under Secretary for Health for Policy and Services. The Principal Deputy Under Secretary for Health provides leadership for the Office for Quality, Safety and Value, Office of Nursing, Office for Workforce Services, Office of Strategic Integration, Office of Health Equity, and Office of Finance. The Deputy Under Secretary for Health for Operations and Management (DUSHOM), oversees field operations, providing broad and general operational direction and guidance. The DUSHOM is also responsible for other VHACO administrative programs (e.g., business operations, environmental programs management, canteen services, health care engineering, safety and technical services, acquisition and procurement, capital assets) and clinical operations (e.g., surgical services, primary care, dentistry, geriatrics, mental health, sterile processing, disability medical assessment, and the homeless program). The Deputy Under Secretary for Health for Policy and Services provides leadership for the offices responsible for health care policy, projecting the demand for health care services for strategic planning and budgeting, addressing the public health needs of Veterans, overseeing the policy development of all clinical care provided by the healthcare workforce, developing and coordinating collaboration with DoD and other federal agencies, developing and providing the health informatics and analytical and business intelligence to support the nation s largest integrated health care system, a robust research and development portfolio and ensure adherence to the highest ethical standards in health care. National Consolidated Activities Consolidated Patient Account Centers (CPACs) to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Obligations ($000)... $291,958 $304,900 $290,000 $311,303 $305,000 $314,150 $15,000 $9,150 Consolidated Patient Account Center (CPAC) business model utilizes industry-proven methods, processes, business tools, and increased accountability to achieve superior levels of sustained revenue cycle management. Under the CPAC program, VHA consolidated traditional revenue program functions into seven regionalized account centers. Under this model, each of the 144 VA Hospitals maintains ownership of key patient-facing revenue functions, while back-end revenue cycle processes are performed at the CPACs. The CPAC model was tested in a 2006 pilot that established the Mid-Atlantic CPAC. Following this, Congress enacted the Veterans Mental Health and Other Improvements Act (P.L ) in October 2008 which mandated national implementation of the CPAC business model by All seven centers were operational by the end of 2012, one year ahead of the date mandated by the law. The seven centers include: Mid Atlantic CPAC Asheville, NC (VISNs 5, 6, and 7) Mid South CPAC Smyrna, TN (VISNs 9, 16, and 17) Florida/Caribbean CPAC Orlando, FL (VISN 8) North Central CPAC Middleton, WI (VISNs 10, 11, and 12) VHA-136 Medical Support and Compliance

139 North East CPAC Lebanon, PA (VISNs 1, 2, 3, and 4) Central Plains CPAC Leavenworth, KS (VISNs 15, 19 and 23) West CPAC Las Vegas, NV (VISNs 18, 20, 21 and 22) Office of Informatics and Analytics (OIA) to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Obligations ($000)... $244,422 $264,700 $242,000 $270,259 $255,000 $262,650 $13,000 $7,650 Office of Informatics and Analytics (OIA) has the Program Office located in Washington, DC with satellite offices across the country, and offers advanced and secure health information tools, including a world-class electronic health record, patient-facing health technology applications, enterprise data systems, sophisticated analysis and measurement, user-centered decision support, and agile business intelligence. OIA facilitates evidencebased decisions for individual Veterans and their families, patient populations, clinicians, and those managing health care delivery systems. 1. Analytics and Business Intelligence (ABI)- The role of ABI is to provide timely, reliable and sophisticated analytic and business intelligence solutions and to facilitate evidence-based decisions for Veterans and their families, clinicians, and those managing health care delivery systems. ABI serves the data management needs of VHA to assure that managers, clinicians, researchers and stakeholders using VA s extensive health data resources possible to deliver high quality health care in the most efficient and effective manner possible. Critical functions performed by ABI include measuring the quality, accessibility and safety of health care, evaluating productivity, assessing Veteran s satisfaction and experience of care, internal and public reporting of data (including at the point-of-care), and training employees throughout VHA to apply data thoughtfully 2. Connected Health Office (CHO) CHO collaborates with partners throughout VA to leverage technology and innovation in transforming the delivery of care for Veterans, their families and Caregivers with unified, integrated and personalized virtual services that connect them with a state-of-the-art system of care. CHO creates solutions that enable VA health care teams to seamlessly provide and coordinate services across geography and the care continuum as well as produces a consistent experience for users and continuously improve based on user input, research and evaluation. CHO s Web & Mobile Solutions develops mobile solutions, including mobile applications (apps and mobile-optimized Web sites, to assist Veterans, Caregivers and clinicians and to address a range of health, management and administrative needs. CHO s VHA Innovation Program allows critical health care innovations to emerge from the field. My HealtheVet, which joined CHO in January 2014, is VA s online personal health record, which provides Veterans, active duty Servicemembers, their dependents and caregivers with opportunities and tools to make informed decisions and manage their health care. 3. Health Informatics (HI) HI is the focal point for the advancement of VA s electronic health record (EHR) and information systems and serves as the primary advocate for field clinicians as it relates to health information technology (HIT). HI is the home to such 2016 Congressional Submission VHA-137

140 programs as Veterans Integrated System Technology Architecture (VistA) Evolution, Virtual Lifetime Electronic Record (VLER) Health Program, Bar Code Medication Administration (BCMA), Informatics Patient Safety; Applied Informatics Service; Human Factors; Knowledge-Based Systems; Informatics Patient Safety.; 4. Health Information Governance (HIG) HIG provides subject matter expertise, policy guidance, compliance monitoring, and support in the areas of information access, privacy, Freedom of Information Act (FOIA) requests, health care information security, data systems, person identity services, health information management (HIM), records management, data quality and library services. It represents VA on national and international health care policy initiatives regarding Veterans data. HIG serves as VHA's subject matter and policy expert regarding data contained in Veterans' electronic health records (EHR) and in national data systems. 5. Strategic Investment Management (SIM) SIM informs decision making for prioritization of health-focused Information Technology (IT) funding/investments and business-driven sequencing of future health information functionality. SIM provides leadership with a comprehensive understanding of needed VHA business capabilities including business requirements, processes, information needs, IT strategy and priorities, and investment analysis. SIM provides a wide range of services including, business requirements/architecture development for health IT solution development or acquisition, business process re-engineering, software release management, health IT governance management, health IT analysis and budget development, health IT strategic planning and business transformation, as well VistA Standardization coordination with the Open Source Community. SIM is comprised of four organizational services: Business Architecture, Common Services and Investment Management, Open Source Management, and Requirements Development and Management. 6. Program Support Operations This office supports all of OIA by providing budget, finance, procurement, human resources, and communication services. Chief Business Office Purchased Care (CBOPC) to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Obligations ($000)... $253,927 $222,800 $252,000 $227,479 $265,000 $272,950 $13,000 $7,950 Chief Business Office Purchased Care (CBOPC), previously referred to as Health Administration Center (HAC), is responsible for a broad range of activities to support the delivery of health care benefits for Veterans and eligible dependents. CBOPC provides assistance to VHA medical facilities by leading the transformation of purchased care business practices, implementing health benefits policy, and supporting the delivery of quality health care through management of the following programs: Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) CHAMPVA In-House Treatment Initiative (CITI) VHA-138 Medical Support and Compliance

141 CHAMPVA Meds by Mail Program Spina Bifida Health Care Program Children of Women Vietnam Veterans Health Care Program Foreign Medical Program Caregiver Support Program Non-VA Medical Care (NVC) Veterans Choice Program Patient-Centered Community Care (PC3) State Veterans Home (SVH) Per Diem Program Project Access Received Closer to Home (ARCH) Indian Health Services(IHS)/Tribal Health Program (THP) Camp Lejeune In addition, CBOPC provides communications support for the programs it manages and stakeholder briefings for Veterans, beneficiaries, Veterans Service Officers, and other external stakeholders. Employee Education Service Center to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Obligations ($000)... $71,363 $70,800 $70,686 $72,287 $73,703 $75,914 $3,017 $2,211 Within VHA, the Employee Education Service Center (EES), located in Washington, D.C., with satellite offices across the country, partners with VHA program offices, VISNs, and medical centers to assess and determine learning requirements, design curricula and courses, and deliver and evaluate education and training to meet the workforce development, continuing education, and competency-based needs of clinical, administrative and technical employees. EES maintains accreditations with professional organizations in order to ensure quality and relevance of all training offered to VHA employees who provide or support health care programs and services to Veterans. Learning is delivered via a comprehensive set of training modalities which can be offered singularly or as part of a blended learning strategy. EES develops and delivers quality educational programs, products and services using sound educational design and evaluation and employing a variety of delivery methods designed to be responsive to VHA employees learning needs and preferences. In addition to traditional approaches, EES employs contemporary and emerging technologies, including clinical simulation training, that meet the learning needs of a highly skilled and mobile workforce. EES continues to lead the cultural transformation of VHA into a learning organization, which links learning outcomes to organizational health, employee engagement and patient satisfaction. EES coordinates inter-agency sharing initiatives within and beyond VA that benefit learners in a number of other Federal agencies Congressional Submission VHA-139

142 VHA Service Center (VSC) to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Obligations ($000)... $257,316 $250,700 $255,000 $255,964 $268,000 $276,040 $13,000 $8,040 The VHA Service Center (VSC), located in Independence, Ohio, provides a wide-range of fiscal, payroll, travel and/or human resource management services to the Office of Informatics and Analytics (OIA), Office of Resolution Management (ORM), and the Service Area Offices (SAO) West, East and Central organizations. The VSC also provides Fiscal Services to the Employee Education System (EES). VSC s mission is to provide quality Fiscal and Human Resources services through superior customer service, experience, and innovation. An itemized list of Fiscal and Human Resources services is shown below. VSC is committed to education and developing our managers and employees to provide our customers with the most qualified and knowledgeable staff. In 2014, VSC provided Fiscal and HR services to over 4,300 customers from VA Central Office, VHA and the Veterans Benefits Administration (VBA). VSC Services: Fiscal: Financial Accounting & Budgeting, Payroll, Travel, Auditing, Purchases Human Resources: Recruitment & Staffing, Classification, Personnel Security, (federal employees/contractors), Employee/Labor Relations, Benefits, Performance and Recognition review Health Resource Center (HRC) to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Obligations ($000)... $51,225 $50,300 $50,686 $51,356 $52,703 $54,284 $2,017 $1,581 Health Resource Center (HRC) provides customer service and support to Veterans, their beneficiaries, caregivers, other government agencies and the general public regarding VA health benefits, eligibility, billing and pharmacy-related inquiries. HRC also assists with a variety of other interests within VA, such as disaster support, payroll administration and technical support. HRC has served as a national point of contact for VA in support of Veterans and related administrative initiatives since FY 2014, the HRC responded to over 6 million Veteran inquiries by way of phone, , and web chat. HRC has a primary campus on the grounds of the Eastern Kansas Health Care System in Topeka, Kansas, and a second campus on the grounds of the Central Texas Health Care System in Waco, Texas. HRC is organizationally aligned under CBO. VHA-140 Medical Support and Compliance

143 Health Eligibility Center (HEC) to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Obligations ($000)... $47,196 $48,100 $47,000 $49,110 $49,000 $50,470 $2,000 $1,470 Health Eligibility Center (HEC), located in Atlanta, GA, supports VA s health care delivery system by providing centralized eligibility verification and enrollment processing services. HEC determines a Veteran s health eligibility and facilitates the process by providing guidance to the field, informational outreach, training, policy development and implementation. HEC enables the ability to execute a seamless handoff from enrollment decision to provision of care. Additionally, the HEC provides direct and indirect systems management support to numerous other VA business lines improving the ability to provide care to Veterans. Consolidated Mail Outpatient Pharmacies (CMOP) to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Obligations ($000)... $16,358 $16,500 $16,000 $16,847 $17,000 $17,510 $1,000 $510 VA CMOP program provides outpatient pharmaceutical dispensing support services to Veterans being cared for at VA healthcare facilities and medical centers located within each of the VISNs throughout the United States. The CMOP acts as an extension of the medical facility pharmacies providing the fulfillment services for 80 percent of all outpatient prescriptions provided to Veterans by VHA. This is accomplished through the use of highly automated technologies that support the dispensing of over 474,000 prescriptions every work day and million prescriptions a year. The CMOP program consists of a network of seven pharmacies located in Chelmsford, MA; Charleston, SC; Dallas, TX; Hines, IL; Leavenworth, KS; Murfreesboro, TN and Tucson, AZ. CMOP activities are funded through user fees paid by the VHA medical facilities utilizing the service. CMOP provides prescription fulfillment services, i.e., filling and mailing outpatient prescriptions, directly to beneficiaries of the Indian Health Service as well as all of VHA. Seventy-eight IHS/tribal health program sites have been set up to participate in the CMOP program. National Center for Patient Safety (NCPS) to to Budget Current Advance Revised Advance Increase/ Increase/ Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Obligations ($000)... $6,323 $7,300 $6,000 $7,453 $6,000 $6,180 $0 $180 NCPS, a highly collaborative branch of the Office of Quality Safety and Value (QSV), is field-based in Ann Arbor, MI and White River Junction, VT, with a minimal presence in Washington, DC. The fundamental mission of NCPS is prevention of patient harm. NCPS approaches, products, services, and research are developed on behalf of and for use by Veterans, Facilities, Networks and Central Office Program Offices and are based on High Reliability Organization (HRO) and Human Factors Engineering (HFE) experience and science. Some core functions include: information and tools designed for Veterans and their 2016 Congressional Submission VHA-141

144 families/caregivers (e.g., The Daily Plan, Healthcare Literacy); training and education for all levels of VHA staff and trainees (e.g., Basic Patient Safety, Clinical Team Training, Residency Curriculum); national data collection, analysis and feedback related to adverse events and close calls (e.g., Root Cause Analysis, Healthcare Failure Mode and Effects Analysis) and; analysis of high risk situations and dissemination of solution based information and guidance (e.g., Alerts, Advisories, Product Recalls, Lessons Learned, etc.). VHA-142 Medical Support and Compliance

145 Medical Support and Compliance Program Resource Data Summary of Total Request, Medical Support & Compliance (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Advance Appropriation... $6,033,000 $5,879,700 $5,879,700 $6,144,000 $6,144,000 $6,524,000 $264,300 $380,000 Annual Appropriation Adjustment... $0 $0 $0 $0 $69,961 $0 $69,961 ($69,961) Subtotal Appropriation Request... $6,033,000 $5,879,700 $5,879,700 $6,144,000 $6,213,961 $6,524,000 $334,261 $310,039 Rescissions, P.L (From Medical Support & Compliance). ($50,000) $0 $0 $0 $0 $0 $0 $0 Rescission, P.L $0 $0 ($5,609) $0 $0 $0 $5,609 $0 Net Appropriations... $5,983,000 $5,879,700 $5,874,091 $6,144,000 $6,213,961 $6,524,000 $339,870 $310,039 Transfers: To North Chicago Demo. Fund... ($24,740) ($26,222) ($26,608) ($26,935) ($27,332) ($28,067) ($724) ($735) To Med. Services from Med. Support and Compliance... ($59,830) $0 $0 $0 $0 $0 $0 $0 Subtotal Transfers... ($84,570) ($26,222) ($26,608) ($26,935) ($27,332) ($28,067) ($724) ($735) Total Budget Authority... $5,898,430 $5,853,478 $5,847,483 $6,117,065 $6,186,629 $6,495,933 $339,146 $309,304 Reimbursements... $12,224 $35,000 $23,671 $36,000 $23,671 $23,671 $0 $0 Adjustments to Obligations: Unobligated Balance (SOY): Veterans Access - PL , Section $0 $0 $0 $0 $17,000 $0 $17,000 ($17,000) No-Year... $0 $0 $1,503 $0 $0 $0 ($1,503) $0 H1N1 No-Year (PL )... $2,368 $1,500 $0 $0 $0 $0 $0 $0 2-Year... $84,121 $40,000 $41,149 $0 $0 $0 ($41,149) $0 Subtotal... $86,489 $41,500 $42,652 $0 $17,000 $0 ($25,652) ($17,000) Prior Year Recoveries... $0 $0 $0 $0 $0 $310 $0 $310 Transfer of Unobligated Balance, PL , Section $0 $0 $27,500 $0 $0 $0 ($27,500) $0 Unobligated Balance (EOY): Veterans Access - PL , Section $0 $0 ($17,000) $0 $0 $0 $17,000 $0 No-Year... ($1,503) $0 $0 $0 $0 $0 $0 $0 H1N1 No-Year (PL )... $0 $0 $0 $0 $0 $0 $0 $0 2-Year... ($41,149) $0 $0 $0 $0 $0 $0 $0 Subtotal... ($42,652) $0 ($17,000) $0 $0 $0 $17,000 $0 Change in Unobligated Balance (Non-Add)... $43,837 $41,500 $25,652 $0 $17,000 $0 ($8,652) ($17,000) Lapse... ($510) $0 $0 $0 $0 $0 $0 $0 Obligations... $5,953,981 $5,929,978 $5,924,306 $6,153,065 $6,227,300 $6,519,914 $302,994 $292,614 Less: Veterans Choice Act Obligations... $0 $0 ($10,500) $0 ($17,000) $0 ($6,500) $17,000 Obligations Excluding Veterans Choice Act... $5,953,981 $5,929,978 $5,913,806 $6,153,065 $6,210,300 $6,519,914 $296,494 $309, Congressional Submission VHA-143

146 FTE by Type Medical Support and Compliance (Excludes Veterans Choice Act) to to Budget Current Advance Revised Advance Increase/ Increase/ Account Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Physicians Dentists Registered Nurses... 3,074 2,960 3,291 2,960 3,365 3, LP Nurse/LV Nurse/Nurse Assistant Non-Physician Providers Health Technicians/Allied Health... 1,143 1,206 1,092 1,206 1,119 1, Wage Board/Purchase & Hire , All Other 1/... 44,216 42,994 46,490 42,994 47,550 48,678 1,060 1,128 Total... 50,323 49,014 52,814 49,014 54,020 55,300 1,206 1,280 1/ The All Other category includes: Administrative Support Clerk, Administrative Specialist, Police, Personnel Management Specialist, Management And Program Analyst, Medical Records Clerk/Technician, Budget/Fiscal, Contract Administrator, Supply Technician, Medical Support Assistance, and other staff that are necessary for the effective operations of VHA Medical Support & Compliance. VHA-144 Medical Support and Compliance

147 Medical Support & Compliance Employment Summary, FTE by Grade VA Medical Centers, VISNs, & Other Field Activities (Excludes Veterans Choice Act) 2015 to to Increase/ Increase/ GS Grade or Title 38 Actual Estimate Estimate Estimate Decrease Decrease SES Title ,461 3,678 3,783 3, or higher ,022 1,052 1, ,340 2,487 2,558 2, ,500 3,719 3,826 3, ,743 3,978 4,091 4, ,697 3,929 4,041 4, ,929 2,050 2,108 2, ,500 5,845 6,012 6, ,782 7,208 7,413 7, ,294 4,563 4,694 4, ,884 2,002 2,059 2, Wage Board ,025 1, Total Number of FTE... 39,733 42,224 43,430 44,710 1,206 1, Congressional Submission VHA-145

148 Medical Support & Compliance Employment Summary, FTE by Grade VHA Central Office (Excludes Veterans Choice Act) 2015 to to Increase/ Increase/ GS Grade or Title 38 Actual Estimate Estimate Estimate Decrease Decrease SES Title or higher Wage Board Total Number of FTE... 1,757 1,757 1,757 1, VHA-146 Medical Support and Compliance

149 Medical Support & Compliance Employment Summary, FTE by Grade VHA National Consolidated Activities (Excludes Veterans Choice Act) 2015 to to Increase/ Increase/ GS Grade or Title 38 Actual Estimate Estimate Estimate Decrease Decrease SES Title or higher ,352 1,352 1,352 1, ,913 1,913 1,913 1, ,154 1,154 1,154 1, Wage Board Total Number of FTE... 8,833 8,833 8,833 8, Congressional Submission VHA-147

150 Obligations by Object Medical Support and Compliance (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease 10 Personnel Compensation and Benefits: Physicians... $185,048 $196,000 $194,900 $204,900 $204,700 $215,400 $9,800 $10,700 Dentists... $3,721 $4,700 $2,900 $4,900 $3,100 $3,300 $200 $200 Registered Nurses... $387,611 $391,500 $422,300 $404,100 $442,400 $463,500 $20,100 $21,100 LP Nurse/LV Nurse/Nurse Assistant... $5,777 $5,800 $6,700 $6,000 $7,200 $7,600 $500 $400 Non-Physician Providers... $35,815 $36,800 $33,600 $38,100 $35,300 $37,000 $1,700 $1,700 Health Technicians/Allied Health... $121,331 $130,600 $118,000 $134,800 $123,900 $130,200 $5,900 $6,300 Wage Board/Purchase & Hire... $55,890 $57,200 $59,100 $58,900 $61,700 $64,400 $2,600 $2,700 All Other 1/... $3,612,535 $3,658,400 $3,861,300 $3,780,000 $4,042,400 $4,247,200 $181,100 $204,800 Permanent Change of Station... $9,298 $11,500 $9,500 $11,700 $9,700 $9,900 $200 $200 Employee Compensation Pay... $40,858 $44,900 $41,700 $45,800 $42,500 $43,400 $800 $900 Subtotal... $4,457,884 $4,537,400 $4,750,000 $4,689,200 $4,972,900 $5,221,890 $222,900 $248, Travel & Transportation of Persons: Employee... $45,703 $41,600 $57,100 $41,600 $71,400 $89,300 $14,300 $17,900 Beneficiary... $30 $0 $0 $0 $0 $0 $0 $0 Other... $5,388 $4,100 $6,000 $4,300 $6,700 $7,500 $700 $800 Subtotal... $51,121 $45,700 $63,100 $45,900 $78,100 $96,800 $15,000 $18, Transportation of Things... $15,314 $11,300 $17,100 $12,400 $19,000 $21,200 $1,900 $2, Rent, Communications, and Utilities: Rental of Equipment... $45,982 $36,500 $51,800 $56,700 $58,400 $65,800 $6,600 $7,400 Communications... $72,026 $80,500 $72,900 $102,100 $73,800 $74,700 $900 $900 Utilities... $0 $0 $0 $0 $0 $0 $0 $0 GSA Rent... $26 $0 $0 $0 $0 $0 $0 $0 Other Real Property Rental... $844 $0 $0 $0 $0 $0 $0 $0 Subtotal... $118,878 $117,000 $124,700 $158,800 $132,200 $140,500 $7,500 $8, Printing & Reproduction:... $17,852 $10,700 $18,300 $11,100 $18,800 $19,300 $500 $ Other Contractual Services: Non-VA Outpatient Dental Care 2/... $0 $0 $0 $0 $0 $0 $0 $0 Medical and Nursing Non-VA Care 3/... $3,894 $4,100 $3,900 $4,500 $4,000 $4,100 $100 $100 Repairs to Furniture/Equipment... $3,137 $3,500 $3,400 $6,900 $3,700 $4,100 $300 $400 Maintenance & Repair Contract Services... $1,482 $0 $0 $0 $0 $0 $0 $0 Non-VA Hospital Care 4/... $0 $0 $0 $0 $0 $0 $0 $0 Community Nursing Homes... $0 $0 $0 $0 $0 $0 $0 $0 Repairs to Prosthetic Appliances... $1 $0 $0 $0 $0 $0 $0 $0 Home Oxygen... $0 $0 $0 $0 $0 $0 $0 $0 Personal Services Contracts... $19,800 $5,000 $20,300 $5,400 $20,800 $21,300 $500 $500 House Staff Disbursing Agreement... $58 $0 $0 $0 $0 $0 $0 $0 Scarce Medical Specialists... $0 $0 $0 $0 $0 $0 $0 $0 VHA-148 Medical Support and Compliance

151 Obligations by Object Medical Support and Compliance (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease 25 Other Contractual Services (continued) Other Medical Contract Services... $11,637 $14,200 $11,900 $14,800 $12,200 $12,500 $300 $300 Administrative Contract Services... $1,089,226 $1,033,078 $755,906 $1,055,765 $799,800 $825,724 $43,894 $25,924 Training Contract Services... $12,613 $10,500 $12,900 $10,500 $13,200 $13,500 $300 $300 CHAMPVA... $0 $0 $0 $0 $0 $0 $0 $0 Subtotal... $1,141,848 $1,070,378 $808,306 $1,097,865 $853,700 $881,224 $45,394 $27, Supplies & Materials: Provisions... $3,843 $0 $0 $0 $0 $0 $0 $0 Drugs & Medicines... $0 $0 $0 $0 $0 $0 $0 $0 Blood & Blood Products... $0 $0 $0 $0 $0 $0 $0 $0 Medical/Dental Supplies... $2,611 $0 $0 $0 $0 $0 $0 $0 Operating Supplies... $29,837 $29,400 $30,600 $29,400 $31,400 $32,200 $800 $800 Maintenance & Repair Supplies... $67 $0 $0 $0 $0 $0 $0 $0 Other Supplies... $67,038 $70,800 $68,700 $70,800 $70,400 $72,200 $1,700 $1,800 Prosthetic Appliances... $0 $0 $0 $0 $0 $0 $0 $0 Home Respiratory Therapy... $0 $0 $0 $0 $0 $0 $0 $0 Subtotal... $103,396 $100,200 $99,300 $100,200 $101,800 $104,400 $2,500 $2, Equipment... $46,685 $37,300 $33,000 $37,600 $33,800 $34,600 $800 $ Lands & Structures: Non-Recurring Maintenance... $0 $0 $0 $0 $0 $0 $0 $0 All Other Lands & Structures... $1,003 $0 $0 $0 $0 $0 $0 $0 Subtotal... $1,003 $0 $0 $0 $0 $0 $0 $0 41 Grants, Subsidies & Contributions: State Home... $0 $0 $0 $0 $0 $0 $0 $0 Grants 5/... $0 $0 $0 $0 $0 $0 $0 $0 Subtotal... $0 $0 $0 $0 $0 $0 $0 $0 43 Imputed Interest... $0 $0 $0 $0 $0 $0 $0 $0 Total, Obligations... $5,953,981 $5,929,978 $5,913,806 $6,153,065 $6,210,300 $6,519,914 $296,494 $309,614 1/ The All Other category includes: Administrative Support Clerk, Administrative Specialist, Police, Personnel Management Specialist, Management And Program Analyst, Medical Records Clerk/Technician, Budget/Fiscal, Contract Administrator, Supply Technician, Medical Support Assistance, and other staff that are necessary for the effective operations of VHA Medical Support & Compliance. 2/ Formerly known as Medical & Nursing Fees. No change in methodology. 3/ Formerly known as Outpatient Dental Fees. No change in methodology. 4/ Formerly known as Contract Hospital. No change in methodology. 5/ Formerly known as Homeless Programs revised to Grants to better represent all grants, not just grants associated with VA's Homeless programs. No change in methodology Congressional Submission VHA-149

152 This Page Intentionally Left Blank VHA-150 Medical Support and Compliance

153 Medical Facilities Medical Facilities Appropriation $7.000 B i l l i o n s $4.957 $4.739 $4.737 $4.915 $5.020 $5.074 $ Actual 2015 Budget Estimate 2015 Current Estimate 2016 Adv. Approp Revised Estimate 2017 Adv. Approp. Medical Facilities Net Appropriations Total (Excludes Veterans Choice Act) (dollars in thousands) Description 2014 Actual Budget Estimate Current Estimate Advance Approp. Revised Estimate Advance Approp. Increase / Decrease Increase / Decrease Advance Appropriation... $4,872,000 $4,739,000 $4,739,000 $4,915,000 $4,915,000 $5,074,000 $176,000 $159,000 Mandatory Appropriation (P.L )... $0 $0 $0 $0 $0 $0 $0 $0 Annual Appropriation Adjustment... $85,000 $0 $0 $0 $105,132 $0 $105,132 ($105,132) Subtotal Appropriation Request... $4,957,000 $4,739,000 $4,739,000 $4,915,000 $5,020,132 $5,074,000 $281,132 $53,868 Rescission, P.L $0 $0 ($2,000) $0 $0 $0 $2,000 $0 Net Appropriations... $4,957,000 $4,739,000 $4,737,000 $4,915,000 $5,020,132 $5,074,000 $283,132 $53,868 Appropriation Language For necessary expenses for the maintenance and operation of hospitals, nursing homes, domiciliary facilities, and other necessary facilities of the Veterans Health Administration; for administrative expenses in support of planning, design, project management, real property acquisition and disposition, construction, and renovation of any facility under the jurisdiction or for the use of the Department; for oversight, engineering, and architectural activities not charged to project costs; for repairing, altering, improving, or providing facilities in the several hospitals and homes under the jurisdiction of the Department, not otherwise provided for, either by contract or by the hire of temporary employees and purchase of materials; 2016 Congressional Submission VHA-151

154 for leases of facilities; and for laundry services; $105,132,000, which shall be in addition to funds previously appropriated under this heading that became available on October 1, 2015; and, in addition, [$4,915,000,000]$5,074,000,000, plus reimbursements, shall become available on October 1, [2015]2016, and shall remain available until September 30, [2016]2017: Provided, That, of the amount made available on October 1, 2016, under this heading, $250,000,000 shall remain available until September 30, (Military Construction and Veterans Affairs, and Related Agencies Appropriations Act, 2015.) Appropriation Transfers See Appropriation Transfers & Supplementals Chapter for a detailed explanation of the appropriation transfers that affect the Medical Facilities appropriation Funding and 2017 Advance Appropriations Request The Medical Facilities appropriation supports the operation and maintenance of the Department of Veterans Affairs (VA) hospitals, community-based outpatient clinics (CBOC), community living centers, domiciliary facilities, Vet Centers, and the health care corporate offices. The appropriation also supports the administrative expenses of planning, designing, and executing construction or renovation projects at these facilities. VHA operates approximately 5,559 buildings on 15,968 acres of land, and over 1,651 leases, totaling over 148 million owned square feet and 16 million leased square feet in its portfolio. The staff and associated funding supported by this appropriation are responsible for: keeping the VA hospitals and clinics climate controlled; maintaining a clean and germand pest- free environment; sanitizing and washing hospital linens, surgical scrubs, and clinical coats; cleaning and sterilizing the medical equipment; keeping the hospital signage clear and current; maintaining the trucks, buses and cars in good operating condition; ensuring the parking lots and walk ways are sanded and free of snow and ice; cutting the grass; keeping the boiler plants and air conditioning units operating effectively; and undertaking certain repairs and alterations to the buildings to keep them in good condition. Construction of new or replacement facilities are paid for under the Major Construction or Minor Construction appropriations; see Volume 4 for additional detail. VHA-152 Medical Facilities

155 2016 Annual Appropriation Adjustment Update to the 2016 Advance Appropriation Request Medical Facilities (Excludes Veterans Choice Act) (dollars in thousands) 2016 Advance Revised Increase/ Description Approp. Estimate Decrease Engineering & Environmental Management Services... $487,100 $615,591 $128,491 Plant Operation... $1,113,128 $874,598 ($238,530) Leases... $808,400 $493,300 ($315,100) Transportation Services... $135,750 $173,097 $37,347 Grounds Maintenance & Fire Protection... $82,717 $99,205 $16,488 Recurring Maintenance & Repair... $514,786 $728,000 $213,214 Non-Recurring Maintenance (NRM) 1/... $460,600 $708,000 $247,400 Operating Equipment Maintenance & Repair... $434,010 $231,198 ($202,812) Engineering Service... $661,331 $847,802 $186,471 Other Facilities Operation Support... $36,292 $66,904 $30,612 Textile Care Processing & Management... $174,279 $166,205 ($8,074) Obligations [Total]... $4,908,393 $5,003,900 $95,507 Funding Availability: Appropriation... $4,915,000 $4,915,000 $0 Trns to North Chicago Demo. Fund... ($32,607) ($36,455) ($3,848) Reimbursements... $26,000 $20,223 ($5,777) Funding Availability [Total]... $4,908,393 $4,898,768 ($9,625) Annual Appropriation Adjustment... $0 $105,132 $105,132 Additional 2016 Appropriation Request Medical Facilities A 2016 advance appropriation of $4.9 billion for Medical Facilities was enacted in P.L This budget request an additional $105.1 million to support the operation and maintenance of VA facilities. The additional funding is required primarily for increased costs in Administrative Contract Services and non-recurring maintenance (NRM). Obligations for NRM are expected to increase by $247.4 million over the 2016 advance to address high-priority emerging capital needs as identified through the Strategic Capital Investment Planning (SCIP) process. Offsetting these increases is a decrease in leases of $311.4 million based on revised estimates. The 2016 request will support 24,209 FTE, which is an increase of 1,391 FTE over the initial advance appropriation estimate Congressional Submission VHA-153

156 The funding below represents total estimated obligations in 2016 and 2017 (excluding Veterans Choice Act). Program Resources $5.004 billion in 2016 $5.072 billion in 2017 The programmatic needs in this section reflect VA operational changes that impact resources in 2016 and Included under this heading are provisions for costs associated with utilities, engineering, capital planning, leases, laundry services, grounds maintenance, trash removal, housekeeping, fire protection, pest management, facility repair and maintenance, and property disposition and acquisition. VHA-154 Medical Facilities

157 Medical Care Number of Installations 1/ to to Budget Current Advance Revised Advance Increase / Increase / Description Actual Estimate Estimate Approp. Estimate Approp. Decrease Decrease Veterans Integrated Service Networks (VISN) VA Medical Centers (VAMC), Total 2/ Included in VA Medical Centers, Total: VA Hospitals Community Living Centers Residential Rehabilitation Care (DRRTP) VAMC-Based Outpatient Care Sites... N/A N/A 167 N/A Health Care Centers (HCC) 3/... N/A N/A 14 N/A Community-Based Outpatient Clinics (CBOC) Multi-Specialty CBOC 4/... N/A N/A 186 N/A Primary Care CBOC 5/... N/A N/A 568 N/A Other Outpatient Services Sites, Total 6/... N/A N/A 264 N/A Included in Other Outpatient Services Sites, Total: Dialysis Centers Community Resource and Referral Centers (CRRC) Vet Centers Mobile Vet Centers / In an effort to better clarify the types of outpatient health care settings, VA developed and implemented a new Site Classifications and Definitions Handbook (effective December 30, 2013). As a result, the above table provides more granular level of detail (based on the services provided) and is consistent with the new counting methodology. 2/ A VA Medical Center is a facility that provides two or more categories of care (inpatient, outpatient, residential rehabilitation, or institutional extended care). Using the new site classifications and definitions: * A VA Hospital provides both inpatient acute care and outpatient care; it may also provide residential rehabilitation care and/or institutional extended care. * A Community Living Center (CLC) provides institutional extended care services and may be part of a VA Hospital (e.g, a wing), or a free-standing structure. * Residential Rehabilitation Care (i.e., a Domiciliary Residential Rehabilitation Treatment Progam (DRRTP)) provides rehabilitative care in a residential setting. Like a CLC, it may be part of a VA Hospital or a free-standing structure. * A VAMC-Based Outpatient Care site is a VA Medical Center that provides outpatient care. By definition, all VA Hospitals provide outpatient care, but some free-standing Community Living Centers and/or DRRTPs also provide outpatient care and are therefore included in this classification. In 2015, the number of VA Medical Centers (VAMC) is projected to increase from 150 to 167, of which 144 will be VA Hospitals. The following six facilities that were classified as VA Hospitals in 2014 are now classified as VAMC-Based Outpatient Care Sites, since they no longer provide inpatient acute services: Canandaigua, NY; New Orleans, LA; Kerrville, TX; West Texas Health Care System (HCS), TX; Walla Walla, WA; and, Palo Alto-Menlo Park, CA. 3/ A Health Care Center is a VA-owned, VA-leased, contract, or shared clinic operated 5 days per week that provides primary care, mental health care, on-site specialty services, and performs ambulatory surgery and/or invasive procedures which may require moderate sedation or general anesthesia. 4/ Multi-Specialty Community-Based Outpatient Clinic (formerly known as CBOC) is a VA-owned, VA-leased, mobile, contract, or shared clinic that offers both primary and mental health care and two or more specialty services physically on site. 5/ Primary Care Community-Based Outpatient Clinic (formerly known as Mobile Outpatient Clinic) is a VA-owned, VA-leased, mobile, contract, or shared clinic that offers both primary and mental health care services (on site or via Telehealth). 6/ An Other Outpatient Services site is a site where Veterans receive services that do not meet the criteria to be classified as a CBOC or HCC (e.g., Dialysis Centers, CRRC). Many of the services provided at these sites are contacts made by VA or VHA personnel to provide information, social and support services. Other services could be more clinical in nature, in which clinical services are provided to remote areas through a Telehealth clinic or other arrangement. Any services provided in the venue external to a VA clinic or facility must be associated with, attached to, and coordinated by a health care delivery site located in a clinic or facility Congressional Submission VHA-155

158 Site Classifications and Definitions Handbook Crosswalk Current Name Current Definition Old Name Old Definition Comments VA Hospital Any VA-owned, staffed, and operated facility VA Hospital A VA Hospital is a type of medical center (health As more acute inpatient programs close, fewer providing acute inpatient and/or rehabilitation care site with two or more services) that is VAMCs will be Hospitals, and more will be services. owned, staffed and operated by VA and whose composed of non-hospital categories of care, primary function is to provide inpatient services. such as Outpatient, Residential, and Institutional VA Medical Center A VA facility that provides two or more VA Medical Center A medical center is a unique VA site of care Extended Care. categories of care (inpatient, outpatient, providing two or more types of services that residential, or institutional extended care). reside at a single physical site location. The All current Hospitals are also VA Medical services provided are the primary service as tracked in the VHA Site Tracking (VAST) (i.e., VA hospital, nursing home, domiciliary residential rehabilitation treatment program, IOC, HBOC), and CBOC). N/A N/A Independent An IOC is a full-time, self-contained, freestanding, Centers (VAMC). No longer counted. The new classifications counts Outpatient Clinic ambulatory care clinic that has no management, will not be a one-to-one match. (IOC) program, or fiscal relationship to a VA medical facility. Primary and specialty health care services are provided in an outpatient setting. Health Care Center A VA-owned, VA-leased, contract, or shared HBOC A HBOC consists of the outpatient clinic functions (HCC) clinic operated at least 5 days per week that located at a hospital. provides primary care, mental health care, on site specialty services, and performs ambulatory surgery and/or invasive procedures which may require moderate sedation or general anesthesia. Multi-Specialty A VA-owned, VA-leased, mobile, contract, or Community-Based A CBOC is a VA-operated, VA-funded, As site classifications are based on historical CBOC shared clinic that offers both primary and Outpatient Clinic or VA-reimbursed health care facility or site workload, the newly added sites will be given a mental health care and two or more specialty (CBOC) geographically distinct or separate from a parent conditional classification pending the first year services physically on site. medical facility. This term encompasses all types of workload. This may cause changes in the counts of VA outpatient clinics, except hospital-based, in the first few years after implementation. independent and mobile clinics. Satellite, community-based, and outreach clinics have been redefined as CBOCs. Primary Care A VA-owned, leased, mobile, contract, or Mobile Outpatient A MOC is a specially equipped van that makes CBOC shared clinic that offer both Medical and Clinic (MOC) multiple scheduled stops providing outpatient Mental Health services (either on site or via care. A mobile clinic is under the jurisdiction of a Telehealth). Primary Care in the VA includes parent medical facility. both Medical and Mental Health Services as they are inseparable in providing personalized, proactive, patient-centered health care. Other An outpatient site where Veterans receive Outreach Clinics An outreach clinic is defined as a part-time Former Outreach and Annex Clinics will now be Outpatient services that do not meet the criteria to be operation, operated by staff based at the parent able to have station numbers, and can now be Services Site classified as a CBOC or HCC. CBOC or parent medical center that meets the counted as CBOC sites. As a result, VA anticipates Examples include but are not limited to: distance criteria for highly rural areas specified in an increase of nearly 200 CBOCs (mostly Primary Dialysis Centers, CRRCs, Telehealth clinics. the national planning criteria. Care but also Multi-Specialty Care). N/A N/A Annex Clinics A site of care established to reduce space constraints at a Medical Center located within 5 No longer counted. The new classifications counts miles of the parent medical center. will not be a one-to-one match. VHA-156 Medical Facilities

159 Composition of 2014 Obligations by Function Medical Facilities Textile Care Processing, 4% Other Facilities Operation Support, 1% Leases, 10% Engineering & Environmental Management, 11% Plant Operations, 16% Environmental Management Service, 15% Transportation, 3% Operating Equipment Maintenance & Repair, 4% Non-Recurring Maintenance, 21% Grounds Maintenance & Fire Protection, 2% Recurring Maintenance & Repair, 13% Percentages may not add up due to rounding Congressional Submission VHA-157

160 Summary of Obligations by Functional Area Medical Facilities (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Estimate Approp. Decrease Decrease Engineering & Environmental Management Services... $540,390 $476,167 $598,935 $487,100 $615,591 $634,481 $16,656 $18,890 Plant Operation... $770,813 $1,152,617 $853,194 $1,113,128 $874,598 $901,436 $21,404 $26,838 Leases... $470,064 $677,300 $468,800 $808,400 $493,300 $691,900 $24,500 $198,600 Transportation Services... $152,659 $130,934 $169,072 $135,750 $173,097 $178,409 $4,025 $5,312 Grounds Maintenance & Fire Protection... $88,409 $79,783 $97,154 $82,717 $99,205 $102,249 $2,051 $3,044 Recurring Maintenance & Repair... $641,235 $496,416 $710,000 $514,786 $728,000 $750,339 $18,000 $22,339 Non-Recurring Maintenance (NRM) 1/... $1,027,823 $460,600 $636,200 $460,600 $708,000 $460,600 $71,800 ($247,400) Operating Equipment Maintenance & Repair... $203,693 $418,577 $225,895 $434,010 $231,198 $238,293 $5,303 $7,095 Engineering Service... $747,118 $637,833 $828,372 $661,331 $847,802 $873,818 $19,430 $26,016 Other Facilities Operation Support... $32,136 $35,934 $65,171 $36,292 $66,904 $68,957 $1,733 $2,053 Textile Care Processing & Management... $172,961 $168,096 $162,154 $174,279 $166,205 $171,305 $4,051 $5,100 Total... $4,847,301 $4,734,257 $4,814,947 $4,908,393 $5,003,900 $5,071,787 $188,953 $67,887 1/ 2014 Actual includes Object Class 10, & 31, 32, 41 and 43). Fiscal Year 2014 Actuals Medical Facilities (Excludes Veterans Choice Act) (dollars in thousands) Pay & All Description Benefits /1 Capital /2 Other /3 Total FTE Engineering & Environmental Management Services... $362,418 $25,977 $151,995 $540,390 3,441 Plant Operation... $123,856 $16,294 $630,663 $770,813 1,335 Leases... $0 $19,608 $450,456 $470,064 0 Transportation Services... $80,559 $1,330 $70,770 $152,659 1,199 Grounds Maintenance & Fire Protection... $55,707 $2,463 $30,239 $88, Recurring Maintenance & Repair... $267,192 $180,843 $193,200 $641,235 3,294 Non-Recurring Maintenance & Repair... $6,149 $1,000,900 $20,774 $1,027, Operating Equipment Maintenance & Repair... $69,095 $11,736 $122,862 $203, Engineering Service... $549,016 $6,901 $191,201 $747,118 10,777 Other Facilities Operation Support... $442 $1,698 $29,996 $32,136 5 Textile Care Processing & Management... $74,851 $28,625 $69,485 $172,961 1,272 Obligations [Total]... $1,589,285 $1,296,375 $1,961,641 $4,847,301 23,026 1/ Pay Benefits = 10 Personnel Compensation and Benefits. 2/ Capital = 31 Equipment and 32 Lands and Structures. 3/ All Other = 31 Travel & Transportation of Persons; 22 Transportation of Things; 23 Rent, Communications & Utilities; 24 Printing & Reproduction; 25 Other Contractual Services; and 26 Supplies & Materials. Engineering and Environmental Management Services to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Estimate Approp. Decrease Decrease Obligations ($000)... $540,390 $476,167 $598,935 $487,100 $615,591 $634,481 $16,656 $18,890 Engineering and Environmental Management Services provide the design, oversight, and management of all engineering activities that take place in VHA facilities. Examples include the planning and implementation of disability accessibility projects, sidewalk and road repairs, and installation of equipment. VHA-158 Medical Facilities

161 Plant Operations to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Estimate Approp. Decrease Decrease Obligations ($000)... $770,813 $1,152,617 $853,194 $1,113,128 $874,598 $901,436 $21,404 $26,838 Plant Operations support all the basic functions of the hospitals and medical clinics. Examples of these activities include: the purchase of utilities such as water, electricity, steam, gas, and sewage; general operations supervision; operation of emergency electrical power systems, elevators, renewable energy, and all plant operations. Leases to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Estimate Approp. Decrease Decrease Obligations ($000)... $470,064 $677,300 $468,800 $808,400 $493,300 $691,900 $24,500 $198,600 VHA has approximately 1,651 leases, encompassing over 16 million square feet of space in its portfolio. Leases fall into the following two primary categories: space procured by the General Services Administration (GSA) on behalf of VA and space procured directly by VA (via delegated authority from GSA) in commercial venues. Leases can have many functions, ranging from clinical space for CBOCs to warehouses for storage of supplies and equipment, all in support of the operational needs of the local medical center. Leases complement the portfolio of VA-owned medical facilities and provide additional flexibility in providing services to Veterans in the right place and at the right time. VHA typically does not utilize GSA to procure medical facility space on behalf of VA. Instead, VHA utilizes a delegation of authority from GSA to procure the space directly. This delegation is granted on a lease-by-lease basis by GSA, following GSA s review of the lease data, but all of the procurement and contracting activities are managed by VHA. These leases are critical to meeting Veteran needs by allowing VA to operate clinics or other necessary services close to Veteran populations, but maintaining flexibility so that these points of service can be relocated or resized on a regular basis due to shifting demographic trends. While owned facilities provide some benefit over leasing in some situations, the flexibility and adaptability provided by leasing is key to VHA s mission. Transportation Services to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Estimate Approp. Decrease Decrease Obligations ($000)... $152,659 $130,934 $169,072 $135,750 $173,097 $178,409 $4,025 $5,312 Transportation Services include the costs to operate facilities motor vehicles, including the purchase and operations of VA vans and buses, facility maintenance vehicles, and the clinical motor vehicle pool operations Congressional Submission VHA-159

162 Grounds Maintenance and Fire Protection to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Estimate Approp. Decrease Decrease Obligations ($000)... $88,409 $79,783 $97,154 $82,717 $99,205 $102,249 $2,051 $3,044 Grounds Maintenance and Fire Protection costs are associated with the maintenance of roads, walks, parking areas, and lawn management, as well as fire truck operation, supplies, and materials. Recurring Maintenance and Repair to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Estimate Approp. Decrease Decrease Obligations ($000)... $641,235 $496,416 $710,000 $514,786 $728,000 $750,339 $18,000 $22,339 Recurring Maintenance and Repair services encompass all projects where the minor improvement is below $25,000, such as maintenance service contracts and routine repair of facilities and upkeep of land. Examples include: painting interior and exterior walls; the repair of water leaks in pipes and roofs; and the replacement of light bulbs, carpet, and ceiling and floor tiles. Non-Recurring Maintenance (NRM) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual /1 Estimate Estimate /2 Approp. Estimate /2 Approp. /2 Decrease Decrease Obligations ($000)... $1,027,823 $460,600 $636,200 $460,600 $708,000 $460,600 $71,800 ($247,400) 1/ 2014 Actual includes Object Class 10, & 31, 32, 41 and 43. 2/ 2015, 2016, and 2017 Estimates include Object Class 32 (Non-Recurring Maintenance). VHA uses its NRM projects to make additions, alterations, and modifications to land, buildings, other structures, nonstructural improvements of land, and fixed equipment (when the equipment is acquired under contract and becomes permanently attached to or part of the building or structure). NRM projects are renovations within the existing square footage of a facility, or renovations requiring the expansion of new space (up to 1,000 square feet of new space). NRM projects include renovations up to $10 million, although there is no upper limit for infrastructure projects, which improve the basic, underlying framework and fundamental systems serving VA facilities (e.g., boiler replacement, utilities modernization). VHA uses its NRM program as its primary means of addressing its most pressing infrastructure needs as identified by Facility Condition Assessments (FCA). These assessments are performed at each facility every three years and highlight a building s most pressing and mission critical repair and maintenance needs. VHA specifically supports research and development infrastructure projects by ensuring that the Office of Research and Development is involved in the identification of gaps to support the Strategic Capital Investment Planning (SCIP) process. This inclusion ensures a research VHA-160 Medical Facilities

163 focus for mitigation within a 10-year window of identified research infrastructure deficiencies. NRM Projects are broken into three categories, as defined below. Sustainment Projects Sustainment is the provision of resources for improvements to existing buildings to ensure they are state-of-the-art and in good condition to continue to house the services provided to the Veteran. These projects are primarily within the building s envelope and range from $25,000 to $10 million, including costs associated with the expansion of space (not to exceed 1,000 square feet). Budget formulation is supported by the sustainment projects submitted and prioritized through the Strategic Capital Investment Planning (SCIP) process. Infrastructure Improvements These projects improve the infrastructure of existing buildings and land beyond sustainment. They include reducing the FCA deficiency backlog, upgrading and replacing infrastructure systems, demolishing buildings, land improvements, and surface parking. These projects start at $25,000 and have no upper limit due to their pure infrastructure nature. Budget formulation for these projects is also supported and prioritized through the SCIP process. The FCA deficiency backlog for infrastructure include all the infrastructure systems and components that have been given grades of D and F by independent consultants. Demolition of buildings is an initiative to remove the vacant and underutilized buildings from our inventory to reinvest operational savings for services to our Veterans. Clinical Specific Initiatives Clinical Specific Initiative (CSI) projects are emergent projects that cannot be planned due to dynamic healthcare environments. Associated funding for these projects is distributed to the VISNs at the beginning of each year to obligate towards VHA s high-four profile categories: women s health/pact, mental health, high-cost/high-tech equipment, and donated buildings. Examples of uses for this funding include: acquisition of modular buildings immediately upon notification that VA Central Office mandates the hiring of staff; flexibility needed for room retrofit to install high-tech/high-cost equipment, which has about a six-month lead time from when the high-tech/high-cost equipment is ordered; and providing a quick response ability for medical centers to create quick access points for special interests, such as women s health. This funding allows for the flexibility to meet the unplanned capital demands of these high priority VHA programs. Budget formulation is based on current year needs Congressional Submission VHA-161

164 Operating Equipment Maintenance and Repair to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Estimate Approp. Decrease Decrease Obligations ($000)... $203,693 $418,577 $225,895 $434,010 $231,198 $238,293 $5,303 $7,095 Operating Equipment Maintenance and Repair costs are associated with maintenance and repair of all non-expendable operating equipment, furniture and fixtures, when performed by maintenance personnel or procured on a contractual basis, including rental equipment. Engineering Service to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Estimate Approp. Decrease Decrease Obligations ($000)... $747,118 $637,833 $828,372 $661,331 $847,802 $873,818 $19,430 $26,016 The Environmental Management Service is associated with the oversight and management of environmental management activities, including the recycling operation; pest management; grounds management; environmental sanitation operations; bed services and patient assistance; and collection, removal, and transportation of all waste materials. Other Facilities Operation Support to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Estimate Approp. Decrease Decrease Obligations ($000)... $32,136 $35,934 $65,171 $36,292 $66,904 $68,957 $1,733 $2,053 This function includes other costs associated with inpatient and outpatient providers and miscellaneous benefits and services. Textile Care Processing and Management to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Estimate Approp. Decrease Decrease Obligations ($000)... $172,961 $168,096 $162,154 $174,279 $166,205 $171,305 $4,051 $5,100 Textile Care Processing and Management includes the receipt, washing, drying, dry cleaning, folding, and return of textiles such as bed linens, surgical towels, and nursing uniforms. Processing also involves the activities concerning the maintenance and repair of textile processing equipment. Textile management activities include the procurement, inventory, delivery, issuance, repair, and marking of all the various types of textiles contained within the facility. VHA-162 Medical Facilities

165 Medical Facilities Program Resource Data Summary of Total Request, Medical Facilities (dollars in thousands) Budget Current Advance Revised Advance Increase / Increase / Description Actual Estimate Estimate Approp. Estimate Approp. Decrease Decrease Advance Appropriation... $4,872,000 $4,739,000 $4,739,000 $4,915,000 $4,915,000 $5,074,000 $176,000 $159,000 Mandatory Appropriation (P.L )... $0 $0 $0 $0 $0 $0 $0 $0 Annual Appropriation Adjustment... $85,000 $0 $0 $0 $105,132 $0 $105,132 ($105,132) Subtotal Appropriation Request... $4,957,000 $4,739,000 $4,739,000 $4,915,000 $5,020,132 $5,074,000 $281,132 $53,868 Rescission, P.L $0 $0 ($2,000) $0 $0 $0 $2,000 $0 Net Appropriations... $4,957,000 $4,739,000 $4,737,000 $4,915,000 $5,020,132 $5,074,000 $283,132 $53,868 Transfers: To North Chicago Demo. Fund... ($32,998) ($31,743) ($35,490) ($32,607) ($36,455) ($37,436) ($965) ($981) Subtotal Transfers... ($32,998) ($31,743) ($35,490) ($32,607) ($36,455) ($37,436) ($965) ($981) Total Budget Authority... $4,924,002 $4,707,257 $4,701,510 $4,882,393 $4,983,677 $5,036,564 $282,167 $52,887 Reimbursements... $14,389 $24,000 $20,223 $26,000 $20,223 $20,223 $0 $0 Adjustments to Obligations: Unobligated Balance (SOY): Veterans Access - PL , Section $0 $0 $0 $0 $755,000 $0 $755,000 ($755,000) No-Year... $265 $2,750 $321 $0 $0 $0 ($321) $0 H1N1 No-Year (PL )... $102 $0 $0 $0 $0 $0 $0 $ Emergency Supplemental (PL ) (No-Yr)... $327 $250 $6,012 $0 $0 $0 ($6,012) $0 Hurricane Sandy (PL 113-2)... $662 $0 $0 $0 $0 $0 $0 $0 2-Year... $848 $0 $86,881 $0 $0 $0 ($86,881) $0 Subtotal... $2,204 $3,000 $93,214 $0 $755,000 $0 $661,786 ($755,000) Prior Year Recoveries... $0 $0 $0 $0 $0 $15,000 $0 $15,000 Transfer of Unobligated Balance, PL , Section $0 $0 $1,771,600 $0 $0 $0 ($1,771,600) $0 Unobligated Balance (EOY): Veterans Access - PL , Section $0 $0 ($755,000) $0 $0 $0 $755,000 $0 No-Year... ($321) $0 $0 $0 $0 $0 $0 $0 H1N1 No-Year (PL )... $0 $0 $0 $0 $0 $0 $0 $ Emergency Supplemental (PL ) (No-Yr)... ($6,012) $0 $0 $0 $0 $0 $0 $0 Hurricane Sandy (PL 113-2)... $0 $0 $0 $0 $0 $0 $0 $0 2-Year... ($86,881) $0 $0 $0 $0 $0 $0 $0 Subtotal... ($93,214) $0 ($755,000) $0 $0 $0 $755,000 $0 Change in Unobligated Balance (Non-Add)... ($91,010) $3,000 ($661,786) $0 $755,000 $0 $1,416,786 ($755,000) Lapse... ($80) $0 $0 $0 $0 $0 $0 $0 Obligations... $4,847,301 $4,734,257 $5,831,547 $4,908,393 $5,758,900 $5,071,787 ($72,647) ($687,113) Less: Veterans Choice Act Obligations... $0 $0 ($1,016,600) $0 ($755,000) $0 $261,600 $755,000 Obligations Excluding Veterans Choice Act... $4,847,301 $4,734,257 $4,814,947 $4,908,393 $5,003,900 $5,071,787 $188,953 $67, Congressional Submission VHA-163

166 FTE by Type Medical Facilities (Excludes Veterans Choice Act) to to Budget Current Advance Revised Advance Increase / Increase / Description Actual Estimate Estimate Approp. Estimate Approp. Decrease Decrease Physicians Dentists Registered Nurses LP Nurse/LV Nurse/Nurse Assistant Non-Physician Providers Health Technicians/Allied Health Wage Board/Purchase & Hire... 18,975 18, , , All Other 1/... 3,944 4, , , Total... 23,023 22,818 24,098 22,818 24,209 24, /All Other category includes maintenance controllers, engineers/architects, administrative support clerks, safety and occupational health specialists, fire protection and prevention staff, engineering technicians, hospitals housekeepers and managers, industrial hygienists, clinical/biomedical engineers, administrative specialists, and other staff that are necessary for the effective operations of VHA medical facilities. Medical Facilities Employment Summary, FTE by Grade (Excludes Veterans Choice Act) 2015 to to Increase/ Increase/ GS Grade or Title 38 Actual Estimate Estimate Estimate Decrease Decrease SES Title or higher Wage Board... 19,026 19,914 20,007 20, Total Number of FTE... 23,023 24,098 24,209 24, VHA-164 Medical Facilities

167 Obligations by Object Medical Facilities (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease 10 Personnel Compensation and Benefits: Physicians... $68 $0 $0 $0 $0 $0 $0 $0 Dentists... $0 $0 $0 $0 $0 $0 $0 $0 Registered Nurses... $0 $0 $0 $0 $0 $0 $0 $0 LP Nurse/LV Nurse/Nurse Assistant... $148 $0 $0 $0 $0 $0 $0 $0 Non-Physician Providers... $111 $0 $0 $0 $0 $0 $0 $0 Health Technicians/Allied Health... $6,282 $8,400 $7,800 $8,700 $8,000 $8,200 $200 $200 Wage Board/Purchase & Hire... $1,174,478 $1,207,800 $1,242,500 $1,246,400 $1,271,800 $1,306,600 $29,300 $34,800 All Other 1/... $372,643 $412,100 $394,700 $427,900 $403,400 $414,000 $8,700 $10,600 Permanent Change of Station... $851 $1,300 $900 $1,300 $900 $900 $0 $0 Employee Compensation Pay... $34,704 $30,000 $35,400 $30,700 $36,100 $36,900 $700 $800 Subtotal... $1,589,285 $1,659,600 $1,681,300 $1,715,000 $1,720,200 $1,766,570 $38,900 $46, Travel & Transportation of Persons: Employee... $3,557 $1,300 $4,400 $2,700 $5,500 $6,900 $1,100 $1,400 Beneficiary... $1,270 $0 $0 $0 $0 $0 $0 $0 Other... $27,562 $27,300 $29,200 $28,000 $31,000 $32,900 $1,800 $1,900 Subtotal... $32,389 $28,600 $33,600 $30,700 $36,500 $39,800 $2,900 $3, Transportation of Things... $15,792 $14,700 $16,200 $19,500 $16,600 $17,000 $400 $ Rent, Communications, and Utilities: Rental of Equipment... $5,507 $5,900 $5,600 $12,500 $5,700 $5,800 $100 $100 Communications... $2,234 $1,500 $2,300 $3,000 $2,400 $2,500 $100 $100 Utilities... $537,667 $519,200 $551,100 $546,000 $564,900 $579,000 $13,800 $14,100 GSA Rent... $25,987 $25,700 $25,500 $30,600 $26,900 $37,700 $1,400 $10,800 Other Real Property Rental... $451,309 $651,600 $443,300 $777,800 $466,400 $654,200 $23,100 $187,800 Subtotal... $1,022,704 $1,203,900 $1,027,800 $1,369,900 $1,066,300 $1,279,200 $38,500 $212, Printing & Reproduction:... $64 $100 $100 $200 $100 $100 $0 $0 25 Other Contractual Services: Non-VA Outpatient Dental Care 2/... $1 $0 $0 $0 $0 $0 $0 $0 Medical and Nursing Non-VA Care 3/... $0 $0 $0 $0 $0 $0 $0 $0 Repairs to Furniture/Equipment... $24,523 $6,100 $25,100 $20,300 $25,700 $26,300 $600 $600 Maintenance & Repair Contract Services... $177,933 $143,100 $182,400 $178,400 $187,000 $191,700 $4,600 $4,700 Non-VA Hospital Care 4/... $0 $0 $0 $0 $0 $0 $0 $0 Community Nursing Homes... $0 $0 $0 $0 $0 $0 $0 $0 Repairs to Prosthetic Appliances... $0 $0 $0 $0 $0 $0 $0 $0 Home Oxygen... $0 $0 $0 $0 $0 $0 $0 $0 Personal Services Contracts... $8,868 $7,400 $9,100 $10,400 $9,300 $9,500 $200 $200 House Staff Disbursing Agreement... $0 $0 $0 $0 $0 $0 $0 $0 Scarce Medical Specialists... $0 $0 $0 $0 $0 $0 $0 $ Congressional Submission VHA-165

168 Obligations by Object Medical Facilities (Excludes Veterans Choice Act) (dollars in thousands) to to Budget Current Advance Revised Advance Increase/ Increase/ Description Actual Estimate Estimate Approp. Request Approp. Decrease Decrease 25 Other Contractual Services (continued) Other Medical Contract Services... $9,734 $0 $0 $0 $0 $0 $0 $0 Administrative Contract Services... $353,296 $611,257 $581,747 $391,493 $596,300 $626,117 $14,553 $29,817 Training Contract Services... $2,012 $1,600 $2,100 $2,200 $2,200 $2,300 $100 $100 CHAMPVA... $0 $0 $0 $0 $0 $0 $0 $0 Subtotal... $576,367 $769,457 $800,447 $602,793 $820,500 $855,917 $20,053 $35, Supplies & Materials: Provisions... $33 $0 $0 $0 $0 $0 $0 $0 Drugs & Medicines... $14 $0 $0 $0 $0 $0 $0 $0 Blood & Blood Products... $0 $0 $0 $0 $0 $0 $0 $0 Medical/Dental Supplies... $626 $0 $0 $0 $0 $0 $0 $0 Operating Supplies... $115,563 $104,400 $119,400 $124,400 $123,400 $127,500 $4,000 $4,100 Maintenance & Repair Supplies... $141,976 $119,600 $145,500 $162,800 $149,100 $152,800 $3,600 $3,700 Other Supplies... $55,897 $56,800 $57,300 $71,500 $58,700 $60,200 $1,400 $1,500 Prosthetic Appliances... $0 $0 $0 $0 $0 $0 $0 $0 Home Respiratory Therapy... $0 $0 $0 $0 $0 $0 $0 $0 Subtotal... $314,109 $280,800 $322,200 $358,700 $331,200 $340,500 $9,000 $9, Equipment... $78,405 $108,700 $71,800 $109,800 $73,600 $75,400 $1,800 $1, Lands & Structures: Non-Recurring Maintenance... $998,213 $460,600 $636,200 $460,600 $708,000 $460,600 $71,800 ($247,400) All Other Lands & Structures... $219,757 $207,800 $225,300 $241,200 $230,900 $236,700 $5,600 $5,800 Subtotal... $1,217,970 $668,400 $861,500 $701,800 $938,900 $697,300 $77,400 ($241,600) 41 Grants, Subsidies & Contributions: State Home... $0 $0 $0 $0 $0 $0 $0 $0 Grants 5/... $0 $0 $0 $0 $0 $0 $0 $0 Subtotal... $0 $0 $0 $0 $0 $0 $0 $0 43 Imputed Interest... $216 $0 $0 $0 $0 $0 $0 $0 Total, Obligations... $4,847,301 $4,734,257 $4,814,947 $4,908,393 $5,003,900 $5,071,787 $188,953 $67,887 1/All Other category includes maintenance controllers, engineers/architects, administrative support clerks, safety and occupational health specialists, fire protection and prevention staff, engineering technicians, hospitals housekeepers and managers, industrial hygienists, administrative specialists, and other staff that are necessary for the effective operations of VHA medical facilities. 2/ Formerly known as Medical & Nursing Fees. No change in methodology. 3/ Formerly known as Outpatient Dental Fees. No change in methodology. 4/ Formerly known as Contract Hospital. No change in methodology. 5/ Formerly known as Homeless Programs revised to Grants to better represent all grants, not just grants associated with VA's Homeless programs. No change in methodology. VHA-166 Medical Facilities

169 Veterans Access, Choice, and Accountability Act of 2014 On August 7, 2014, President Obama signed into law the Veterans Access, Choice and Accountability Act of 2014 (Public Law ) ( Veterans Choice Act ). The 2016 Budget supports implementation of the Veterans Choice Act and the Administration s goal of providing timely, high-quality health care for our Nation s veterans. The Veterans Choice Act provided $5 billion in mandatory funding in Section 801 to increase veterans' access to health care by hiring more physicians and staff and improving the VA s physical infrastructure. It also provided $10 billion in mandatory funding through 2017 in Section 802 to establish a temporary program ("Veterans Choice Program") improving veterans access to health care by allowing eligible veterans who meet certain wait-time or distance standards to use health care providers outside of the VA system. The Veterans Choice Program provides a measure of short-term relief from the pressure of escalating health care requirements as some current patients in the VA system elect to receive their care through the program. While it is clear that purchased care plays an important role in extraordinary circumstances, it should not be seen as a replacement for a strong and vital Veterans' healthcare system. These investments, together with the 2016 Budget, will provide authorities, funding, and other tools to enhance service to veterans in the short-term while strengthening the underlying VA system to better serve veterans in the future. However, more resources will be required to ensure that the VA system can provide timely, high-quality health care into the future. In the coming months, the Administration will submit legislation to reallocate a portion of Choice Program funding to support essential investments in VA system priorities in a fiscally-responsible, budget-neutral manner. Funding Plan Summary Section 801 VA s funding plan for the $5 billion provided in Section 801 of the Veterans Choice Act is summarized in the tables below. VA plans to obligate $2.4 billion in fiscal year (FY) 2015 and $2.6 billion in FY The first table (see Funding Plan Summary by Function) shows the allocation of these funds by function: of the $5 billion total, $2.3 billion (46.8 percent) will support Veterans health care; $2.3 billion (45.7 percent) will support capital infrastructure; and $376.6 million (7.5 percent) will support information technology (IT) infrastructure and development. VA may revise this allocation based upon experience. The second table (see Veterans Choice Act, Section 801, Allocation of Funds) shows the total allocation and percentage of funds to five budget accounts: Medical Services, Medical Support and Compliance, Medical Facilities, Information Technology, and Minor Construction. The third table (see Obligations by Object, Veterans Choice Act) shows the distribution of the $5 billion by Object Class Congressional Submission VHA-167

170 Funding Plan Summary by Function (dollars in millions) Description Estimate Estimate Total Medical Care: $750.7 $1,589.9 $2,340.6 FTE and Other Costs... $719.5 $1,493.5 $2,213.0 Section 301/302 Activities... $31.2 $96.4 $127.6 Capital Infrastructure: $1,399.8 $883.0 $2,282.8 Emergency Leases... $31.2 $9.5 $40.7 Leases... $132.8 $139.6 $272.4 Non-Recurring Maintenance... $759.2 $532.6 $1,291.8 Legionella Prevention & Control $93.4 $73.3 $166.7 Minor Construction... $383.2 $128.0 $511.2 Information Technology $203.2 $173.4 $376.6 Software Development... $107.5 $43.9 $151.4 Activation of VHA Facilities... $95.7 $129.5 $225.2 Section 801 [Total]... $2,353.7 $2,646.3 $5,000.0 VHA-168 Veterans Choice Act

171 2015 Estimate 2016 Estimate Medical Medical Medical Support & Medical Info. Minor Medical Support & Medical Info. Minor Description Services Compliance Facilities Tech. Cns. Total Services Compliance Facilities Tech. Cns. Total 10 Personnel Compensation & Benefits... $660 $10 $0 $13 $0 $683 $1,368 $16 $0 $28 $0 $1, Leases... $0 $0 $164 $0 $0 $164 $0 $0 $149 $0 $0 $ Other Contractual Services... $30 $1 $0 $101 $0 $132 $96 $1 $0 $45 $0 $ Supplies & Materials... $50 $0 $0 $10 $0 $60 $109 $0 $0 $7 $0 $ Equipment... $0 $0 $0 $80 $0 $80 $0 $0 $0 $95 $0 $95 32 Lands & Structure (NRM & Legionella)... $0 $0 $853 $0 $0 $853 $0 $0 $606 $0 $0 $606 Minor Construction... $0 $0 $0 $0 $383 $383 $0 $0 $0 $0 $128 $128 Obligations [Total]... $740 $11 $1,017 $204 $383 $2,355 $1,573 $17 $755 $175 $128 $2,648 *Differences from Funding Plan are due to rounding. Obligations by Object Veterans Choice Act (dollars in millions)* VA Medical Staff Hiring. While the Veterans Choice Act establishes a temporary program to improve access to health care by allowing eligible Veterans to use eligible providers outside of the VA system (non-va care), it also recognizes that purchased care is not a replacement for a strong and vital Veterans health care system. The Veterans Choice Act also requires that the Secretary use funds appropriated in Section 801 to hire primary care and specialty care physicians for employment in VA, and to hire other medical staff, including nurses, social workers, mental health professionals, and other health care professionals. VA plans to invest $2.2 billion of the $5 billion provided in the Veterans Choice Act to hire 9,613 new permanent medical staff. Of the total, VA estimates it will obligate $719.5 million in FY 2015 and $1.49 billion in FY This investment will enhance Veterans access to care in three critical shortage areas: primary care, specialty care, and mental health care. The funding includes related costs such as pharmacy and laboratory tests. The current staffing projections provide for the hiring of: 2,159 Primary Care staff: Including primary care providers (physicians, nurse practitioners, and physician assistants); registered nurses; licensed practical nurses; medical assistants; medical technicians; and scheduling clerks. 5,309 Specialty Care staff: Including physicians, nurse practitioners, physician assistants, clinical pharmacists, registered nurses, licensed practical nurses, medical assistants, medical technicians, and scheduling clerks. 2,145 Mental Health staff: Including psychiatrists, social workers, registered nurses, licensed practical nurses, mental health technicians, mental health peer support positions, psychologists, licensed professional counselor positions, and other mental health front line support positions (e.g., scheduling clerks). Capital Infrastructure: Emergency Leases. VA plans to obligate $40.7 million of the $5 billion provided in Section 801 of the Veterans Choice Act for 33 leases that will provide immediate and urgent access improvements. All of the emergency leases cost less than $1 million in annual recurring rent and do not require specific authorization from Congress Congressional Submission VHA-169

172 In the spring and summer of 2014, VA conducted reviews to identify market areas with insufficient capacity to meet immediate workload demands. Emergency leases are designed to address those gaps. In some cases, such as those in Fayetteville, NC and Jacksonville, NC, existing medical space available for lease in the community was identified as a way to achieve interim access improvements until future-approved lease projects could be executed and activated. These leases will support primary care and mental health services, as well as parking, in various locations throughout the VA system. Capital Infrastructure: Leases in the Pipeline. VA plans to obligate $272.4 million of the $5 billion provided in Section 801 of the Veterans Choice Act for 123 leases in the pipeline. In the pipeline refers to lease projects that are planned for FY 2015 or FY 2016, approved through the Strategic Capital Investment Planning (SCIP) process, and directly support Veterans improved access to care. These are new leases that will provide increased capacity to deliver services to Veterans and improve access. This plan includes funding for four of the new leases authorized under Section 601 of the Veterans Choice Act. The leases will provide Veterans with increased access to communitybased outpatient clinics, domiciliaries, sleep and ophthalmology labs, mental health clinics, outreach clinics, compensation and pension clinics, dental clinics, and parking. Capital Infrastructure: Non-Recurring Maintenance. VA plans to obligate $1.3 billion of the $5 billion provided in Section 801 of the Veterans Choice Act for non-recurring maintenance (NRM). This funding will provide physical infrastructure improvements to maintain and operate hospitals, community living centers, domiciliary facilities, and other facilities. The funding plan will support NRM projects that have been approved through the SCIP process and Out-of-Cycle process and were pending funding for design and/or construction in FY 2014 or in a prior fiscal year. Capital Infrastructure: Minor Construction. VA plans to obligate $511.2 million of the $5 billion provided in Section 801 of the Veterans Choice Act for Minor Construction. This funding will support 64 physical infrastructure improvement projects to maintain and operate hospitals, community living centers, domiciliary facilities, and other facilities. Capital Infrastructure: Legionella Prevention and Control Improvements. VA plans to obligate $166.7 million of the $5 billion provided in Section 801 of the Veterans Choice Act for Legionella prevention and control improvements. This funding will provide for physical infrastructure improvements to maintain and operate hospitals, community living centers, domiciliary facilities and other facilities specific to the control and mitigation of risk of hospitalacquired Legionella disease. Two categories of projects are planned, including: Category One Projects: Infrastructure repairs, improvements, and upgrades to building systems, such as building water systems, domestic hot water heating systems, and building automation and control systems. The plan includes funding for 41 such projects. VHA-170 Veterans Choice Act

173 Category Two Projects: Mapping of building water systems to include identification of dead-leg branch piping and updates of plumbing system as-built drawings. The plan includes $68 million to establish a single national contract. Medical centers-specific task orders will be issued under this contract. Information Technology: Infrastructure. VA plans to obligate $225.2 million of the $5 billion provided in Section 801 of the Veterans Choice Act for IT infrastructure. Obligations will support the activation of new and replacement medical facilities, provide IT equipment for new medical care staff, and hire additional IT staff (192 FTE are currently planned) to provide support for the new facilities. When VA opens a new medical clinic, or expands an existing one, it must provide IT support for the clinicians and other staff, including computers, printers, cell phones, software licenses, help desk support, and cyber security protection. New clinics require desk phones, shared workstation computers, and dedicated network connections to VA medical network, routers, local wiring, or secure Wi-Fi. VA cost estimates associated with new activations include $28 per square foot for leases and new construction, and $6,600 per new employee. These estimates cover all related IT costs, including network connections, equipment, licenses, expansion servers, and cyberprotection of the VA s electronic healthcare information system. Information Technology: Development. VA plans to obligate $151.4 million of the $5 billion provided in Section 801 of the Veterans Choice Act for IT development. Obligations for IT development activities, include $76.0 million for a new medical appointment scheduling system; $20.1 million for mobile applications; and $55.3 million for enhanced access and customer service. Medical Appointment Scheduling System: VA is planning to purchase a highly capable, tested, private-sector system to meet its medical scheduling needs. This approach will yield the best results in the most efficient, timely, and effective manner. VA expects to award a contract to procure the system in early calendar year The benefit of this new scheduling system will allow Veterans to more easily schedule multiple appointments, check availability of providers and allow the Veterans to interact with the VA by phone, over the internet or through smartphones and other devices. Mobile Applications: VA has identified two mobile applications that will significantly improve Veterans ability to interact with the VA healthcare system and improve their health outcomes. The first application is a Mobile Scheduling application, which will allow Veterans to check on an existing appointment, or schedule a new one, with a smartphone, ipad, or other tablet device. The second application is Mobile Video Visits, which will allow a Veteran to have a secure video medical visit with a VA provider. The application will initially be pilot-tested at five sites; this technology will be especially helpful with the treatment of rural Veterans. Veterans Relationship Management: Funding will accelerate and expand Veterans access and improve customer service. The funds will provide one VA site 2016 Congressional Submission VHA-171

174 that will allow a Veteran to access health care information and services; support agent-assisted call centers; and provide increased and expanded self-service capabilities for new health care initiatives. In addition, this funding will be used to accelerate integrated online support for Veterans to ensure a positive resolution to questions or requests for services. This effort also will help reduce the number of different logon screens that Veterans must navigate. Sec. 301: Staffing Assessment Report and Medical Residents. VA plans to obligate $121.0 million of the $5 billion provided in Section 801 of the Veterans Choice Act for activities authorized in Section 301 of the Act. This includes $2.0 million for contract costs for a Biennial Report on Staffing of Medical Facilities of the Department of Veterans Affairs, and $119.0 million to increase the number of graduate medical education residency positions at VA medical facilities by up to 1,500 positions over five years. Sec. 302: Education Debt Reduction Program. VA plans to obligate $6.6 million of the $5.0 billion provided in Section 801 of the Veterans Choice Act to fund the cost of increased payments under the Education Debt Reduction Program as directed by Section 302 of the Choice Act. The funds will allow VA to increase the maximum coverage from the current $60,000 to a maximum of $120,000 per individual. Funding Plan Summary Section 802 Summary VA launched the Veterans Choice Program (VCP) on November 5, The program is administered by two private third-party administrators, with programmatic direction and oversight provide by VHA s Chief Business Office. As of January 23, 2015, VA has issued nearly 7 million Veterans Choice Cards and fielded nearly 403,000 calls from veterans, health care providers, and staff, resulting in about 18,000 scheduled veteran appointments. VA s current estimate of the healthcare cost of the VCP over three years is between $3.8 billion and $12.9 billion. This estimate is still uncertain and highly dependent on the number of eligible Veterans who choose to participate in the VCP. Additional detail and cost estimates are provided below. Veterans Choice Program and Funding Eligibility. Veterans must meet specific criteria under the Veterans Choice Program (VCP), established by section 101 of the Veterans Choice Act, to be eligible to elect to receive hospital care and medical services from an eligible entity or provider. To be eligible to participate in VCP, Veterans must have been enrolled in the VA health care system on or before August 1, 2014, or must be within five years of post-combat deployment (see 38 U.S.C. 1710(e)(1)(D) and 1710 (e)(3)). Veterans must also either be unable to schedule an appointment within the waittime goals of the Veterans Health Administration or qualify based on their place of residence. Veterans may qualify based on their place of residence if they live more than 40 miles from the closest VA medical facility; if they reside in a state without a VA medical facility that provides hospital care, emergency medical services, and surgical care rated by the Secretary as VHA-172 Veterans Choice Act

175 having a surgical complexity of standard, and they reside more than 20 miles from a medical facility that offers these services in another state; or, with certain exceptions, if they reside 40 miles or less from a VA medical facility and must travel by air, boat, or ferry, or face an unusual or excessive burden in traveling to a VA medical facility because of geographical challenges. In addition, non-va health care entities and providers must meet certain standards to participate in the program. Specifically, entities and providers must either be participating in the Medicare program, be a Federally-qualified health center, or be the Department of Defense or the Indian Health Service. To furnish care, an entity or provider must be accessible to the Veteran (meaning they provide timely care, have the necessary qualifications, and be within a reasonable distance of the Veteran) and must enter into an agreement with VA. Eligible non-va entities and providers must maintain at least the same or similar credentials and licenses as VA providers, and they must submit information verifying their compliance with this requirement annually. To determine the cost of non-va care that VA anticipates financing through the VCP, VA first identified the projected number of Veterans that could potentially seek and obtain non-va health care through VCP. These projections are based on specific cohorts that would meet the criteria of the law. These projections are uncertain and subject to revision as VA gains more experience with the VCP. Choice Cards. In order to implement the VCP, the Choice Act required VA to issue identification cards ( Choice Cards ) to eligible Veterans that the Veterans would use in order to gain access to non-va care. As described below, VA undertook a staggered implementation to ensure all eligible Veterans received their Choice Cards. Implementation and Milestones. VA implemented the VCP in a phased approach as described below for the two specific cohorts eligible for care under the VCP: (1) Cohort 1 Veterans likely to experience wait times in excess of the wait-time goals of the Veterans Health Administration and Veterans on the Electronic Wait List (EWL); and (2) Cohort 2 Veterans who qualify based on their place of residence. Choice Cards were mailed first to Veterans in Cohort 1 between November 4, 2014, and November 6, Veterans in Cohort 2 were mailed Choice Cards between November 15, 2014, and November 17, The final group of Choice Cards and letters are being sent between December 2014 and January 2015 to the remainder of all Veterans enrolled for VA health care who may be eligible for the Choice Program in the future Congressional Submission VHA-173

176 VA also signed contracts with two private health care companies to help VA administer the VCP including establishing a toll-free number for Veterans and their families to call for information and assistance. In addition, VA is proactively conducting outreach to all Veterans with appointment wait times in excess of the wait-time goals of the Veterans Health Administration and Veterans on the Electronic Wait List (EWL). VA is in the process of calling approximately 106,672 Veterans on these lists to make sure they know they are eligible to use the Veterans Choice Program. As of January 23, 2015, VA has contacted 61 percent of these Veterans. Estimated Cost Impact. While it is not envisioned that every Veteran who is eligible for the Choice Program will use the Program, the maximum cost of the Program must be identified to ensure that those costs will be within the appropriate funding limit. Based on the analysis performed of the eligible population, their current use of VA care, their distance to the VA facilities, their insurance profile, and the potential for cost-sharing among some of the population, VA believes that there will be a higher use of the VCP among the 40-mile group (Cohort 2) than the 30-day group (Cohort 1). The 30 day group is comprised of mostly Veterans who are high utilizers of VA services and may prefer to wait for care in the VA with their established providers. Since some of the 40 mile group are Veterans who have never used the VA before, their utilization of the program will most likely be higher than those in the 30 day group who are consistent VA users. For these reasons, at the time the Veterans Choice Program was launched, VA believed that the most reasonable assumption was that the 40 mile group will have utilization in the high range (high participation rates) and the 30 day group will have utilization in the medium range (medium participation rates) as highlighted in the table below. VA examined ten scenarios for this program that have a large range of costs for the three years, from $3.8 billion to $12.9 billion. This estimate of cost is highly uncertain and will depend upon Veterans utilization of the program. Range of Cost of Care Estimates Scenarios FY2015 FY2016 FY2017 Total High 40-Mile and Low 30-Day $2,760,660,664 $2,953,373,021 $3,175,565,227 $8,889,598,912 High 40-Mile and Medium 30-Day $3,150,557,152 $3,256,907,437 $3,383,845,916 $9,791,310,504 High 40-Mile and High 30-Day $3,540,453,639 $3,560,441,853 $3,592,126,604 $10,693,022,096 Medium 40-Mile and Low 30-Day $2,022,796,002 $2,110,879,151 $2,214,456,882 $6,348,132,035 Medium 40-Mile and Medium 30-Day $2,412,692,490 $2,414,413,567 $2,422,737,571 $7,249,843,628 Medium 40-Mile and High 30-Day $2,802,588,978 $2,717,947,982 $2,631,018,260 $8,151,555,220 Low 40-Mile and Low 30-Day $1,284,931,341 $1,268,385,280 $1,253,348,538 $3,806,665,159 Low 40-Mile and Medium 30-Day $1,674,827,829 $1,571,919,696 $1,461,629,227 $4,708,376,751 Low 40-Mile and High 30-Day $2,064,724,316 $1,875,454,112 $1,669,909,916 $5,610,088,344 Maximum $4,511,044,597 $4,301,552,150 $4,062,270,544 $12,874,867,291 For initial planning purposes VA assumed the medium range for the 30 day group and the high range for the 40 mile group most closely represented the estimated annual number of Veterans who will elect and be found eligible for services under this law. The healthcare costs associated with this assumption are estimated to be $3.2 billion in FY 2015 and $9.8 billion over a three year period. However, as VA gains experience with this program, the actual utilization will impact the cost of the program; lower utilization than originally anticipated could result in excess VHA-174 Veterans Choice Act

177 funding that could then be made available to support investments in other Veterans medical care or other VA priorities. Estimated costs and projections are based on the best reasonably obtainable and available economic information to implement the provisions of the Veterans Choice Program. Table: 3-Year Total Costs (Medium Range for Cohort 1 and High Range for Cohort 2) Fiscal Year Cost of Care Admin. Costs Total Costs 2015 $3,150,557,152 $394,087,091 $3,544,644, $3,256,907,437 $183,798,144 $3,440,705, $3,383,845,916 $183,621,101 $3,567,467,016 3-Year Total $9,791,310,504 $761,506,336 $10,552,816,840 Other Cost Impacts. The Veterans Choice Program may provide a measure of short-term relief from the pressure of escalating health care requirements as some current patients in the VA system elect to receive their care through the program. The 2016 and 2017 requests for Medical Care appropriations assume that some Veterans who would otherwise receive care in the VA health care system will now receive that care through the VCP, instead. This introduces a shift of health care costs from the discretionary program to the new mandatory source of funding in the Veterans Choice Fund, thereby reducing the discretionary appropriations request by the same amount. The assumed cost-shift is $452 million in 2016 and $733 million in These estimates are highly dependent on the number of Veterans who choose to participate in the VCP; to the extent that participation is higher or lower than anticipated, VA will realize more or less of a cost-shift Congressional Submission VHA-175

178 This Page Intentionally Left Blank VHA-176 Veterans Choice Act

179 Enrollee Health Care Projection Model (EHCPM) and CHAMPVA Model Models Used to Inform Budget Request The Department of Veterans Affairs (VA) uses two actuarial models to support formulation of the majority of the VA health care budget, to conduct strategic and capital planning, and to assess the impact of potential policies and changes in a dynamic health care environment. The two actuarial models are the VA Enrollee Health Care Projection Model (Model) and the Civilian Health and Medical Program Veterans Administration (CHAMPVA) Model. Activities and programs that are not projected by either the Enrollee Health Care Projection Model or the CHAMPVA Model are called non-modeled and can change from year to year. In general, they include non-recurring maintenance (NRM), state-based long term services and supports programs (LTSS), readjustment counseling, recently-enacted programs, and some components of CHAMPVA programs (spina bifida, foreign medical program, children of women Vietnam Veterans). VA Enrollee Health Care Projection Model The VA Enrollee Health Care Projection Model supports more than 90 percent of the VA health care budget. The Model, which was first developed in 1998, is a sophisticated health care demand projection model and uses actuarial methods and approaches to project Veteran demand for VA health care. These approaches are consistent with the actuarial methods employed by the Nation s insurers and public providers, such as Medicare and Medicaid. The Model projects enrollment, utilization, and expenditures for the enrolled Veteran population for 83 categories of health care services 20 years into the future. The Model consists of three main components. First, VA uses the Model to project how many Veterans will be enrolled in VA health care each year and their age, gender, priority level, and geographic location. Next, VA uses the Model to project the total health care services needed by those enrollees and then estimates the portion of that care that those enrollees will demand from VA (known as reliance ). Finally, total health care expenditures are developed by multiplying the expected VA utilization by the anticipated cost per service. The projections are supported by extensive research and analyses of the Veteran enrollee population and the drivers of demand for VA health care. VA program, field, and research staff provide expertise on program strategies and initiatives, the unique needs of the enrollee population, and the VA health care system. The 2014 Model (Base Year 2013, i.e., based on FY 2013 actual enrollment, utilization, and expenditure) was used to build the FY 2016 / FY 2017 Veterans Health Administration (VHA) Medical Care budget request. The expenditure basis used to build the projections includes the 2016 Congressional Submission VHA-177

180 Medical Services, Medical Support & Compliance, and Medical Facilities appropriations, but excludes non-recurring maintenance. The projections include all care provided in VA facilities or paid for by VA (non-va care). The 2014 Model has not been adjusted for any potential new enrollment or growth in services, or any other changes, as a result of the Veterans Access, Choice, and Accountability Act of 2014, (Veterans Choice Act); such impacts have been accounted for separately as part of the the 2016 budget and 2017 Advance Appropriations requests. All assumptions in the Model are revisited with each annual update. Key Drivers of Growth in Projected Resource Requirements In projecting future Veteran demand for VA health care, the Model accounts for the unique characteristics of the Veteran population and the VA health care system and environmental factors that impact Veteran enrollment and use of VA health care services. The current growth in the Model is primarily driven by health care trends, the most significant of which is medical inflation. Health care trends are key drivers of annual cost increases for all health care providers Medicare, Medicaid, commercial providers, and the VA health care system. Health care trends increase VA s cost of care independent of any growth in enrollment or demographic mix changes. Enrollment dynamics contribute to a portion of the expenditure growth; however, their impact varies significantly by the type of health care service. An assumption that VA s level of management in providing health care will improve over time is expected to reduce the cost of providing care to enrollees. Figure A quantifies the key drivers of the projected increase in expenditure requirements for FY 2016 for all modeled services. Figure A *Modeled initiatives, economic conditions, and reliance changes. VHA-178 Models used to Inform Budget Request

181 These drivers and their impact on the resources required to provide health care to enrolled Veterans are discussed in detail in the following sections. Health Care Trends Health care trends represent a significant driver of growth in the cost of health care in the United States and in the VA health care system. Health care trends (inflation, utilization, and intensity) represent anticipated changes in health care utilization and cost due to advances in technology, including new diagnostics, drugs, and treatments, as well as price inflation. Health care trends affect VA s projected expenditure requirements independent of any enrollment growth or demographic mix changes. The health care trends incorporated into the Model are informed by Federal policy and anticipated trends in Medicare, together with VA-specific trends for pharmacy and prosthetics, and private sector trends for services that VA routinely purchases (for example, maternity services). Inflation is comprised of personnel and non-personnel components. Inflation on VA s personnel costs is determined by Federal wage policy, including wage increases. VA s projected inflation for pharmacy and prosthetics products reflects VA s well-managed purchasing programs for these products. VA s expected inflation on supplies, utilities, etc., is based on projected Consumer Price Index - Urban (CPI-U) and Producer Price Index (PPI) inflation trends for these items. Utilization and intensity (cost) trends increase health care costs due to changes in health care practice and new technology. VA s costs are driven by these trends similar to other health care insurers and providers, because Veterans expect access to these advances in the VA health care system. The newly approved drug therapy to treat individuals infected with Hepatitis C is an example of how new technology increases VA s costs to care for the enrolled Veteran population. These expensive drugs significantly increased VA s expected intensity trend for pharmacy in the 2014 Model. VA s utilization and intensity trends for Medicare-covered medical services are informed by anticipated Medicare utilization and intensity trends, as projected by the Center for Medicare and Medicaid Services Office of the Actuary. They have been adjusted downward for efficiencies in the VA health care system as compared to Medicare s primarily fee-for-service environment. VA s pharmacy and prosthetics trends are set by VA workgroups to reflect VA s unique practice patterns for these services. Net Enrollment Growth and Demographic Mix Changes Veteran demand for VA health care is influenced by the following demographic characteristics of the Veteran population and environmental factors. Many of these factors are dynamic and are expected to change over time. Some can be anticipated (e.g. changing demographics) and some cannot (e.g. future economic downturns). Growth of the Operation Enduring Freedom/Operation Iraqi Freedom/ Operation New Dawn (OEF/OIF/OND) and female Veteran populations. Enrollee age, gender, mortality, income, travel distance to VA facilities, and geographic migration patterns Congressional Submission VHA-179

182 Increases in prevalence of service-connected conditions and changes in enrollee income levels. These are associated with transitions between enrollment priorities. Unique health care utilization patterns of OEF/OIF/OND, female, and new enrollees, and other enrollee cohorts with unique utilization patterns for particular services. Economic conditions, including changes in local unemployment rates and home values (as a proxy for asset values) and the long-term downward trend in labor force participation. New policies, regulations, and legislation, as introduced, such as the five-year OEF/OIF/OND combat enrollment eligibility period. In the 2014 Model, using current assumptions, Veteran enrollment in VA is projected to grow by 6.6 percent from FY 2013 to FY 2021 even though the Veteran population is declining (see Figure B). This growth is largely due to the high enrollment rates for Gulf War and OEF/OIF/OND Veterans. After FY 2021, enrollment is projected to decline slightly as the impact of mortality in the enrollee population begins to outweigh new enrollment. As described below, costs for VA health care are dependent not just on the number of enrollees but on the demographics of the enrolled Veteran population. Figure B Veteran enrollment in VA is dynamic and responds to all of the demographic factors discussed above. Changes in the broader environment also impact Veterans decisions to enroll. The decrease in new enrollment in FY 2006 and FY 2007 seen in Figure C was partially driven by the availability of the new Medicare drug benefit (Part D). The chart also shows the growth in new enrollment as a result of the economic recession and the decline in new enrollment as the economy has recovered. Of note, it is sometimes difficult to ascertain causal impacts due to the multiple factors changing over any given time period. VHA-180 Models used to Inform Budget Request

183 Figure C While the enrolled Veteran population is expected to continue to grow, net enrollment growth (new enrollment minus deaths) is not a significant driver of increases in annual expenditure requirements for VA health care. This is because the enrollees who are dying are generally sicker and more reliant on VA health care than new enrollees. However, the cost of caring for enrollees can change due to other demographic factors (e.g., aging) and changes in the broader environment (e.g., the economic recession). Within the enrollee population, two dynamic demographic trends are impacting the projected future cost of VA health care: the aging of the Vietnam Era enrollee population and the increasing number of enrollees being adjudicated for service-connected disabilities, which increases the number of enrollees in Priorities 1, 2, and 3. These demographic trends combine in the Vietnam Era enrollee population with particular implications for demand for Long Term Services and Supports (LTSS). Figure D shows actual enrollment in FY 2013 and projected enrollment by age and highlights the relative size of the Vietnam Era enrollee cohort compared to other period-of-service cohorts Congressional Submission VHA-181

184 Figure D* * The period of service cohorts in this and other charts are defined by enrollee age in 2013 because enrollee level data on period of service is not available for all enrollees. Note, an enrollee may be in the age range for the cohort and not have served in the conflict, and the cohorts are not mutually exclusive. An enrollee s enrollment priority is dynamic. In recent experience, approximately 40 percent of new enrollees transitioned to a new priority level within three years of enrolling. Enrollees transition between Priorities 5, 7, and 8 due to changes in income. Enrollees also transition into Priorities 1, 2, and 3 as a result of adjudication for service-connected disabilities by the Veteran Benefits Administration. The number and percentage of enrollees being adjudicated for service-connected disabilities has increased in recent years. As of FY 2013, about 7 percent of enrollees had transitioned from a non-service-connected priority into Priority 1, 2, or 3 within the previous three years, about double the rate as of FY Based on historical experience, these enrollees are also expected to increase their reliance on VA health care, resulting in an increase in the cost of care. Figure E shows the significant projected growth in service connected status for OEF/OIF/OND, Gulf War, and Vietnam enrollee populations over the next 20 years. As a result of the increasing numbers of enrollees moving into Priorities 1-3, projected enrollment in Priorities 5, 7, and 8 is declining slightly. VHA-182 Models used to Inform Budget Request

185 Figure E Further, as of FY 2013, 4.5 percent of enrollees had transitioned into Priority 1a (70 percent or higher service-connected disability) over the previous three years, compared with 2 percent as of FY As a result, the Priority 1a population is projected to grow by 25 percent between FY 2013 and FY 2016 and 72 percent between FY 2013 and FY Aging and the changes in the Priority 1a population are significant drivers of projected expenditure increases for LTSS. VA is mandated by law to provide continuing care nursing home services to Priority 1a enrollees. Additionally, World War II enrollees are in the age bands (greater than age 75) that are the highest users of LTSS and are driving the recent and near-term annual growth in LTSS expenditure requirements, and Vietnam Era Veterans will be an increasing driver of LTSS expenditures, with most having aged beyond age 75 by Enrollee Morbidity The VA enrollee population consists largely of older males, which is typically the segment of the population with the highest healthcare costs. Even after accounting for the age and gender mix of the enrollee population, the VA enrollee population is significantly more morbid (sicker) than the general population in the United States, and this higher morbidity further increases VA s cost of providing care. In the 2013 VHA Survey of Enrollees, 31 percent of enrollees rated their health as fair or poor compared to other people their age. Only 12 percent of the U.S. population responded similarly in Centers for Disease Control s (CDC) National Center for Health Statistics 2012 National Health Interview Survey. Similarly, only 37 percent of enrollees rated their health as excellent or very good compared to 61 percent of the U.S. population in the CDC survey. Using a diagnosis-based methodology, the average morbidity of the VA enrollee population is estimated to be approximately 40 percent higher than that of the general U.S. population. Morbidity varies significantly by priority level and health care service. For example, the morbidity of Priority 4 (catastrophically disabled) enrollees results in inpatient care costs that are five times that of the general U.S. population, even after accounting for the demographic 2016 Congressional Submission VHA-183

186 differences in the populations. Figure F shows the relative morbidity of enrollees compared to the morbidity of the general population by priority for several large categories of health care services. In the figure, 100 percent reflects the cost of health care based on the morbidity of the general U.S. population. Figure F Enrollee Reliance on VA Health Care An important aspect of the enrolled Veteran population is that many enrollees have multiple options for health care coverage in addition to VA: Medicare, Medicaid, TRICARE, and private insurance. According to the 2013 VHA Survey of Enrollees, approximately 81 percent of enrollees have some type of public or private health care coverage in addition to VA: 56 percent have one other source, 23 percent have two other sources, and three percent have coverage through three or more sources in addition to VA. As a result, enrollees on average rely on VA for approximately one-third of their health care needs. Figure G presents the impact of insurance coverage on reliance on VA health care. There is no clear information on why enrollees with no other form of insurance coverage are not 100-percent reliant on VA care. It may due to a combination of factors, including personal choice, ease of access to VA health care, access of community health centers, availability of charity care, and/or survey response issues. VHA-184 Models used to Inform Budget Request

187 Figure G Figure H shows reliance by priority for several large categories of health care services. For example, Priority 4 enrollees get approximately 35 percent of the inpatient care they need in VA. Figure H Like Veteran enrollment and demographics, enrollee reliance on VA health care is dynamic. Changes in enrollee reliance occur as a result of many factors: enrollee movement into serviceconnected priorities; changing economic conditions; VA s efforts to provide Veterans access to the services they need (e.g., mental health and homeless initiatives); VA s efforts to enhance its practice of health care (e.g., Patient Aligned Care Teams (PACT)); the opening of new or expanded facilities; the cost sharing associated with services (e.g., dialysis) in the private sector compared to VA Congressional Submission VHA-185

188 For example, enrollees reliance on VA for dialysis services has increased from 18 percent in FY 2006 to 31 percent in FY 2013 and is expected to continue to increase through FY This increase is due in part to significantly lower cost sharing in VA. Enrollees have either a $15 copayment or no co-payment for dialysis treatments in VA. For Medicare enrollees, the copayment is 20 percent of the cost of the treatment or approximately $50 per treatment. This represents a potential difference of as much as $7,500 in out-of-pocket expenses per year. Enrollee Cohorts Within the enrollee population, several cohorts of enrollees exhibit unique health care utilization patterns that reflect their morbidity and/or reliance on VA health care. These include OEF/OIF/OND, Vietnam Era, post-vietnam Era, World War II Era, and female enrollees. OEF/OIF/OND enrollees have notably higher utilization rates than non-oef/oif/ond enrollees of the same age for many services. For mental health services, this is attributable to higher morbidity levels. However, for other services, the difference is attributable to the higher utilization rates typically experienced by new enrollees, and therefore, is not expected to persist over time. OEF/OIF/OND represents 12 percent of the enrollee population in FY 2013 and is expected to grow to 19 percent in FY Women are one of the fastest growing enrollee cohorts. Women comprise seven percent of the enrollee population in FY 2013 and are expected to grow to 10 percent by FY Females tend to use more health care than males at younger ages and fewer services than males at older ages. Women enrollees also use a different mix of services than the historically male-dominated enrollees. For example, females are more likely to use physical therapy and preventive services, but less likely to use cardiovascular services. Enrollees who used VA prior to the Eligibility Reform Act of 1996 ( Pre enrollees) differ from those who enrolled after ( Post enrollees). Pre enrollees are both sicker and more reliant on VA for health care and therefore, have higher utilization rates. These higher utilization rates are observed even after accounting for the higher average age of the Pre enrollees. Pre enrollees represented only 21 percent of enrollees in FY 2013, but accounted for 39 percent of modeled expenditures. Since there are no new Pre enrollees, this group is declining over time due to mortality; Pre enrollees are projected to decline to 12 percent of the population by FY 2023, but still account for 25 percent of expenditures. Vietnam Era enrollees (those born between 1947 and 1952) exhibit higher-than average levels of utilization for some services, notably mental health and homeless services. Currently, this cohort is aging into Medicare eligibility with a corresponding drop in reliance on VA health care. As they age and transition into Priority 1a, Vietnam Era enrollees are expected to be significant users of LTSS. Vietnam Era enrollees represent 19 percent of the enrollee population in FY Enrollees who served immediately after Vietnam (those born between 1953 and 1963) have the highest healthcare utilization relative to other enrollees of the same age. These VHA-186 Models used to Inform Budget Request

189 enrollees exhibit higher than expected needs for almost all mental health and substance abuse services and for a number of non-mental health services as well (e.g. emergency room visits). This cohort represents about 18 percent of the enrollee population FY World War II Era enrollees are high utilizers of Long Term Services and Supports, since those services are typically provided to older enrollees. This cohort represents less than 8 percent of overall enrollment in FY Expenditure Requirements by Enrollee Age As discussed, many demographic and environmental factors influence Veteran demand for VA health care and the resources required to provide that care. Some of these factors increase VA s resource requirements and some decrease VA s resource requirements. Figure I shows the net impact of all the factors on expenditures. In Figure I, the actual FY 2013 expenditures by age highlight the impact of key factors influencing the cost per enrollee. For the under age 65 enrollee population, the figure shows the impact of the increase in the need for health care services as enrollees age. It also highlights how the impact of aging is mitigated by a steep decline in reliance on VA health care beginning at age 65 when enrollees typically become eligible for Medicare. Figure I also displays the projected increase in expenditure requirements to provide care to enrolled Veterans in FY Figure I Dynamics of the VA Health Care System The VA health care system is continually evolving due to VA s efforts to enhance its practice of health care, provide Veterans access to the services they need, and improve its level of health care management. The Model includes assumptions for initiatives to increase capacity for mental health, homeless, LTSS, and dental services. These initiatives are discussed in the service-specific discussions in the next section Congressional Submission VHA-187

190 The Model also includes assumptions that VA s level of management in providing health care will improve over time and reduce the cost of providing care to enrollees. The majority of these efficiencies result from improvements in VA s level of management in inpatient care. The future improvements are expected to result from a wide range of activities that collectively improve VA s level of management, including: VHA s well-established inpatient system redesign initiative (FIX), which focuses on improving management processes, such as early discharge planning Admission appropriateness and continued stay reviews through the National Utilization Management Initiative (NUMI) Improved coordination of care as a result of the Patient Aligned Care Team (PACT) initiative, VA s model for patient-centered medical homes, as well as expansion of home telehealth services, and other disease management activities that result in reductions in hospitalizations for ambulatory care sensitive conditions A focus on creating alternative services, such as intensive outpatient mental health programs, support services, and alternative locations of care. Expenditure Requirements by Service Category The following sections discuss the key drivers of increases in expenditure requirements for categories of health care services. Ambulatory Primary and Specialty Care Ambulatory care projections are developed for the full range of services provided under a typical private sector health plan (e.g., office visits, radiology, pathology, surgeries) as well as specialized services offered by VA (e.g., nutritional counseling, hearing aid services, recreational therapy). These services are broadly classified into Diagnostics and Therapies, Evaluation and Management Services (office visits), and Professional Services and Procedures. Requirements to provide ambulatory care services to enrolled Veterans are expected to grow in both FY 2016 and FY The projected increase in expenditures is largely due to the impact of health care trends. VA s cost of providing ambulatory services is expected to increase due to inflation and changes in health care practice that increases the cost per service (intensity trends). Further, utilization of ambulatory care is expected to grow due to changes in health care practice independent of any changes in enrollee demographics. For example, utilization of ambulatory surgery and the cost per service of ambulatory surgeries is expected to increase as more complex surgeries are provided in the ambulatory environment. VHA-188 Modeled Ambulatory Primary and Specialty Care Diagnostics and Therapies Radiology Pathology Cardiovascular Office Administered Drugs and Misc. Medical Dialysis and Related Services Physical Medicine Chiropractic Immunizations Recreational Therapy Allergy Testing and Immunotherapy Evaluation and Management Services Office Visits, including Physical Exams, Urgent Care Visits, and Telephone Care Visits Professional Services and Procedures Surgery and Anesthesia Emergency Room Visits Hearing and Speech Exams Hearing Aid Services Prosthetics and Orthotics Services Vision Exams Maternity Nutritional Counseling Compensation & Pension Exams Models Medication used to Therapy Inform Management Budget Request Ambulance

191 Enrollment dynamics are driving small increases in annual expenditure requirements for ambulatory care. Net enrollment growth (new enrollment minus deaths) and the growth in the Priority 1-3 population has a positive impact. Aging has a relatively neutral impact overall for ambulatory services due to the drop in enrollee reliance on VA health care at age 65. However, the impact of aging is material for some services. For example, use of hearing aid services increases significantly with age, while use of maternity services decreases significantly with age. Changes in enrollee reliance are increasing VA s expenditure requirements for providing dialysis services. From FY 2008 to FY 2013, enrollees reliance on VA for dialysis services increased an average of 9 percent per year and is expected to continue increasing by 6 percent per year from FY 2014 to FY This increase in reliance is due in part to lower cost sharing in VA. In VA, enrollees pay a $15 co-payment per treatment, and many enrollees do not pay a copayment. For many Medicare enrollees, the co-payment is 20 percent or approximately $50 per treatment. For enrollees, this represents a potential savings of as much as $7,500 per year. Pharmacy Outpatient Prescriptions Pharmacy workload projections are developed for prescription drugs that are typically covered under a private sector health plan, as well as pharmacy items that are not but that are covered by VA, such as over-the-counter (OTC) medication and supplies. Requirements to provide pharmacy services to enrolled Veterans are expected to grow in both FY 2016 and FY The projected increase in expenditures is largely due to the impact of health care trends. VA moderates the impact of inflation on prescription drugs with its well managed pharmacy benefit management program and contracting practices; however, inflation is still increasing VA s cost of providing prescription drugs. The new Hepatitis C drugs are driving intensity (cost) trend for pharmacy and are driving increases in the expenditure requirements in FY 2015 and FY 2016 as the new expensive Hepatitis C drugs are replacing less expensive, less effective drugs. Further, utilization of pharmacy services is expected to grow due to changes in health care practice independent of any changes in enrollee demographics. For example, when a new drug is added to an existing drug treatment regimen, this increases the number of prescriptions provided to enrollees independent of any changes in enrollee demographics. Inpatient Acute Care Inpatient projections are developed for acute bed days of care for medicine, surgery, and maternity. In order to support workforce planning, the Model also projects utilization for inpatient encounters that occur during inpatient stays. The inpatient encounters projected by the Model will be expanded to include additional diagnostics, therapies, professional services, and procedures provided in an inpatient environment. The cost of all inpatient encounters is included in the cost of acute bed days of care. Modeled Inpatient Acute Care Inpatient Acute Medicine Surgery Maternity Deliveries Maternity Non-Deliveries Inpatient Encounters Medication Therapy Management Surgical Procedures 2016 Congressional Submission VHA-189

192 Requirements to provide inpatient acute services to enrolled Veterans are expected to grow in both FY 2016 and FY The projected increase in expenditures is largely due to the impact of health care trends. VA s cost of providing acute inpatient services is expected to increase due to inflation and changes in health care practice that increases the cost of services (intensity trends). For example, as more surgeries are performed in an ambulatory environment, the average cost per service of the remaining inpatient surgeries, which are more complex, is expected to increase. While the cost per service of inpatient medical and surgical care is increasing, utilization is expected to decline slightly due to two factors: Net enrollment growth (new enrollment minus deaths) is reducing inpatient utilization because the enrollees who are dying are generally sicker and more reliant on VA for inpatient care than new enrollees. Improvements in VA s level of management in inpatient care reduces utilization by improving management processes (e.g. early discharge planning), reducing hospitalizations for ambulatory care sensitive conditions and readmissions through care coordination, disease management, expansion of home telehealth services, etc., and the continuing transition of care from an inpatient to outpatient environment. VA s cost of providing inpatient maternity care is increasing due to high health care trends for maternity services in the private sector (most maternity care is purchased) and an increase in utilization due to the growth in enrollment for younger, female Veterans. Mental Health Care Mental health projections are developed for a continuum of primary and specialty care services including general outpatient mental health, evidence-based psychotherapies, intensive outpatient programs, residential rehabilitation treatment, and inpatient mental health care. These services treat a variety of common mental health conditions in primary care as well as treatment in specialty mental health programs for conditions requiring more specialized and/or intensive interventions including the most severe and persisting mental health conditions. Requirements to provide mental health services to enrolled Veterans are expected to grow by in both FY 2016 and FY The projected increase in expenditures is due to the impact of health care trends, primarily inflation, on the cost per service and VA s initiatives to expand access to mental health care. VHA-190 Modeled Mental Health Care Mental Health Inpatient Acute Psychiatric Acute Substance Abuse Mental Health Residential Rehab Compensated Work Therapy/Transitional Residence (CWT/TR) Sustained Treatment and Rehabilitation (STAR) Mental Health Outpatient Outpatient Mental Health Psychotherapy Outpatient Substance Abuse Psychosocial Rehabilitation and Recovery Centers Mental Health Intensive Case Management Work Therapy Mental Health RRTP Aftercare/Screening/Outreach Homeless Models used to Inform Budget Request

193 Utilization of several mental health services is expected to grow (independent of any change due to enrollment dynamics) due to VA s initiatives to increase capacity and patient referrals: Mental Health Residential Rehabilitation and Compensated Work Therapy/Transitional Residence (CWT/TR) are projected to grow 16 percent and 32 percent respectively through FY 2016; Outpatient Mental Health (three percent), Psychotherapy (six percent), and Outpatient Substance Abuse (three percent) through 2014; and Homeless (37 percent) through FY These assumptions are revisited with each annual Model update. Overall, the impact of enrollment dynamics on utilization of mental health services is minimal. However, enrollment dynamics are driving growth in mental health services for certain segments of the enrollee population. The continued growth of the OEF/OIF/OND enrollee population (26 percent from ) and their increase in service-connected conditions (and the resulting transition into service connected Priorities 1-3) is driving increases in utilization between 17 and 42 percent per service from FY 2013 to FY In addition, post-vietnam Era enrollees (those born between 1951 and 1961) use a significant amount of mental health and substance abuse services. However, the aging of the non-oef/oif/ond enrollee population is mitigating the projected growth in utilization of mental health services because use of mental health services declines at older ages. For example, utilization of Mental Health Residential Rehabilitation and Compensated Work Therapy services peaks between ages 40 to 55 and drops off dramatically by age 65 as enrollees age into Social Security. The growth in expenditure requirements slows from FY 2016 to FY 2017 as the mental health initiative ends and utilization changes solely based on the demographics of the enrollee population. Rehabilitative Care Projections are developed for two special rehabilitative care inpatient services provided by VA: Blind Rehabilitation, and Spinal Cord Injury/ Disorders (SCI/D) services. These services promote the health, independence, quality of life, and productivity of individuals. Modeled Inpatient Rehabilitative Care Blind Rehabilitation Services Spinal Cord Injury and Disorders VA operates 13 Blind Rehabilitation Centers, which provide 4-6 weeks of inpatient adjustmentto-blindness training to help blinded veterans achieve a realistic level of independence. VA operates 25 Spinal Cord Injury Centers. These provide expertise in treating new and longstanding spinal cord injuries and disorders and provide rehabilitation, medical care, prosthetics, and training in skills needed to live and work with SCI/D and maintain quality of life Congressional Submission VHA-191

194 Requirements to provide Rehabilitative Care to enrolled Veterans are expected to grow in both FY 2016 and FY The projected increase in expenditures largely due to the impact of inflation on the cost per bed day for rehabilitative care. Enrollment dynamics have a minimal impact on expenditure requirements. Aging is driving growth in utilization for Blind Rehabilitation inpatient services, as diagnoses of vision problems increase with age. Utilization of SCI/D inpatient services in SCI Centers has declined slightly in recent years. SCI/D utilization rates for Pre enrollees (those who enrolled prior to Eligibility Reform) are approximately five times that of Post enrollees. Therefore, as Pre enrollees become a smaller portion of the total enrolled population (due to deaths), the overall SCI/D utilization rate is falling. Prosthetics VA provides a full range of medically-prescribed medical equipment and products to enrolled Veterans. VA is the largest and most comprehensive provider of prosthetic devices and sensory aids in the country. Although the term "prosthetic device" may suggest images of artificial limbs, it actually refers to any device that supports or replaces a body part or function. These include devices worn by the Veteran, such as an artificial limb or hearing aid; those that improve accessibility, such as wheelchairs, ramps, and vehicle modifications; and implants surgically placed in the Veteran, such as hips and pacemakers. The relative cost of these devices varies dramatically, e.g., basic medical supplies cost very little while sophisticated implant and artificial limbs are much more expensive. Modeled Prosthetics Glasses/Contacts Hearing Aids Surgical Implants Cardiothoracic Surgical Implants Medical Equipment & Supplies (e.g. diabetic socks, blood pressure monitors, dressing aids) Home Telehealth Devices Oxygen Respiratory Equipment Wheelchairs Orthotics Blind Aids (e.g. magnifiers, talking products, training computer software) VA Specialized Products and Services (e.g. environmental modifications (ramps), services for service dogs) Requirements to provide prosthetic services to enrolled Veterans are expected to grow in both FY 2016 and FY The projected increase in expenditures is due to health care trends and enrollment dynamics. The cost of prosthetics devices grows each year due to inflation and changes in health care practice. Extensive development and use of national committed-use contracts, as well as regional and local contracts, are expected to mitigate the expected inflation trends for prosthetics to some extent. These contracts provide quality assurance through active participation of clinicians and subject matter experts in developing requirements of the devices and the ability to obtain best value for VA. The cost of prosthetic devices such as cardiothoracic surgical implants, hearing aids, and wheelchairs is also expected to increase due to advancements in technology (intensity trends); for example, hearing aids with wireless or frequency modulation technology are replacing less sophisticated, less expensive hearing aids. VHA-192 Models used to Inform Budget Request

195 Changes in health care practice also drive growth in prosthetics utilization independent of any changes in enrollee demographics. With the increased use of technologies in all aspects of health care, more clinical specialties are using advanced prosthetic technology and devices to treat patients. Clinicians are better informed about the availability of technologies and are becoming more comfortable with prescribing these devices to treat and assist patients with specific conditions. As a result, VA has observed an increase in the number of purchase orders (work actions) and associated prosthetic devices that are prescribed and provided per unique patient. In recent years, VA has seen the portfolio of prosthetic devices expanded and the types of available and prescribed devices diversified. For example, wireless communication devices and other devices compatible with hearing aids are being prescribed and provided in conjunction with hearing aids with wireless capabilities. The increased diversity of prosthetic devices coupled with technological advances is driving material increases in utilization of prosthetic devices. The increasing number of enrollees being adjudicated for service-connected disabilities is also driving material increases in prosthetics utilization. As enrollees transition from non-service connected priorities into Priorities 1-3, they are expected to reflect the significantly higher utilization rates of enrollees in Priorities 1-3, particularly for blind aids, artificial limbs, wheelchairs, and VA specialized products and services. Aging has a relatively minor impact overall for prosthetic services for enrollees eligible for Medicare due to a decrease in enrollee reliance on VA health care beginning at age 65 with Medicare eligibility. However, the impact of aging is material for some services. For example, the use of hearing aids (which are not covered by private insurance or Medicare) increases significantly with age, while utilization of surgical implants declines as enrollees elect to use Medicare for surgical procedures. Aging is driving material increases in utilization of hearing aids, blind aids, VA specialized products and services, and oxygen. The continued growth of the OEF/OIF/OND enrollee population (26 percent from ) and their increase in service-connected conditions (and the resulting transition into service connected Priorities 1-3) is driving significant growth in utilization for prosthetics services for this population. Since this population is not yet eligible for Medicare (with the corresponding decline in reliance on VA), aging is driving increases in this population s use of prosthetics, particularly for cardiothoracic surgical implants, oxygen, respiratory equipment, VA specialized products and services, and hearing aids. Long Term Services and Supports Long Term Services and Supports (LTSS) include the full range of services provided to help Veterans with functional limitations and chronic health conditions in non-acute settings. These services are provided through facility based care (nursing homes) or via home and community based services (HCBS). Modeled Long Term Services and Supports Facility Based Services VA Community Living Centers, long-stay (>90 days) VA Community Living Centers, short-stay Community Nursing Homes, long-stay Community Nursing Homes, short-stay Home and Community Based Services VA Adult Day Health Care Community Adult Day Health Care Home Based Primary Care Home Respite Care Purchased Skilled Home Care Home Hospice Care Homemaker/ Home Health Aide Programs Spinal Cord Injury Home Care Community Residential Care Home Telehealth 2016 Congressional Submission VHA-193

196 Facility based care is provided in VA Community Living Centers (CLC), Community Nursing Homes (CNH), and State Veterans Homes for durations of both short-stay (90 days or less) and long-stay (more than 90 days). HCBS are provided through both VA and via purchased care. State Veterans Homes provide both facility based and HCBS, but are not included in the Model. Requirements to provide LTSS to enrolled Veterans are in both FY 2016 and FY The projected growth for expenditures is primarily the impact of two enrollment dynamics that are having a very significant impact on LTSS in both facility and HCBS settings: priority transitions and the aging of the enrollee population. Inflation is also driving some growth for these services. Enrollees transitioning into service-connected priorities are driving significant growth in utilization for facility-based LTSS as well as HCBS. In particular, the growth in Priority 1a enrollees (70 percent service connected or more) is driving significant growth for long-stay facility-based LTSS. VA is legislatively mandated by the Veterans Millennium Health Care and Benefits Act (PL ) to provide continuing care in a nursing home for enrolled Veterans who have a 70 percent or greater service-connected disability, as well as those who need such care for a service-connected disability, or who have a rating of total disability based on individual un-employability. The aging of the enrollee population is also having a significant impact on expenditures and utilization. Unlike other modeled services, reliance on LTSS does not decline after Medicare eligibility, due to limited Medicare coverage for long-stay nursing home services. Currently World War II and Korea era enrollees are in the age bands that are the highest users of LTSS. Vietnam era Veterans will be an increasing driver of LTSS, with most having aged beyond 75 by FY CLC short-stay, which is used primarily for post-acute care and hospice care, is impacted less by aging than the other facility based care categories. Projected utilization for LTSS reflects programmatic changes in approach to these services. VHA, reflecting similar shifts in the health care system at large, is focusing efforts to provide care in the most appropriate setting for enrollees. This change includes deliberate shifts to CLC short-stay care for those who do not need acute care but are not ready to be discharged to home, as well as VA s initiative to provide care through HCBS rather than in nursing homes when appropriate. These approaches are driving some growth for short-stay facility based care and HCBS, but are mitigating expected growth for long-stay facility based care. Dental Projections are developed for three categories of dental care services based on the intensity and complexity of the service. By law, VA provides dental care to enrollees based on special eligibility criteria, which are different than eligibility criteria for other VA medical care benefits. Modeled Dental Care Preventive and Basic Dental Services Minor Restorative Dental Services Major Restorative Dental Services Requirements to provide dental services to enrolled Veterans are expected to grow in both FY 2016 and FY The projected increase is primarily due to the increase in service-connected VHA-194 Models used to Inform Budget Request

197 conditions (and the transition into service connected Priorities 1-3) and the resulting increase in eligibility for dental services. VA s cost of providing dental services is also expected to increase due to inflation and changes in health care practice that increases the cost of services (intensity trends). For example, dental implants have become the standard of care in tooth replacement with the concomitant higher treatment costs. Utilization of Preventive and Basic dental services is expected to grow (independent of any change due to enrollment dynamics) due to VA s initiatives to provide more preventive oral health services for eligible dental patients to maximize their health outcomes. Impact of 2014 Model Update Health care is very dynamic. Further, the Model projections supporting the VA budget are developed based on data this are three years removed from the beginning of the budget year (four years for the Advance Appropriation). During this time, new policies, legislation, regulations, and external factors, such as the economic recession, can occur and change the projected demand for VA health care. Each year, the Model is updated in order to reflect the most recent data and emerging experience. Key updates for the 2014 Model include: Enrollment rates were updated to reflect emerging experience. As a result, projected enrollment is 3.4 percent lower in FY 2023 in the 2014 Model compared to the 2013 Model (Base Year FY 2012). Priority transition assumptions were updated to reflect higher rates of enrollees transitioning into service-connected priorities. This increased the number of enrollees in Priorities 1-3 by 4 percent in FY 2023 in the 2014 Model compared to the 2013 Model. The Model began projecting the impact of new drug therapies to treat enrollees diagnosed with Hepatitis C virus (HCV) on pharmacy intensity trends. Historically, the most significant factors changing the Model s projections have been external and could not have been anticipated in advance, including the civilian wage freeze policy, the impact of the recession, American Reinvestment and Recovery Act (ARRA) funding, and the FY 2007 and FY 2008 VA supplemental funding. Civilian Health and Medical Program Model The Civilian Health and Medical Program Veterans Administration (CHAMPVA) Model, which was adopted in 2010, projects the cost of providing medical coverage to the spouse or widow(er) and to the children of a Veteran, also referred to as a sponsor, who is rated permanently and totally disabled due to a service-connected disability, or was rated permanently and totally disabled due to a service-connected condition at the time of death, or died of service-connected disability, or died on active duty and the dependents are not otherwise eligible for Department of Defense TRICARE benefits. In FY 2013, CHAMPVA covered 385,466 beneficiaries. The 2016 Congressional Submission VHA-195

198 number of beneficiaries is expected to rise to approximately 426,000 beneficiaries in FY 2015 and 445,000 beneficiaries in FY The 2014 CHAMPVA Model was developed using data from FYs 2006 to 2013, publically available research, and input from a development team (including subject matter experts from VHA and VHA s CHAMPVA program). The CHAMPVA Model consists of two major components: the enrollment model and the claims cost model. The enrollment model projects the number of beneficiaries enrolled in CHAMPVA, and the claims cost model projects expenditures for providing care to beneficiaries. The enrollment model projects the number of CHAMPVA beneficiaries in two phases. For each fiscal year, the number of sponsors is projected and then the number of beneficiaries of those sponsors is projected. Within a given year, sponsors are projected by age, gender, degree of service-connected disability, whether the sponsor is living or deceased, and the sponsor s enrollment lag (the number of years a sponsor delays enrolling a beneficiary), while beneficiaries are projected by age, beneficiary type, and gender (if the beneficiary is a spouse). The claims cost model is driven by several factors including: enrollment counts produced from the enrollment model, assumed annual claim cost trends, age/gender factors, and actual fiscal year 2013 CHAMPVA medical claims data. The projected beneficiaries from the enrollment model are then linked to the claims cost model to generate expenditures. VHA-196 Models used to Inform Budget Request

199 Appropriation Transfers & Supplementals Explanation of Veterans Access, Choice, and Accountability Act of 2014 (Veterans Choice Act): Veterans Choice Act. On August 7, 2014, President Obama signed into law the Veterans Access, Choice and Accountability Act of 2014 (Public Law ) ( Veterans Choice Act ). The 2016 budget supports implementation of the Veterans Choice Act and the Administration s goal of providing timely, high-quality health care for our Nation s veterans. The Veterans Choice Act provided $5 billion in mandatory funding in Section 801 to increase veterans' access to health care by hiring more physicians and staff and improving the VA s physical infrastructure. It also provided $10 billion in mandatory funding in Section 802 through 2017 to establish a temporary program ("Veterans Choice Program") improving veterans access to health care by allowing eligible veterans who meet certain wait-time or distance standards to use health care providers outside of the VA system. The $10 billion was deposited in the Veterans Choice Fund in 2014, for purposes of operating the Veterans Choice Program. The $5 billion was deposited in the Medical Services account and allocated among Medical Services ($2,313,100,000), Medical Support & Compliance ($27,500,000), Medical Facilities ($1,771,600,000), Information Technology ($376,600,000) and Minor Construction ($511,200,000). Annual Appropriation Adjustment in 2014: $40,000,000 Addition to the Medical Services Appropriation. This reflects an addition to the funds previously appropriated under Medical Services that became available on October 1, The authority for the addition to Medical Services Appropriation is provided in the Consolidated and Further Continuing Appropriations Act, 204 (P.L ), Division J. $85,000,000 Addition to the Medical Facilities Appropriation. This reflects an addition to the funds previously appropriated under Medical Facilities that became available on October 1, The authority for the addition to Medical Facilities Appropriation is provided in the Consolidated and Further Continuing Appropriations Act, 204 (P.L ), Division J. Explanation of Recissions in 2014: $179,000,000 Rescission to Unobligated Balances in Medical Services. This reflects the VHA portion of a total VA rescission from unobligated balances of 2016 Congressional Submission VHA-197

200 $182,000,000. The authority for the rescissions is provided in the Consolidated and Further Continuing Appropriations Act, 2014 (P.L ), Division J, Section 234. $50,000,000 Rescission to the Medical Support and Compliance Appropriation. This reflects a rescission of appropriations from Medical Support and Compliance ($50,000,000). The authority for the rescission is provided in the Consolidated and Further Continuing Appropriations Act, 2014 (P.L ), Division J, netting Sections 226(a)(2), and 226(b)(2). Explanation of Appropriation Transfers in 2014: $15,000,000 Transfer to the DoD VA Health Care Sharing Incentive Fund (JIF) from Medical Support and Compliance. Title 38, section 8111(d)(2), states that, To facilitate the incentive program, there is established in the Treasury a fund to be known as the DoD VA Health Care Sharing Incentive Fund. Each Secretary shall annually contribute to the fund a minimum of $15,000,000 from the funds appropriated to that Secretary s Department. Such funds shall remain available until expended and shall be available for any purpose authorized by this section. $234,568,867 Transfer to Joint DoD VA Medical Facility Demonstration Fund. This reflects a transfer to the Joint DoD VA Medical Facility Demonstration Fund from Medical Services ($176,831,333), Medical Support and Compliance ($24,739,733) and Medical Facilities ($32,997,801). The authority for this transfer was provided in Public Law , section 223 the "Consolidated and Further Continuing Appropriations Act, 2014, signed on March 26, The Demonstration Fund supports the continuing operations of the Captain James A. Lovell Federal Health Care Center (FHCC), in North Chicago, which began operations on December 20, $59,830,000 Transfer of 1 Percent to Medical Services Appropriation from Medical Support and Compliance to Appropriation. The purpose of this transfer was to cover the cost of higher-than-anticipated participation in programs authorized by the Caregivers and Veterans Omnibus Health Services Act (P.L ). The authority for this transfer was provided in Public Law , section 202 the Consolidated and Further Continuing Appropriations Act, 2014, signed on March 26, VHA-198 Appropriation Transfers

201 Proposed Legislation Legislative Proposals (dollars in thousands) FY 2016 Obligations Allow CHAMPVA Healthcare Benefits for Beneficiaries up to age $51,984 Title 38 Appointment and Compensation System for Medical Center Directors and Network Directors.. $8,829 Grants for Transportation of Highly Rural Veterans... $3,000 U.S.C. 7675, which defines Breach of Agreement Under Employee Incentive Scholarship Program... ($40) Veterans Transportation Services - Extend Authority Permanently... ($361) VA Payment for Medical Foster Home... ($6,236) Smoke-Free Environment... ($7,801) Legislative Proposals Total... $49, Congressional Submission VHA-199

202 Extend Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) Eligibility for Covered Children Up to Age 26 Dollars in Thousands ($000) Obligations Collections Appropriation FTE Proposed Program Change in Law: $51,984 $0 $51,984 0 VA proposes to amend section 1781 of title 38 of the United States Code (U.S.C.) to extend eligibility for coverage of children under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) until they reach age 26 so that eligibility for children under CHAMPVA will be consistent with certain private sector coverage under the Affordable Care Act (ACA). Current Law or Practice: Currently, under title 38, U.S.C., an unmarried child of a qualifying Veteran can be covered under CHAMPVA until the age of 18 (or after if the child became permanently incapable of self-support before attaining the age of 18). Eligibility can be extended until the age of 23, if the child is pursuing a course of instruction at an approved school. Section 2714 of the Public Health Service Act, as amended by ACA, requires group health plans and health insurance issuers that offer dependent coverage of children, to make such coverage available for adult children until age 26. Because CHAMPVA is not considered a group health plan or health insurance issuer as those terms are defined by law, those requirements do not apply to CHAMPVA, and a legislative change is required to extend CHAMPVA coverage for children beyond the age limits specified above. Justification: VA proposes to extend coverage of children under CHAMPVA up to age 26 regardless of marital status or school enrollment status so that eligibility for children under CHAMPVA will be consistent with certain private sector coverage under the ACA. VA recommends providing this benefit to the beneficiary at no additional cost, such as a premium, since the Veteran sponsor has a permanent and total service-connected disability, passed away due to a service-connected disability, was at the time of death permanently and totally disabled from a service-connected condition(s), or died on active military service in the line of duty, which may create a financial hardship for CHAMPVA beneficiaries. VHA-200 Proposed Legislation

203 10-Year Cost Table: $ in thousands Year Obligations... $51,984 $55,240 $59,529 $64,137 $68,990 $299,880 Collections... Appropriation... $51,984 $55,240 $59,529 $64,137 $68,990 $299,880 $ in thousands Year Obligations... $74,352 $80,080 $86,269 $92,923 $100,164 $733,668 Collections... Appropriation... $74,352 $80,080 $86,269 $92,923 $100,164 $733, Congressional Submission VHA-201

204 Title 38 Appointment and Compensation System for Medical Center Directors and Network Directors Dollars in Thousands ($000) Obligations Collections Appropriation FTE Proposed Program Change in Law: $8,829 $0 $8,829 0 VA proposes to establish an appointment and compensation system under Title 38 for the Veterans Health Administration (VHA) occupations of Medical Center Director and Veterans Integrated Service Network (VISN) Director that have significant impact on the overall management of VA s health care system. Under this system, the appointments and rates of pay for employees who occupy these positions would be set and adjusted by the Secretary without regard to the provisions of Title 5, United States Code (U.S.C.), with a maximum basic rate of pay set no more than the amount established in Title 3 U.S.C These positions would remain eligible for performance awards in accordance with VA guidance and Secretary approval. Director pay would be determined for each covered executive based on the methodology of a compensation system for VHA physicians and dentists found under 38 U.S.C 7431, Pay for Physicians and Dentists, established by Public Law (P.L.) Each executive would be evaluated against appropriate market pay criteria including but not limited to: complexity of the assignment, applicable labor market salary data, experience, accomplishments, and overall results-driven performance. The aggregate pay limitation for this system would be the same as the VHA physicians and dentists pay system no more than the amount of $400,000 established under 38 U.S.C 7431(e)(4). Current Law or Practice: There is no authority for VA to make appointments or set rates of pay for these positions under U.S.C. Title 38 sections 7401 and Justification: VHA has a challenge addressing the rapidly evolving and changing health care industry. Healthcare leaders, from large multi-hospital systems and academic medical centers to smaller community hospitals and physician practices, are addressing ways to achieve transformation of the healthcare enterprise. In order for VHA to be part of this transformation, VHA must have executive leadership with the skill set to provide enterprise solutions for our Nation s Veterans and other persons served by VHA and that work with VHA to provide care. While there are many reasons why individuals choose to serve Veterans in VHA s hospital system, compensation is one of the key drivers to ensure VHA is successful in recruitment and retention of dedicated health care leadership who can make the tough decisions in delivering sustainable quality health care and continual performance improvement for our Nation s Veterans. The sustainability of VHA quality health care is dependent on our greatest asset the individuals who work within the VHA system and VHA must have the ability to recruit VHA-202 Proposed Legislation

205 the best talent that lives by VA core values of integrity, pursuit of excellence, accountability, collaboration and has a passion for the mission. To recruit the health care executive that represents a depth of expertise across the healthcare industry and that ensures transparency and accountability, the salary structure of VHA senior health care executives must be addressed. In order to successfully recruit qualified candidates, who can best meet the challenges of the health care industry, VHA s executive salary structure must be more comparable to the private industry. The executive skill sets required to lead and manage the largest integrated healthcare system in the United States are separate and distinct from other Federal executives, and as such, deserving of compensation more closely aligned with the private sector. These senior health care executives have oversight of the Nation s largest integrated health care delivery system within all 50 states, several U.S. territories, and the District of Columbia. Within the 21 VISNs, there are 144 VA Hospitals; 14 Health Care Centers (HCC); 186 Multi-Specialty Community-Based outpatient clinics; 568 Primary Care Community- Based outpatient clinics; 264 Outpatient Services Sites; 135 community living centers; 108 domiciliary rehabilitation treatment programs; 300 readjustment counseling centers; and 80 mobile vet centers. VHA seeks consideration of this legislative proposal to ensure that VHA is best prepared to meet and exceed the call to deliver quality health care to our Nation s Veterans. This proposal will help to mitigate the three key factors affecting the ability of VA to attract and retain high quality, experienced senior health care executives: 1. Existing pay compression within the current SES pay system and the close proximity rates of pay within the VA system for direct reports to SES, resulting in declining SES applicant pools; 2. High number of SES employees eligible for retirement; and 3. Available private sector pay for comparable health care leadership positions. Pay Compression. Recent changes in pay for non-senior Executive Service (SES) VHA leaders paid under other pay systems has exacerbated the issue of pay inequity. While these recent changes have addressed much needed pay issues for these other deserving groups of senior leaders and key clinical executive leaders such as physicians, dentists, nurses and pharmacists, it has also served to highlight the pay disparity between SES and non-ses senior health care leaders throughout VHA. The growing inequity in pay for VHA senior health care executives becomes more apparent when Medical Center Director s compensation, at an average of $168,941, is compared to that of their direct reports medical center Associate Directors, Chiefs of Staff, and Nurse Executives. Public Law implemented a market-based pay system for physicians and dentists. As a result, the average rate of pay for Chiefs of Staff is currently $249,844 with the highest salary at $389,471. Further, P.L legislation provided special pay between $10,000 and $100,000 for Nurse Executives that is added to their base pay and is included in their retirement computation. The current mean base salary for Nurse Executives is $135,943. The average salary for the Nurse 2016 Congressional Submission VHA-203

206 Executive is $151,994 with the top salary of $201,700. For GS-15 Associate Directors, the average annual salary now stands at $135,584 with the highest salary at $157,100. There is little to no financial incentive to progress to the position of Medical Center Director with the scope and responsibility inherent in these positions. Candidates from the ranks of Associate Directors, Chiefs of Staff and Nurse Executives are fewer and fewer because there are minimal financial incentives associated with the disruption of a geographical move and the much broader managerial span of control and responsibility. There is also a lack of an appropriate pay differential when considering the position of VISN Network Director. Network Directors managing the largest and most complex organizations in health care with an average employment of 12,893 and annual budgets averaging $1.1 billion, earn the same, or in some cases far less, than their direct reports. After reviewing data it has been determined that since 2012 the average salary of a person entering the SES is $152,559, with the highest salary of $181,500. The SES pay system provides for no pay differential based on the locality of the position so that in many cases, a promotion into the SES provides little to no actual increase in available income. Losses due to retirement. The average age of a VHA Medical Center Director is 55, with more than 27 years of service. Fifty-two percent of Medical Center Directors/VISN Directors are now eligible for retirement. Many are several years beyond retirement eligibility, with little financial incentive for continued service to the government because of retirement benefits. Within the next two to five years, 74 percent will be eligible to retire and most will likely do so as they reach eligibility. VHA must create competitive compensation that attracts private sector healthcare executives, current VHA healthcare executives, and VHA Title 38 clinical executives. In doing so, VHA will expand the succession pipeline and afford a bench strength that can be relied upon to fill current and future healthcare executive positions. Private sector pay for comparable positions. Growing pay disparities between VHA and private sector entities make it more difficult to attract experienced individuals. Public sector executive pay is dramatically below the private sector for comparable positions. This fact is nowhere more apparent than in the health care industry where VHA competes directly with private sector health care organizations for the same labor pool. The Healthcare Compensation Survey conducted by the Hay Group for 2013 reflects individuals holding the position of Chief Executive Officer (CEO) in private sector health care systems receive on average $731,800 annual cash compensation. CEOs of a single facility within an overall system receive an average of $393,100. SES pay rates, maximum compensation for VHA senior executives is $181,500 for Under this proposal, compensation would continue to remain far less than that of CEOs in private sector healthcare systems; however, increasing the compensation of VHA Network Directors and Medical Center Directors would acknowledge and recognize the clinical and VHA-204 Proposed Legislation

207 healthcare expertise and experience that these healthcare executives provide to our Nation s Veterans. 10-Year Cost Table: $ in thousands Year Obligations... $8,829 $8,813 $9,472 $9,464 $9,456 $46,034 Collections... Appropriations $8,829 $8,813 $9,472 $9,464 $9,456 $46,034 $ in thousands Year Obligations... $9,451 $9,442 $9,434 $9,429 $9,420 $93,210 Collections... Appropriations $9,451 $9,442 $9,434 $9,429 $9,420 $93, Congressional Submission VHA-205

208 Grants for Transportation of Highly Rural Veterans Dollars in Thousands ($000) Obligations Collections Appropriation FTE Proposed Program Change in Law: $3,000 $0 $3,000 0 VA proposes an extension of Congresses authorization of $3 million dollars to be appropriated for the conduct of the Department of Veterans Affairs (VA) Grant Program for Transportation of Highly Rural Veterans for each of Fiscal Year (FY) 2016 through FY Current Law or Practice: Public Law , Section 307, of the Caregivers and Veterans Omnibus Health Services Act 2010 specified that VA shall establish a grant program to provide innovative transportation options to veterans in highly rural areas. Eligible applicants under the law include Veteran Service Organizations (VSOs) and State Veteran Agencies (SVAs) seeking to provide innovative transportation services to Veterans residing in highly rural counties (i.e., those having an average of seven or less persons per square mile). Selected grantees are eligible to receive grants up to a maximum amount of $50,000. Transportation services provided to rural Veterans using these grants are provided free of charge. To conduct the program, P.L authorized $3 million to be appropriated for each of FY 2010 through FY Due to delays caused by the need to promulgate regulations and the need to twice extend the application process, VA did not award the first set of grants until FY Public Law , Department of Veterans Affairs Expiring Authorities Act of 2014, extended the existing authorization of appropriations through fiscal year Justification: VA wants to be sure that all Veterans, including those living in remote areas, can receive the health care they need and have earned through service in the U.S. Armed Forces. VSOs, SVAs and county government already participate in transportation of Veterans and additional grants will encourage them to employ innovative approaches to transportation services for Veterans in highly rural areas. Funds granted through this new program will help provide grantees greater flexibility to employ new approaches to serving such Veterans, resulting in improved service and health care access for Veterans. VHA-206 Proposed Legislation

209 10-Year Cost Table: $ in thousands Year Obligations... $3,000 $3,000 $3,000 $3,000 $3,000 $15,000 Collections... Appropriation... $3,000 $3,000 $3,000 $3,000 $3,000 $15,000 $ in thousands Year Obligations... $3,000 $3,000 $3,000 $3,000 $3,000 $30,000 Collections... Appropriation... $3,000 $3,000 $3,000 $3,000 $3,000 $30, Congressional Submission VHA-207

210 38 U.S.C Section 7675, Which Defines Liability for Breach of Agreement Under the Employee Incentive Scholarship Program (EISP) Dollars in Thousands ($000) Obligations Collections Appropriation FTE Proposed Program Change in Law: ($40) $0 ($40) $0 VA proposes to amend 38 U.S.C Section 7675, which defines liability for breach of agreement under the Employee Incentive Scholarship Program (EISP). This proposal would amend the current public law to provide that full-time student participants in EISP would have the same liability as part-time students for breaching an agreement by leaving VA employment. Current Law or Practice: The current statute limits liability to part-time student participants who leave VA employment prior to completion of their education program. This allows a scholarship participant who meets the definition of full-time student to leave VA employment prior to completion of the education program and breach the agreement with no liability. 38 U.S.C Chapter 76 Section 7675 Subchapter VI as currently written states: Breach of agreement: liability (b) Liability during Course of Education or Training (E) In the case of a participant who is a part-time student, the participant fails to maintain employment, while enrolled in the course of training being pursued by the participant, as a Department employee. Justification: This is a resubmission from prior year proposals. This proposal would provide the same liability for both full-time and part-time students who breach their scholarship agreement by leaving VA employment. All other employee recruitment /retention incentive programs have a service obligation and liability component. This proposal would result in cost savings for the Department by recovering the education funds provided to employees who leave VA employment prior to fulfilling their agreement. Additionally, by promoting employee retention, the funds used to recruit and train replacement employees would also be saved. The proposal provides a direct positive impact on the provision of care for Veterans by health care professionals as it retains those individuals for service in VHA. In accordance with 38 U.S.C. Section 7671, the purpose of EISP is to assist, through the establishment of an incentive program for individuals employed in the Veterans Health VHA-208 Proposed Legislation

211 Administration, in meeting the staffing needs of the Veterans Health Administration for health professional occupations for which recruitment or retention of qualified personnel is difficult. The current statute does not support this purpose, as it allows participants who elect full-time student status to receive the education funds and then leave VA employment with no liability for those funds. In contrast, participants who are in part-time student status, and leave VA employment, are held liable for repayment of the education funds received. 10-Year Cost Table: $ in thousands Year Obligations ($40) ($41) ($41) ($42) ($42) ($206) Collections Appropriation ($40) ($41) ($41) ($42) ($42) ($206) $ in thousands Year Obligations ($43) ($43) ($44) ($45) ($45) ($426) Collections Appropriation ($43) ($43) ($44) ($45) ($45) ($426) 2016 Congressional Submission VHA-209

212 Veterans Transportation Service (VTS) - Transportation of Individuals to and from Facilities of the Department of Veteran Affairs Dollars in Thousands ($000) Obligations Collections Appropriation FTE Proposed Program Change in Law: ($361) $0 ($361) $0 VA proposes legislation to extend the authority in 38 U.S.C. 111A(a) for VA to transport any person to or from a VA facility or other place in connection with certain services and treatment. This authority was enacted in January 2013 in section 202 of Public Law of the Dignified Burial and Other Veterans Benefits Improvement Act of Section 401 of Public Law recently extended this authority to December 31, This proposal would make the authority permanent. Current Law or Practice: Under 38 U.S.C. 111A(a), the Secretary has the authority to transport any person to or from a VA facility or other place in connection with vocational rehabilitation, counseling, or for the purpose of examination, treatment, or care. This provision authorizes use of paid VA staff to transport Veterans and caregivers. Justification: Through the VTS initiative, local VA facilities have hired staff and purchased vehicles to complement existing access to care provided by volunteers. With increasing numbers of transportation-disadvantaged Veterans, there simply are not enough volunteers in all regions of the country to sustain the current level of service. Without the proposed extension to Section 111A(a), transportation of Veterans will be significantly reduced or curtailed, particularly in rural areas of the country. During FY 2013, VTS provided more than 280,000 trips that totaled more than 15 million miles. The average length of a round trip is almost 60 miles a considerable distance in some rural communities, and a prohibitive distance for those with poor health if transportation was not available. Due to delay in permanent authorization for use of VA employees to transport Veterans, VTS has not expanded as originally intended. Permanent authority will allow the program to expand as previously planned, bringing more Veterans to the care they ve earned while improving overall satisfaction and offsetting costs in Beneficiary Travel. Year to year authority has impacted expansion as VA facilities have been cautious in adding staff that may not be able to perform their functions in the future. This has had a harmful effect on the programs ability to bring Veterans to care. It has also impacted cost offset and savings provided by VTS and subsequent cost estimates. The cost estimate VHA-210 Proposed Legislation

213 provided below is based on savings in Beneficiary Travel (BT) special mode transportation and does not include other potential offsets currently being assessed such as reductions in BT mileage reimbursement, missed appointments and bed days of care. 10-Year Cost Table: $ in thousands Year Obligations ($361) ($934) ($1,416) ($1,799) ($2,205) ($6,715) Collections Appropriation ($361) ($934) ($1,416) ($1,799) ($2,205) ($6,715) $ in thousands Year Obligations ($2,632) ($3,084) ($3,561) ($4,064) ($4,594) ($24,650) Collections Appropriation ($2,632) ($3,084) ($3,561) ($4,064) ($4,594) ($24,650) 2016 Congressional Submission VHA-211

214 VA Payment for Medical Foster Home (MFH) Dollars in Thousands ($000) Obligations Collections Appropriation FTE Proposed Program Change in Law: ($6,236) $0 ($6,236) $0 VA proposes legislation to give VA authority to pay for Veterans care (room, board, and caregiver services) in VA-approved Medical Foster Homes (MFHs), for Veterans who would otherwise need nursing home care. This proposal is limited in scope and is intended to cover only VA-approved MFH caregivers serving three Veterans or fewer per home. This proposal does not create general authority to cover Veterans who reside in assisted living facilities. Current Law or Practice: Currently, all Veterans in VA s MFH program must pay for MFH. VA does not have authority to pay for assisted living facilities except in two limited situations, the assisted living pilot program for certain Veterans with TBI authorized by section 1705 of Public Law (38 U.S.C. 1710C note) and the authority in 38 U.S.C. 1720(g) to provide assisted living to certain Veterans with traumatic brain injury). VA currently has authority to pay for nursing home level of care only in a nursing home that are either VA or community-based. VA does not presently have the authority to pay for nursing home level of care in non-nursing home settings. Justification: Authorizing VA to pay for certain MFH care would result in Veterans receiving long-term care in a preferred setting, with substantial reductions in costs to the Government. MFHs merge traditional adult foster care with comprehensive care provided in the home by a VA interdisciplinary team that includes a physician, nurse, social worker, rehabilitation therapist, mental health provider, dietitian and pharmacist. In 2000, VA launched the MFH initiative as an alternative to traditional long-stay nursing home care. So far, MFHs have demonstrated significant success in 43 states and are in development in another three states. Presently, over 600 VA-approved caregivers provide MFH care in their homes to over 700 Veterans daily nation-wide, albeit paid by the Veterans themselves. For all current Veterans served in MFHs, their care needs are fundamentally no different whether they reside in a MFH or in a nursing home; however, their care needs can be met at substantially lower costs in a MFH than in a long-stay nursing home. MFH is a proven alternative in the community that allows Veterans who are referred for or currently reside in nursing homes to receive this care in a community MFH. Many more service-connected Veterans referred to or residing in nursing homes would choose MFH if VHA-212 Proposed Legislation

215 VA paid the costs for MFH. Instead, they presently choose nursing home care because VA pays the full cost of nursing home care but not for the cost of Veterans care in a MFH. 10-Year Cost Table: $ in thousands Year Obligations ($6,236) ($8,749) ($10,364) ($12,276) ($14,541) ($52,166) Collections Appropriations ($6,236) ($8,749) ($10,364) ($12,276) ($14,541) ($52,166) $ in thousands Year Obligations ($17,223) ($20,401) ($24,165) ($28,623) ($33,904) ($176,482) Collections Appropriations ($17,223) ($20,401) ($24,165) ($28,623) ($33,904) ($176,482) 2016 Congressional Submission VHA-213

216 Smoke-Free Environment Dollars in Thousands ($000) Obligations Collections Appropriation FTE Proposed Program Change in Law: ($7,801) $0 ($7,801) $0 The proposal would repeal the requirement for designated smoking areas at certain VA medical facilities, as required by Public Law (P.L.) It would also prohibit smoking on the grounds of all VA health care facilities in order to make them completely smoke-free. Current Law or Practice: Section 526 of P.L , enacted in 1992, requires the Veterans Health Administration (VHA) to provide suitable smoking areas, either an indoor area or detached building, for patients who desire to smoke tobacco products. Justification: Currently, there are no VA health care facilities with smoke-free grounds because in 1992, P.L required designated smoking areas for patients. Because of this requirement, the Department of Veterans Affairs continues to fall far behind the public and private sectors in promoting smoke-free facilities. As a result, Veterans, VHA health care providers, and visitors do not have the same level of protection from the hazardous effects of secondhand smoke exposure as patients and employees in other health care systems. For example, as of January 1, 2015, there are over 3,822 local and/or state/territory/commonwealth hospitals, healthcare systems and clinics and four national healthcare systems (Kaiser Permanente, Mayo Clinic, SSM Health Care, and CIGNA Corporation) in the United States that have adopted 100 percent smoke-free policies that extend to all their facilities, grounds, and office buildings. In July 2013, the state of New York enacted a law requiring 100% smoke-free grounds on general hospitals and nationally, 33 municipalities have enacted laws requiring 100% smoke-free hospital grounds. Numerous Department of Defense (DoD) medical treatment facilities (MTF) have become tobacco-free as well. In addition, on July 1, 2011, the U. S. Department of Health and Human Services (HHS) adopted a policy banning the use of all tobacco products (including cigarettes, cigars, pipes, smokeless tobacco, or any other tobacco products, and e-cigarettes) at all times on its grounds, making all facilties tobacco free. With this, HHS became the first Federal Department to implement a tobacco-free policy. Fifty years after the landmark 1964 Surgeon General Report on the health effects of smoking, tobacco use remains the leading cause of preventable death and disease in the VHA-214 Proposed Legislation

217 United States, accounting for more deaths than HIV/AIDS, alcohol and drug abuse, automobile accidents, fires, homicides and suicides combined. Smoking is responsible for 1 in every 5 deaths or nearly 480,000 preventable deaths in the United States each year, including deaths due to secondhand smoke exposures (U.S. Surgeon General Report 2006; U.S. Surgeon General Report 2010; U.S. Surgeon General Report 2014). Research on the health effects of secondhand smoke has greatly increased in the last two decades. In 1992, the Environmental Protection Agency (EPA) designated secondhand smoke as a Class A carcinogen and the 2006 U.S. Surgeon General Report was the first to conclude that there is no risk-free level of exposure to secondhand smoke (U.S. Surgeon General Report, 2006). It is estimated that exposures to secondhand smoke account for more than 3,000 deaths from lung cancer, approximately 46,000 deaths from coronary heart disease, and 430 newborn deaths from sudden infant death syndrome (SIDS) in the United States each year (U.S. Surgeon General Report, 2010). The U.S. Surgeon General issued its 30 th tobacco-related Surgeon General Report since 1964, How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease (December 9, 2010). This report concluded that exposure to tobacco smoke-even occasional smoking or secondhand smoke- - - causes immediate damage to your body that can lead to serious illness or death. The U.S. Surgeon General Report reviewed the body of clinical research to date and reported that even brief exposures to secondhand smoke can cause cardiovascular disease and could trigger acute cardiac events, such as health attack, by causing damage to blood vessels and increased clotting. As the Nation s largest single health caresystem and a national leader in health care, VHA has fallen far behind the health care community in this regard. This was not the case in 1992 when VHA led nationally on smoke-free policies. The medical research since that time has demonstrated the serious and sometime life-threatening consequences of secondhand smoke exposures. In a 2009 Institute of Medicine (IOM) Report, Combating Tobacco Use in Military and Veteran Populations, an IOM expert committee stated the requirement for smoking areas at VA health care facilities has precluded VA from going entirely smoke-free and it prevents VA from protecting its patients, employees, and visitors from exposure to tobacco smoke and also hinders efforts to encourage tobacco cessation. The IOM Committee recommended that Congress provide legislation to allow VHA health care facilities to adopt smoke-free grounds. While in the past there had been resistance to smoke-free policies, there have been a number of successes in adopting policies that may not have been accepted a decade ago. A notable example is that of North Carolina, a state that has long been recognized as a home to the tobacco industry and tobacco farming. As of July 6, 2009, all public and private hospitals in North Carolina became smoke-free. A December 2009 publication authored by policy leaders at The Joint Commission noted that at the end of 2009, the majority of U.S. hospitals would have a smoke-free campus. The article noted the Department of Veterans Affairs health care system as an exception because of legislation 2016 Congressional Submission VHA-215

218 that makes it virtually impossible for VA hospitals to adopt a completely smoke-free campus (Williams, Hafner et al. 2009). The provisions of P.L that require smoking areas are not consistent with nearly two decades of medical and scientific literature that followed. An October 2009 IOM Report, Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence, reviewed U.S. and international evidence and concluded that secondhand smoke exposure increased the risk of coronary health disease and heart attacks by 25 to 30 percent and that smoking bans reduce heart attacks. The IOM Report concluded, Given the prevalence of heart attacks, and the resultant deaths, smoking bans can have a substantial impact on public health. The savings, as measured in human lives, is undeniable. The clear health benefits of smoke-free policies have been supported by numerous studies to date. For example, an Indiana University study found that after a countywide smoking ban was implemented, hospital admissions for non-smokers with no other risk factors for acute myocardial infarction (MI) or heart attack dropped by 70% (Seo & Torabi, 2007). In addition, additional studies have found significant decreases in the rates of total admissions for heart attacks following smoke-free policies in Helena, Montana and Pueblo, Colorado. International studies have also found similar effects following the implementation of smoke-free policies in Scotland and Italy (Pell et al., 2008; Cesaroni et al., 2008; U.S. Surgeon General Report 2014). Because of the increasing knowledge about the health effects of secondhand smoke, there have also been a number of cases where nonsmoker employees who have been harmed by such exposures have successfully filed lawsuits or disability claims against their employers. In 1995, a widower of an employee of a VA hospital was awarded a death benefit on the grounds that his wife s fatal lung cancer was caused by exposure to secondhand smoke while treating patients (CDC, 2006). Legislation to make the grounds of all VA healthcare facilities smoke-free would be a Veteran-centric measure that would serve to protect the right and health of the large majority of Veterans who do not smoke. Currently, approximately 20 percent of Veterans enrolled in VA health care are smokers, while approximately 80 percent are non-smokers (VHA, 2011). Many of the non-smokers are also older Veterans, a population that may be at higher risk for underlying cardiac conditions that could make them even more vulnerable to the cardiovascular events associated with secondhand smoke exposures (CDC, 2010). As with patients of other health care systems, Veteran patients have a right to be protected from secondhand smoke exposures when seeking health care at a VA facility. For Veterans who are inpatients, nicotine replacement therapy is currently available so they would not have to experience nicotine withdrawal during hospital admissions. VHA-216 Proposed Legislation

219 10-Year Cost Table: $ in thousands Year Obligations ($7,801) ($7,939) ($8,083) ($8,232) ($8,386) ($40,441) Collections Appropriations ($7,801) ($7,939) ($8,083) ($8,232) ($8,386) ($40,441) $ in thousands Year Obligations ($8,546) ($8,711) ($8,882) ($9,058) ($9,241) ($84,879) Collections Appropriations ($8,546) ($8,711) ($8,882) ($9,058) ($9,241) ($84,879) 2016 Congressional Submission VHA-217

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221 VHA Performance Plan Mission Honor America s Veterans by providing exceptional health care that improves their health and well-being. Vision Veterans Health Administration (VHA) will continue to be the benchmark of excellence and value in healthcare and benefits by providing exemplary services that are both patientcentered and evidence-based. This care will be delivered by engaged, collaborative teams in an integrated environment that supports learning, discovery, and continuous improvement. It will emphasize prevention and population health and contribute to the Nation s wellbeing through education, research, and service in national emergencies. Clientele VHA serves Veterans and their families. National Contribution VHA supports the public health of the Nation through medical, surgical, and mental health care, medical research, medical education, and training. VHA also plays a key role in homeland security by serving as a resource in the event of a national emergency or natural disaster. Stakeholders Numerous stakeholders have a direct interest in VHA s delivery of health care, medical research and medical education. They include: Veterans and their families The White House Administration and Congress DoD and other Federal Agencies Veteran Service Organizations State/County Veterans offices State Veterans homes Local communities Academic affiliates Health care professional trainees Researchers Contract providers VA employees Public-at-large 2016 Congressional Submission VHA-219

222 VHA Strategic Framework Overview VHA s National Leadership Council (NLC) developed a strategic planning framework to accomplish its mission and achieve VHA s vision, as cited above. Strategic Framework The VHA Strategic Framework shown below guides planning and decision-making to enable VA to provide Veterans with health care that is personalized, proactive, and patient-drive. The framework is informed by VA s Core Values of Integrity, Commitment, Advocacy, Respect, and Excellence (ICARE). The framework also utilizes VHA s Principles of being Patient-Centered, Team-Based, Data-Driven/Evidence-Based and focusing on Prevention/Population Health, Providing Value, and Continuously Improving. VHA STRATEGIC FRAMEWORK VHA-220 VHA Performance Plan

223 Goals VHA is charting a deliberate course to guide strategic change to assure a health care system that will define excellence in the 21 st Century. The following VHA Strategic Goals represent VHA s strategy over the next four years to focus on personalized health care that will deliver sustained value to Veterans. Strategic Goal #1: PROVIDE VETERANS PERSONALIZED 1, PROACTIVE 2, PATIENT-DRIVEN 3 HEALTH 4 CARE. Strategic Goal #2: ACHIEVE MEASURABLE IMPROVEMENTS IN HEALTH OUTCOMES. Strategic Goal #3: ALIGN RESOURCES TO DELIVER SUSTAINED VALUE TO VETERANS. Performance Measures VHA s performance measurement system is the final component of the strategic planning framework. Eighteen performance measures have been identified that meet the strategic intent of VHA s mission and vision. The performance measures cover a range of clinical, administrative, and financial actions required to support VHA s Strategic Framework cited above. To be included, the measure will meet the mandatory criteria: 1. Specific interest to the public AND 2. Collectively cover a substantial portion of the organization's budget request. The performance measures contained in the 2015 VHA Performance Plan have been screened and determined to satisfy the above criteria and are an appropriate platform for assessing VHA health care services and programs. 1 Personalized a dynamic adaptation or customization of recommended education, prevention and treatment that is specifically relevant to the individual user, based on the user s history, clinical presentation, lifestyle, behavior and preferences. 2 Proactive acting in advance of a likely future situation, rather than just reacting; taking initiative to make things happen rather than just adjusting to a situation or waiting for something to happen. 3 Patient-Driven an engagement between a patient and a health care system where the patient is the source of control such that their health care is based in their needs, values, and how the patient wants to live 4 Health a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity (World Health Organization) 2016 Congressional Submission VHA-221

224 Performance Indicators, Historical Milestones & Agency Priority Goals Performance Results & History (Final) Fiscal Year Targets 2016 (Pres. Budget) 2017 Strategic Target 2020 (Target) End Veteran Homelessness: Number of Homeless Veterans Permanently Housed. (Supports N/Av N/Av 53,475 49,000 49,000 TBD N/Av Agency Priority Goal) End Veteran Homelessness: Rapid engagement of street homeless Veterans. (Supports N/Av N/Av 89% 80% 80% TBD N/Av Agency Priority Goal) Access: Percent of patients who access VHA health care using a virtual format (Including N/Av N/Av N/Av N/Av (Baseline) TBD TBD elephone care) (New) (Supports Agency Priority Goal) Prevention Index V 92% 93% 92% 94% 93% 93% 95% Clinical Practice Guidelines Index IV 94% 92% 93% 93% 93% 93% 94% Percent of patients who responded yes on Patient Centered Medical Home survey questions that contribute to the Self-Management Support Composite (providers support you in taking care of your own health). N/Av N/Av 57% 58% 58% 59% 63% The average rating by patients of their health careon a scale from 0 to 10 (Outpatient) The average rating by patients of their health careon a scale from 0 to 10 (Intpatient) Percent of patients who responded "Always" regarding their ability to get an appointment for a routine checkup as soon as needed. Percent of patients who responded "Always" regarding the ease of getting an appointment with VA specialist N/Av N/Av N/Av N/Av N/Av N/Av N/Av N/Av 53% 56% 57% 58% 66% N/Av N/Av 42% 45% 46% 47% 57% Percent of patients who responded "Always" regarding their ability to get an appointment for needed care right away. The average rating by patient- of their VA provider, on a scale from 0 to 10, on the Patient Centered Medical Home Survey. N/Av N/Av 44% 47% 48% 49% 58% N/Av N/Av N/Av VHA-222 VHA Performance Plan

225 Performance Indicators, Historical Milestones & Agency Priority Goals Performance Results & History (Final) Fiscal Year Targets 2016 (Pres. Budget) 2017 Strategic Target 2020 (Target) Patient Safety Composite (New). N/Av N/Av N/Av N/Av (Baseline) N/Av N/Av Patient Aligned Care Team Implementation Progress Index (Pi2) (New). Mental Health Balanced Scorecard (New). Percentage of Veterans reporting employment at discharge from VA homeless residential programs (New). Percent of participants (Veterans and households) that were admitted as homeless through SSVF that were rapidly rehoused (New). Percent of participants at-risk for homeless (Veterans and their households) served in SSVF that were prevented from becoming homeless (New). N/Av N/Av N/Av N/Av (Baseline) N/Av N/Av N/Av N/Av N/Av (Baseline) N/Av N/Av N/Av N/Av N/Av 43% 30% 30% TBD TBD N/Av 79% 74% 80% TBD TBD TBD N/Av 90% 88% 90% TBD TBD TBD 2016 Congressional Submission VHA-223

226 Table 2: Performance Measure Summary Information End Veteran Homelessness: Number of Homeless Veterans Permanently Housed a) Means and Strategies Placing homeless Veterans into permanent housing is the key factor in successfully ending homelessness among Veterans. Tracking this data point therefore provides VA visibility into progress on this fundamentally important metric. This metric will be equally important to track after the formal initiative to end Veteran homelessness ends, to ensure that gains are maintained. VHA Homeless Program Office will conduct studies and analysis of this metric across homeless program types, Veteran need or subtype, and link to the homeless gap analysis to evaluate progress against need by location. These analyses will expand focus far beyond basic performance measurement to overall clinical effectiveness as well as inform budget decisions. b) Data Source(s). Homeless Operations and Management Evaluation System (HOMES) Entry and Exit Forms. This measure includes Veterans who move into HUD Veterans Affairs Supportive Housing (HUD-VASH) housing, rapid rehousing placements through Supportive Services for Veteran Families (SSVF) program, and moves from VA residential treatment programs (including Grant and Per-Diem, Health Care for Homeless Veterans Contract Residential Services, Domiciliary Care for Homeless Veterans and Compensated Work Therapy- Transitional Residence) into permanent housing. c) Data Verification. Staff from the VHA's Homeless Program Office as well as VISN and VAMC Homeless Program Coordinators will ensure VA staff input data on a timely basis, while also providing quality control through review of data at the national, VISN, and VAMC levels. Extensive data validation efforts have been performed by the VHA Homeless Program Office, VHA Support Service Center (VSSC), Northeast Program Evaluation Center (NEPEC), as well as VISN and VAMC Homeless Program Providers, to ensure that the numerator and denominator are reliable and valid. d) Measure Validation. Extensive data validation efforts have been performed by the VHA Homeless Program Office, VHA Support Service Center (VSSC), Northeast Program Evaluation Center (NEPEC), as well as VISN and VAMC Homeless Program Providers, to ensure that the numerator and denominator are reliable and valid. e) Crosscutting Activities Funds are granted to private non-profit organizations and consumer cooperatives who will assist Veterans and their families by providing a range of services. There is also ongoing interagency collaboration between VA and HUD as well as other agencies that includes state, federal, county, city, profit and not for profit agencies. f) External Factors Macro-economic factors such as unemployment and availability of market rate affordable housing will impact outcomes. Reductions in available mainstream benefit programs may impact income and resources available to Veterans and their families. Availability of suitable and affordable housing where needed. g) Other Supporting Information None. h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1. Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care VHA-224 VHA Performance Plan

227 Table 2: Performance Measure Summary Information End Veteran Homelessness: Rapid engagement of street homeless Veterans. a) Means and Strategies A key element to ending homelessness among Veterans is the rapid movement of unsheltered homeless Veterans to safe and stable housing. This metric gauges the percent of unsheltered Veterans who are moved out of unsheltered status within 30 days of engagement by VA homeless programs, either to a VA Residential program for homeless Veterans or permanent housing. Thus, this metric provides VA visibility into its front-end work with homeless Veterans, and pushes homeless program operations towards adopting rapid, efficient, and effective outreach and engagement strategies with the street homeless population. Strategies for implementations include written and teleconference communications. b) Data Source(s). Homeless Operations and Management Evaluation System (HOMES) intake assessment and program entry forms. c) Data Verification. Data will be reviewed monthly by subject matter experts and confirmed with selected local VAMCs. d) Measure Validation. This measure was chosen as a key element of the initiative to end Veteran homelessness, as it represents the core of the rescue mission moving Veterans off the streets and into safe and stable housing. e) Crosscutting Activities There is ongoing interagency collaboration between VA and HUD as well as other agencies that includes state, federal, county, city, profit and not for profit agencies. f) External Factors Macro-economic factors such as unemployment and availability of market rate affordable housing will impact outcomes. g) Other Supporting Information None. h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1. Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care 2016 Congressional Submission VHA-225

228 Table 2: Performance Measure Summary Information Percent of patients who access VHA health care using a virtual format (including telephone care) (New). (Supports Agency Priority Goal) a) Means and Strategies 1) Today's Veteran expects instant access and opportunities that extend beyond traditional modalities. 2) Leadership teams and clinical/administrative services at all levels of the organization examine usage rates and various virtual care modalities offered. b) Data Source(s). The Virtual Care data is suppled from the Virtual Care Report. c) Data Verification. This data is available on a monthly basis. Staff have the option to drill down to SSN numbers to validate VSSC reports. d) Measure Validation. 1) This measure demonstrates Veteran Participation in virtual care through evaluation and usage rates of various virtual modalities (including telehealth) offered. 2) This metric reflects increased access to care for critical groups of Veteran patients using a variety of options. e) Crosscutting Activities None. f) External Factors None. g) Other Supporting Information 1)The target for this metric is the result of considered investments and responsiveness to Veterans' willingness to receive care in this way. 2) The denomimator for this measure is the number of Veteran patients that accessed VHA health care in the prior year. The numerator is the cumulative number of Veteran patients that access care using one or more of the virtual modalities in the current year. 3) The virtual modalities include: o Home telehealth o Clinical Video Telehealth o Store and forward Telehealth o Electronic consults o Specialty Care Access Network Extension for Community Healthcare Outcomes (SCAN- ECHO) o Secure Messaging o Telephone Care h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1. Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care VHA-226 VHA Performance Plan

229 Prevention Index V a) Means and Strategies Table 2: Performance Measure Summary Information The index is a composite measure comprised of evidence and outcome-based indicators of preventative care to promote health, including weight management, cancer screening, immunizations, tobacco counseling and medications, and screening for depression, PTSD, and alcohol misuse. b) Data Source(s). Chart Abstraction through External Peer Review process. c) Data Verification. External Peer Review, electronic and on-site review. Contractor evaluates the validity and the reliability of the data using accepted statistical methods. d) Measure Validation. Elements of care are reviewed annually to ensure the quality efforts are focused on clinical areas identified as areas critical to improving care. e) Crosscutting Activities None. f) External Factors None. g) Other Supporting Information The Prevention Index demonstrates the degree to which VHA provides evidence-based clinical interventions to Veterans seeking preventive care in VA. This measure changes over time and new versions of the measure are added when the previous target level is reached. These changes continuously improve the measure. The results and targets are PI V. h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1. Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care 2016 Congressional Submission VHA-227

230 Clinical Practice Guidelines Index IV a) Means and Strategies Table 2: Performance Measure Summary Information The index is a composite measure comprised of evidence and outcome-based indicators of high prevalence and high risk diseases that impact overall health status. b) Data Source(s). Chart Abstraction through External Peer Review process. c) Data Verification. External Peer Review, electronic and on-site review. Contractor evaluates the validity and the reliability of the data using accepted statistical methods. d) Measure Validation. Elements of care are reviewed annually to ensure the quality efforts are focused on clinical areas indentified as areas critical to improving care. e) Crosscutting Activities Ongoing work with DoD to implement and refine Clinical Practice Guidelines which serve as a basis and reference for many of the Clinical Practice Guidelines Index (CPGI) measures. f) External Factors None. g) Other Supporting Information CPGI is an index that assesses our progress and results associated with our treatment of patients with chronic diseases. This measure changes over time and new versions of the measure are added when the previous target is reached. These changes continuously improve the measure.the results and targets are CPGI IV. h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1. Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care VHA-228 VHA Performance Plan

231 Table 2: Performance Measure Summary Information Percent of patients who responded yes on Patient Centered Medical Home survey questions that contribute to the Self-Management Support Composite (providers support you in taking care of your own health). a) Means and Strategies To improve patient satisfaction and involvment in their own care, VHA will implement methods for advancing patient-centric care and opportunities for the Veteran to participate in the decision-making regarding their care. b) Data Source(s). Patient Centered Medical Home (PCMH Surveys) c) Data Verification. The SHEP program uses survey uses the Consumer Assessment of Healthcare Providers and Systems (CAHPS) family of survey instruments. These surveys have been rigorously developed and tested to assess the experiences of patients who receive healthcare through public and private programs. The CAHPS Surveys are part of the family of surveys developed by a consortium of researchers from American Institutes for Research, Harvard Medical School, the RAND Corporation, and RTI International under a cooperative agreement between CMS and the Agency for Healthcare Research and Quality (AHRQ), a component of the U.S. Public Health Service. For more information about the CAHPS Project, please go to Survey Administration Summary: All patients who had received provider-based ambulatory care in the sampling month and who had not responded in a previous SHEP survey in the past 12 months are eligible. Random samples of ~60,000 patients receiving such care in the sampling month are included. A survey is mailed to selected patients early in the second calendar month following their outpatient visit. d) Measure Validation. Network managers and agency officials will monitor this metric to ensure patients have easy access to healthcare. Officials should also monitor how urgent, non-urgent, and speciality care appointments are made; how test results are obtained; how information is exchanged between VHA and their patients; ensure sufficient staffing levels; and other interactions the agency has with their patients to ensure easy and efficient access to care. e) Crosscutting Activities None f) External Factors None g) Other Supporting Information None h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1. Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care 2016 Congressional Submission VHA-229

232 Table 2: Performance Measure Summary Information The average rating by patients of their health care on a scale from 0 to 10 (Outpatient) a) Means and Strategies To improve patient satisfaction ratings related to general ambulatory care experiences with their Primary Care Provider. b) Data Source(s). SHEP Ambulatory Care Survey c) Data Verification. The SHEP program uses survey uses the Consumer Assessment of Healthcare Providers and Systems (CAHPS) family o survey instruments. These surveys have been rigorously developed and tested to assess the experiences of patients who receive healthcare through public and private programs. The CAHPS Surveys are part of the a family of surveys developed by a consortium of researchers from American Institutes for Research, Harvard Medical School, the RAND Corporation, and RTI International under a cooperative agreement between CMS and the Agency for Healthcare Research and Quality (AHRQ), a component of the U.S. Public Health Service. For more information about the CAHPS Project, please go to Survey Administration Summary: All patients who had received provider-based ambulatory care in the sampling month and who had not responded in a previous SHEP survey in the past 12 months were eligible. Random samples of ~5,000 patients receiving such care in the sampling month are included. A survey is mailed to selected patients early in the second calendar month following their outpatient visit. d) Measure Validation. The information is collected using industry standard survey instruments and data collection protocols as described above. The data integrity is also monitored using a detailed Quality Assurance Surveillance Plan. Network managers and agency officials will monitor this metric to ensure patients have easy access to healthcare. Officials should also monitor how urgent, non-urgent, and specialty care appointments are made; how test results are obtained; how information is exchanged between VHA and their patients; ensure sufficient staffing levels; and other interactions the agency has with their patients to ensure easy and efficient access to care. e) Crosscutting Activities None. f) External Factors None. g) Other Supporting Information None. h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1. Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care VHA-230 VHA Performance Plan

233 Table 2: Performance Measure Summary Information The average rating by patients of their health care on a scale from 0 to 10 (Inpatient) a) Means and Strategies To improve patient satisfaction ratings related to experiences in the inpatient setting. b) Data Source(s). SHEP Inpatient Survey c) Data Verification. The SHEP program uses survey uses the Consumer Assessment of Healthcare Providers and Systems (CAHPS) family of survey instruments. These surveys have been rigorously developed and tested to assess the experiences of patients who receive healthcare through public and private programs. The CAHPS Surveys are part of the a family of surveys developed by a consortium of researchers from American Institutes for Research, Harvard Medical School, the RAND Corporation, and RTI International under a cooperative agreement between CMS and the Agency for Healthcare Research and Quality (AHRQ), a component of the U.S. Public Health Service. For more information about the CAHPS Project, please go to Survey Administration Summary: All patients who had received provider-based inpatient care in the prior month were eligible. All sites providing such care were included. Samples of patients were drawn at each of these sites. Sample size was determined to achieve at least 300 completed surveys per facility for a 12- month reporting period. A survey was mailed to selected patients between 48 hours and six weeks after discharge from inpatient care. Data collection was closed no later than six weeks following the date of the first survey mailing. d) Measure Validation. The information is collected using industry standard survey instruments and data collection protocols as described above. The data integrity is also monitored using a detailed Quality Assurance Surveillance Plan. Network managers and agency officials will monitor this metric to ensure patients have easy access to healthcare. Officials should also monitor how urgent, non-urgent, and specialty care appointments are made; how test results are obtained; how information is exchanged between VHA and their patients; ensure sufficient staffing levels; and other interactions the agency has with their patients to ensure easy and efficient access to care. e) Crosscutting Activities None. f) External Factors None. g) Other Supporting Information None. h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1. Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care 2016 Congressional Submission VHA-231

234 Table 2: Performance Measure Summary Information Percent of patients who responded "Always" regarding their ability to get an appointment for needed care right away. a) Means and Strategies Access to health care is a high priority for VA. Data will be gathered via mailed survey of veteran patients with a recent encounter with VHA. Data will be collected on a monthly basis in such volume that results can be reported at the system level. b) Data Source(s). Patient Centered Medical Home (PCMH Surveys) c) Data Verification. The SHEP program uses survey uses the Consumer Assessment of Healthcare Providers and Systems (CAHPS) family o survey instruments. These surveys have been rigorously developed and tested to assess the experiences of patients who receive healthcare through public and private programs. The CAHPS Surveys are part of the a family of surveys developed by a consortium of researchers from American Institutes for Research, Harvard Medical School, the RAND Corporation, and RTI International under a cooperative agreement between CMS and the Agency for Healthcare Research and Quality (AHRQ), a component of the U.S. Public Health Service. For more information about the CAHPS Project, please go to Survey Administration Summary: All patients who had received provider-based ambulatory care in the sampling month and who had not responded in a previous SHEP survey in the past 12 months were eligible. Random samples of ~60,000 patients receiving such care in the sampling month are included. A survey is mailed to selected patients early in the second calendar month following their outpatient visit. d) Measure Validation. The information is collected using industry standard survey instruments and data collection protocols as described above. The data integrity is also monitored using a detailed Quality Assurance Surveillance Plan. Network managers and agency officials will monitor this metric to ensure patients have easy access to healthcare. Officials should also monitor how urgent, non-urgent, and specialty care appointments are made; how test results are obtained; how information is exchanged between VHA and their patients; ensure sufficient staffing levels; and other interactions the agency has with their patients to ensure easy and efficient access to care. e) Crosscutting Activities None. f) External Factors None. g) Other Supporting Information None. h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1. Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care VHA-232 VHA Performance Plan

235 Table 2: Performance Measure Summary Information Percent of patients who responded "Always" regarding the ease of getting an appointment with VA specialist. a) Means and Strategies Access to health care is a high priority for VA. Data will be gathered via mailed survey of veteran patients with a recent encounter with VHA. Data will be collected on a monthly basis in such volume that results can be reported at the system level. b) Data Source(s). SHEP Ambulatory Care Survey c) Data Verification. The SHEP program uses survey uses the Consumer Assessment of Healthcare Providers and Systems (CAHPS) family o survey instruments. These surveys have been rigorously developed and tested to assess the experiences of patients who receive healthcare through public and private programs. The CAHPS Surveys are part of the a family of surveys developed by a consortium of researchers from American Institutes for Research, Harvard Medical School, the RAND Corporation, and RTI International under a cooperative agreement between CMS and the Agency for Healthcare Research and Quality (AHRQ), a component of the U.S. Public Health Service. For more information about the CAHPS Project, please go to Survey Administration Summary: All patients who had received provider-based ambulatory care in the sampling month and who had not responded in a previous SHEP survey in the past 12 months were eligible. Random samples of ~5,000 patients receiving such care in the sampling month are included. A survey is mailed to selected patients early in the second calendar month following their outpatient visit. d) Measure Validation. The information is collected using industry standard survey instruments and data collection protocols as described above. The data integrity is also monitored using a detailed Quality Assurance Surveillance Plan. Network managers and agency officials will monitor this metric to ensure patients have easy access to healthcare. Officials should also monitor how urgent, non-urgent, and specialty care appointments are made; how test results are obtained; how information is exchanged between VHA and their patients; ensure sufficient staffing levels; and other interactions the agency has with their patients to ensure easy and efficient access to care. e) Crosscutting Activities None. f) External Factors None. g) Other Supporting Information None. h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1. Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care 2016 Congressional Submission VHA-233

236 Table 2: Performance Measure Summary Information Percent of patients who respond "Always" regarding their ability to get an appointment for a routine checkup as soon as needed. a) Means and Strategies Access to health care is a high priority for VA. Data will be gathered via mailed survey of veteran patients with a recent encounter with VHA. Data will be collected on a monthly basis in such volume that results can be reported at the system level. b) Data Source(s). Patient Centered Medical Home (PCMH Surveys) c) Data Verification. The SHEP program uses survey uses the Consumer Assessment of Healthcare Providers and Systems (CAHPS) family o survey instruments. These surveys have been rigorously developed and tested to assess the experiences of patients who receive healthcare through public and private programs. The CAHPS Surveys are part of the a family of surveys developed by a consortium of researchers from American Institutes for Research, Harvard Medical School, the RAND Corporation, and RTI International under a cooperative agreement between CMS and the Agency for Healthcare Research and Quality (AHRQ), a component of the U.S. Public Health Service. For more information about the CAHPS Project, please go to Survey Administration Summary: All patients who had received provider-based ambulatory care in the sampling month and who had not responded in a previous SHEP survey in the past 12 months were eligible. Random samples of ~60,000 patients receiving such care in the sampling month are included. A survey is mailed to selected patients early in the second calendar month following their outpatient visit. d) Measure Validation. The information is collected using industry standard survey instruments and data collection protocols as described above. The data integrity is also monitored using a detailed Quality Assurance Surveillance Plan. Network managers and agency officials will monitor this metric to ensure patients have easy access to healthcare. Officials should also monitor how urgent, non-urgent, and specialty care appointments are made; how test results are obtained; how information is exchanged between VHA and their patients; ensure sufficient staffing levels; and other interactions the agency has with their patients to ensure easy and efficient access to care. e) Crosscutting Activities None. f) External Factors None. g) Other Supporting Information None. h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1. Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care VHA-234 VHA Performance Plan

237 Table 2: Performance Measure Summary Information The average rating by patient- of their VA provider, on a scale from 0 to 10, on the Patient Centered Medical Home Survey. a) Means and Strategies To improve patient satisfaction ratings related to experiences in the inpatient setting. b) Data Source(s). Patient Centered Medical Home (PCMH Surveys) c) Data Verification. The SHEP program uses survey uses the Consumer Assessment of Healthcare Providers and Systems (CAHPS) family o survey instruments. These surveys have been rigorously developed and tested to assess the experiences of patients who receive healthcare through public and private programs. The CAHPS Surveys are part of the a family of surveys developed by a consortium of researchers from American Institutes for Research, Harvard Medical School, the RAND Corporation, and RTI International under a cooperative agreement between CMS and the Agency for Healthcare Research and Quality (AHRQ), a component of the U.S. Public Health Service. For more information about the CAHPS Project, please go to Survey Administration Summary: All patients who had received provider-based ambulatory care in the sampling month and who had not responded in a previous SHEP survey in the past 12 months were eligible. Random samples of ~60,000 patients receiving such care in the sampling month are included. A survey is mailed to selected patients early in the second calendar month following their outpatient visit. d) Measure Validation. The information is collected using industry standard survey instruments and data collection protocols as described above. The data integrity is also monitored using a detailed Quality Assurance Surveillance Plan. Network managers and agency officials will monitor this metric to ensure patients have easy access to healthcare. Officials should also monitor how urgent, non-urgent, and specialty care appointments are made; how test results are obtained; how information is exchanged between VHA and their patients; ensure sufficient staffing levels; and other interactions the agency has with their patients to ensure easy and efficient access to care. e) Crosscutting Activities None. f) External Factors None. g) Other Supporting Information None. h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1. Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care 2016 Congressional Submission VHA-235

238 Patient Safety Composite (New). a) Means and Strategies Table 2: Performance Measure Summary Information A series of indicators that reflect patient safety risk and hospital acquired infections. These include Patient Safety Indicators (PSI), Inpatient Quality Indicators (IQI), and Hospital Acquired Conditions (HAC) that are based on industry-wide definitions from the Agency for Health Research and Quality (AHRQ) and Centers for Disease Control (CDC). b) Data Source(s). Patient Treatment File for PSI and IQI. Rates are automatically calculated using software algorithms obtained from AHRQ. c) Data Verification. Spot checking of code practices and of self-reported data. Review of PSI for agreements rates with chart review and other outcome indicators, such as readmission. d) Measure Validation. All metrics are based on scientifically validated and external agency approved methodologies from AHRQ and CDC. These reflect prevalent, costly, and potentially avoidable complications of hospitalization. e) Crosscutting Activities VA will be partnering with subject matter experts in AHRQ, CDC, and the VA health services research community to implement the measure correctly and identify potential improvement strategies. Public reporting of these measures will occur on Medicare&#39; s Hospital Compare website, as required in the Veterans Access, Choice, and Accountability Act of 2014 (P.L ). f) External Factors None. g) Other Supporting Information None. h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1. Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care VHA-236 VHA Performance Plan

239 Table 2: Performance Measure Summary Information Patient Aligned Care Team Implementation Progress Index (Pi2) (New). a) Means and Strategies The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through care management, improved access, and team-based care that is comprehensive, coordinated, and Patient Centered. The Pi2 was created to measure the extent of PCMH (Patient-Centered Medical Home) implementation, describe variation in implementation and examine the association between the implementation and key outcomes. b) Data Source(s). VA s Corporate Data Warehouse (CDW) and National Patient Survey data. c) Data Verification. The data is available on a quarterly basis. The survey data is collected using industry standard survey instruments and data collection protocols as described above. The data integrity is also monitored using a detailed Quality Assurance Surveillance Plan. Network managers and agency officials will monitor this metric to ensure continued progress is made in PACT implementation. Officials should also monitor access to care and use of non-face-to-face care, such as telephone clinics and secure messaging; continuity of care; use of VHA programs to support care coordination, such as home telemonitoring, 2- day post hospital follow-up. d) Measure Validation. The Pi2 demonstrated satisfactory levels of internal consistency for total score, access, continuity, comprehensiveness, self-management support, patient centered care and communication, shared decision making, and team-based care. The Pi2 shows consistent correlation with important outcomes such as Veterans' overall satisfaction with their care and their provider, use of the emergency department, provider burnout and clinical quality metrics. e) Crosscutting Activities None. f) External Factors None. g) Other Supporting Information The Pi2 composite score is constructed for eight core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care. Clinics that have better Pi2 scores also exhibited significantly higher patient satisfaction, higher performance on several clinical quality measures, lower staff burnout, lower hospitalization rates for ambulatory care-sensitive conditions, and lower emergency department use. h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1. Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care 2016 Congressional Submission VHA-237

240 Mental Health Balanced Scorecard (New). a) Means and Strategies Table 2: Performance Measure Summary Information Balanced scorecard includes 3 composite measures: Experiences of Care, Population Coverage, and Continuity of Care. Experiences of Care is generated annually and includes 6 subcomponents of both Veteran satisfaction and provider survey results. It evaluates self-reported ease of access to mental health services, the Veteran-centered nature of care delivery, and effectiveness of care. The Continuity of Care composite consists of 11 measures and includes measures that assess follow-up within a week after discharge from mental health inpatient and residential care settings, early engagement in psychosocial treatments, prevention of loss to care for patients with serious mental illness, follow-up after detoxification services, and management of patients on antidepressant medications. The Population Coverage composite consists of 15 metrics that assess the proportion of patients with specified mental health conditions who receive indicated mental health specialty care services, and the proportion of local patients with service-connected disability for mental health conditions who receive mental health services from VA. b) Data Source(s). Data sources include the Corporate Data Warehouse, the Veterans Satisfaction Survey, the Mental Health Provider Survey, and the Patient Treatment File. c) Data Verification. The Population Coverage and Continuity of Care composites will be based primarily on VA administrative data which is collected for all patients treated within VHA. The Veterans Experience of Care composites will be generated from respondents stratified by location and randomly selected based on qualification criteria. To increase inclusion of the target population, respondents that complete more than half of included items will be included in the composite, minimizing the impact of missing data. d) Measure Validation. The composites that index Population Coverage and elements of Continuity of Care have been found to correlate with, for example, outpatient staff to patient ratio, Veteran self-reported experience of care, and mental health provider-reported access and quality of care. There is also scientific literature that supports the importance of these domains for the effectiveness of mental health treatment at the population level. e) Crosscutting Activities None f) External Factors Data limitation with the collection of patient-reported experience of care. g) Other Supporting Information None h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1. Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care VHA-238 VHA Performance Plan

241 Table 2: Performance Measure Summary Information Percentage of Veterans reporting employment at discharge from homeless residential programs (New). a) Means and Strategies Employment is one of the key factors in assisting a homeless Veteran with obtaining and maintaining permanent housing. Many homeless Veterans do not qualify for or are unable to obtain a rental subsidy; therefore, competitive employment is the only means of affording a home. Thus, this metric reinforces one of the bedrock factors in the success of the initiative. VAMC homeless programs include plans and strategies related to improving employment outcomes in their monthly operating plans, which are reviewed along with scores on this metric to ensure sufficient progress is being made nationally.. b) Data Source(s). Homeless Operations & Management Evaluation System (HOMES) Residential Treatment Exit Form. Legacy NEPEC Form D. Patient Enrollment File. Data will be extracted by VHA Support Service Center (VSSC). This measure includes Veterans who have indicated employment at exit from VA residential treatment programs, including Grant and Per-Diem, Health Care for Homeless Veterans Contract Residential Services, Domiciliary Care for Homeless Veterans and Compensated Work Therapy- Transitional Residence. c) Data Verification. Staff from the VHA s Homeless Program Office will ensure providers input data on a timely basis, while also providing quality control through review of data at the national, VISN, and VAMC levels. d) Measure Validation. Extensive data validation efforts have been performed by the VHA Homeless Program Office, VHA Support Service Center (VSSC), Northeast Program Evaluation Center (NEPEC), as well as VISN and VAMC Homeless Program Providers, to ensure that the data in the numerator and denominator are reliable and valid. This measure is the best source of information at VA s disposal regarding the contribution that residential programs targeted specifically for homeless Veterans are making to ending homelessness among Veterans. e) Crosscutting Activities There is ongoing interagency collaboration between VA and HUD as well as other agencies that includes state, federal, county, city, profit and not for profit agencies. f) External Factors Macro-economic factors such as unemployment rates and availability of competitive jobs will impact outcomes. g) Other Supporting Information None. h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1. Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care 2016 Congressional Submission VHA-239

242 Table 2: Performance Measure Summary Information Percent of participants (Veterans and households) that were admitted as homeless through the Supportive Services for Veteran Families (SSVF) program that were rapidly re-housed (New). a) Means and Strategies Rapid re-housing is considered a best practice in the provision of homeless services, and seeks to rapidly move a Veteran from literal street homelessness to permanent housing, providing psychosocial and financial supports as needed. This approach represents a second key contributor to ending homelessness, along with permanent supportive housing and prevention. b) Data Source(s). Data will be pulled from the HMIS and Homeless Registry and tracked by the SSVF program office. c) Data Verification. Staff from the SSVF program office will conduct monitoring visits of all grantees. Grantees are also required to submit separate reports, verifying HMIS data entry on a quarterly basis. d) Measure Validation. Fundamental measure to assess the impact of SSVF on reducing homelessness. To meet the goal of ending homelessness among Veterans, rapid rehousing must be a primary strategy. This measure assesses the degree to which the rapid re-housing component of SSVF is successful in this effort. Data from this measure will allow the VHA Homeless Program Office, as well as network and facility homeless program leaders to assess the success of rapid re-housing efforts make informed decisions regarding possible redistribution of resources, etc. e) Crosscutting Activities Funds are granted to private non-profit organizations and consumer cooperatives who will assist Veterans and their families by providing a range of services. f) External Factors Macro-economic factors such as unemployment and availability of market rate affordable housing will impact outcomes. Reductions in available mainstream benefit programs may impact income and resources available to Veterans and their families. Availability of suitable housing where needed. g) Other Supporting Information None. h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: 1 Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care VHA-240 VHA Performance Plan

243 Table 2: Performance Measure Summary Information Percent of at-risk for homelessness Participants (Veterans and their households) served in SSVF that were prevented from becoming homeless (New). a) Means and Strategies For this initiative to ultimately be successful, it is not sufficient to simply place Veterans in housing. We must staunch the flow into homelessness for Veterans in the future. Effective prevention is the key to this effort, and this metric sets the benchmark and will provide VA with monthly feedback on the effectiveness of our prevention efforts. b) Data Source(s). Data will be pulled from the HMIS and Homeless Registry and tracked by the SSVF program office. c) Data Verification. Staff from the SSVF program office will conduct monitoring visits of all grantees. Grantees are also required to submit separate reports, verifying HMIS data entry on a quarterly basis. d) Measure Validation. To meet the goal of ending homelessness among Veterans, successful SSVF interventions must lead to permanent housing. Ongoing work and analysis of data provided by grantees will be validated to ensure quality. e) Crosscutting Activities Funds are granted to private non-profit organizations and consumer cooperatives who will assist Veterans and their families by providing a range of services. f) External Factors Macro-economic factors such as unemployment and availability of market rate affordable housing will impact outcomes. Reductions in available mainstream benefit programs may impact income and resources available to Veterans and their families. Availability of suitable housing where needed. g) Other Supporting Information None. h) Link to Secondary Criteria, Category, and Capability Secondary Criteria: Of demonstrated high visibility to our stakeholders Category: Services for Veterans and Eligible Beneficiaries Capability: 1.2 Health Care 2016 Congressional Submission VHA-241

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245 Selected Program Highlights Introduction This section provides narrative descriptions of the selected programs supported by the Veterans Health Administration (VHA). The funding levels presented in this chapter highlight these programs to provide a better understanding of programmatic services provided to Veterans. However, some programs overlap and therefore cannot be added together to determine the overall funding amount. Selected Program Highlights Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease Obligations ($000) AIDS... $764,761 $855,600 $826,241 $922,400 $890,747 $958,820 $64,506 $68,073 Education and Training... $1,760,920 $1,802,000 $1,708,255 $1,902,000 $1,816,718 $1,924,000 $108,463 $107,282 Energy / Green Management... $206,653 $140,000 $140,000 $140,000 $140,000 $100,000 $0 ($40,000) Enh. of Comp. Emerg. Mgmt. Prog. (CEMP)... $144,606 $174,395 $163,064 $176,540 $152,551 $152,551 ($10,513) $0 Gulf War Programs... $2,132,725 $2,385,500 $2,372,967 $2,652,800 $2,638,669 $2,940,768 $265,702 $302,099 Health Care Sharing: Services Purchased by VA... $1,165,551 $1,297,645 $1,212,173 $1,349,551 $1,260,660 $1,311,086 $48,487 $50,426 Services Provided by VA... $49,423 $51,447 $51,399 $53,505 $53,455 $55,594 $2,056 $2,139 VA/DoD Sharing: Services Purchased from DoD... $101,800 $115,100 $104,900 $117,400 $108,000 $111,200 $3,100 $3,200 Services Provided by VA... $119,000 $187,200 $116,600 $183,500 $114,300 $112,000 ($2,300) ($2,300) Health Professional Educ. Asst. Prog... $37,782 $52,236 $52,536 $56,522 $58,736 $64,136 $6,200 $5,400 Income Verification Match (IVM)... $16,461 $16,461 $19,506 $16,709 $19,754 $20,322 $248 $568 OEF/OIF/OND... $3,742,552 $4,204,500 $4,304,800 $4,737,200 $4,872,900 $5,485,500 $568,100 $612,600 Non-VA Care... $7,012,292 $6,737,000 $6,737,000 $6,645,000 $6,645,000 $6,243,000 ($92,000) ($402,000) Rural Health: Rural Health Initiative... $248,289 $250,000 $250,000 $250,000 $250,000 $250,000 $0 $0 Rural Care and Outreach... $18,387,716 $18,832,902 $18,893,373 $19,524,026 $19,354,594 $19,826,846 $461,221 $472,252 Telehealth... $985,826 $567,211 $1,097,625 $588,143 $1,223,859 $1,371,974 $126,235 $148,115 Traumatic Brain Injury (TBI): TBI - All Vets... $229,059 $229,200 $233,600 $227,200 $231,800 $233,200 ($1,800) $1,400 TBI - OEF/OIF/OND... $54,643 $48,800 $60,800 $46,600 $59,300 $59,800 ($1,500) $500 Electronic Health Record/VistA... $73,865 $123,074 $67,594 $208,265 $159,596 $208,265 $92,002 $48,669 Women Veterans Health Care: Gender Specific Health Care... $379,978 $403,200 $411,800 $436,700 $446,100 $481,700 $34,300 $35,600 Total Care... $3,714,241 $4,624,200 $4,157,100 $5,737,500 $4,659,400 $5,222,200 $502,300 $562, Congressional Submission VHA-243

246 AIDS/HIV Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease Obligations ($000)... $764,761 $855,600 $826,241 $922,400 $890,747 $958,820 $64,506 $68,073 The VA National Human Immunodeficiency Virus (HIV) Program ensures that Veterans with HIV infection receive the highest quality comprehensive clinical care, including diagnosis of their infection, timely linkage to care, treatment of co-morbidities, and reduction in HIV-related health disparities. The program also promotes evidence-based HIV preventive services. In July 2010, the President released a National HIV/Acquired Immunodeficiency Syndrome (AIDS) Strategy (NHAS). As one of the Federal agencies required to implement this strategic plan by 2015, VA has utilized the HIV Care Continuum model to assess gaps in care from diagnosis of HIV infection and active linkage to and retention in care to initiation of antiretroviral therapy (ART) and eventual viral suppression meaning no detectable virus in the blood. As such, VA s National HIV Program, within VHA s Office of Public Health, has implemented a plan to meet the President s goals with a particular focus on increasing HIV testing and improving linkage to care for difficult to reach patients through the use of telehealth and other technologies. It is VHA policy that all Veterans be offered HIV testing at least once in their lifetime, with testing offered at least annually to those who have on-going risk of exposure. Multiple published studies have shown that individuals who are aware that they have HIV infection are less likely to transmit infection to others. HIV-positive individuals who are aware of their diagnosis are more likely to change their high-risk behaviors, decreasing disease transmission. Since 2009, HIV testing has more than tripled among Veterans in VA care to reach 32 percent of all Veterans in 2013, with 99 percent of those newly diagnosed getting linked to care within 90 days of their diagnosis. VA will continue to expand HIV testing, particularly for Veterans at high risk, and maintain effective linkage to care efforts. In 2014, following regulatory action by the Food and Drug Administration (FDA) and guidance from the Centers for Disease Control and Prevention (CDC), VA s Pharmacy Benefits Management (PBM) added the use of HIV Pre-exposure Prophylaxis (PrEP) in VA for the combination medication emtricitabine/tenofovir, which was already on the VA National Formulary. An Information Letter providing clinical guidance on PrEP is currently under development and will be distributed to VA providers in early As of August 2014, nearly half (46%) of VA facilities offer PrEP. VA will promote the broader use of PrEP across the system and will continue to promote HIV prevention by making both male and female condoms available to all Veterans in care. VA will also encourage implementation of evidence-based HIV prevention strategies among HIV negative Veterans to ensure that they remain uninfected, and among HIV-positive Veterans to reduce the risk of transmission to others. VHA-244 Selected Program Highlights

247 VA s National HIV Program will continue to work to ensure that all Veterans diagnosed with HIV infection in VA are not only linked to care in a timely manner but that they are retained in care and engaged in treatment. Under VA policy, VA providers are expected to follow U.S. Department of Health and Human Services treatment guidelines to ensure that all HIV-positive Veterans receive high quality care. All anti-retroviral medications approved by the FDA will be made available to Veterans with HIV infection. Veterans with HIV infection suffer from high rates of medical and psychiatric comorbidities, which include mental health and substance use disorders, cardiovascular disease, renal dysfunction, and metabolic disorders. VA will continue to ensure that all Veterans with HIV infection not only receive the care they need for these conditions but also attain or exceed the favorable health outcomes achieved through the standard of care in their communities. To this end, VA s National HIV Program will continue to collaborate with the VA s Office of Academic Affiliations to support a training program for clinical psychology postdoctoral fellows, with an emphasis on integrated HIV and liver disease care. VA s National HIV Program will also continue to ensure that educational opportunities regarding the management and treatment of HIV infection and related co-morbidities are made available to all VA providers. Through annual data reports, the program will provide feedback to VA providers, leadership, and the public on quality indicators of HIV/AIDS care delivered to Veterans. All HIV-positive Veterans will have equal access to ART, appropriate laboratory testing, and HIV support services. VA s National HIV Program will continue to support integrated care models that address HIV prevention, care, treatment of co-morbidities, and routine vaccination for all Veterans infected with HIV. HIV care will be provided in a manner consistent with the Patient Aligned Care Team (PACT) model being promoted in VHA. In addition, VA s National HIV Program will work with other VA and VHA program offices to improve HIV screening rates and educational efforts in primary care, women s health, mental health and substance use programs, homelessness and jail re-entry programs, and in community-based outpatient clinics. VA s National HIV Program will also work with VHA s Office of Health Equity to reduce disparities in care for Veterans with or at risk for HIV infection. The program will also promote the use of a point-of-care clinical reminder that prompts VA providers to offer HIV testing to all Veterans. VA s HIV Program will also support pilot quality improvement projects at VA medical facilities to develop best practices for improving HIV testing, education, and care in a variety of VA health care settings. These resources and programs will be evaluated over the next year, and those projects that achieve the intended goals will be further developed and disseminated to other facilities in VHA over the next five years. VA s National HIV Program is committed to collaborating with other Federal agencies to ensure that HIV-positive Veterans are linked to the appropriate providers in a timely manner and receive the highest standard of care. These resources will help VHA remain a leader among health care organizations in responding to the challenges posed by the HIV/AIDS epidemic Congressional Submission VHA-245

248 Education and Training - Health Care Professionals Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease Obligations ($000) Education and Training Support¹... $954,054 $901,000 $851,000 $951,000 $908,359 $962,000 $57,359 $53,641 Trainees²... $806,866 $901,000 $857,255 $951,000 $908,359 $962,000 $51,104 $53,641 Total... $1,760,920 $1,802,000 $1,708,255 $1,902,000 $1,816,718 $1,924,000 $108,463 $107,282 Health Profs. Individuals Rotating thru VA Physician Residents & Fellows... 39,637 41,367 40,286 41,682 41,682 41,871 1, Medical Students... 22,100 21,751 22,100 21,851 21,851 22,314 (249) 463 Nursing Students... 27,964 28,942 28,696 28,982 28,982 30, ,128 Associated Health Residents & Students... 27,012 28,122 26,694 28,272 28,272 28,768 1, Total , , , , , ,063 3,011 2,276 ¹ Educational supplement to the Veterans Equitable Resource Allocation (VERA) model in support of the indirect costs of VA medical centers that have clinical training programs. These funds help offset costs such as faculty time, education office staffing, accreditation costs, and space and equipment needs. ² Special Purpose funds that are allocated in the President's Budget to directly fund the stipends and benefits of VA clinical trainees who rotate through VA medical centers during the year. In order to carry out the primary patient care function of VHA and to assist in providing an adequate supply of health personnel to the Nation, VA is authorized by Title 38 Section 7302 to provide clinical education and training programs for developing health professionals. VA conducts these programs in partnership with the Nation s academic institutions, and plays a leadership role in defining the education of future healthcare professionals to meet the changing needs of U.S. healthcare delivery. In 2014, nearly 117,000 trainees, representing more than 40 health care disciplines, received all or part of their clinical training in VA health care facilities. Health professional trainees contribute substantially to VA s ability to deliver cost-effective, high-quality patient care for Veterans. Nearly a third of currently employed VA health professionals have received some or all of their clinical training in VA. To continue to meet its workforce needs while providing innovative Veteran care programs, VA has identified and expanded training positions in critical areas of need as defined by the VA and VHA strategic plans, VA Secretary s priorities and the Veterans Access, Choice, and Accountability Act of 2014 (Veterans Choice Act). Affiliated with 130 allopathic medical schools and 22 osteopathic medical schools, VA is the second largest Federal supporter (after the Centers for Medicare & Medicaid Services) of education for health care professionals. In addition, more than 40 other health professions are represented by affiliations with over 1,800 unique colleges and universities. Among these institutions are Hispanic Serving Institutions, Historically Black Colleges and Universities, Asian American and Native American Pacific Islander Serving Institutions, and Native American Serving Institutions. VHA-246 Selected Program Highlights

249 Energy / Green Management Program Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease Obligations ($000)... $206,653 $140,000 $140,000 $140,000 $140,000 $100,000 $0 ($40,000) A series of Greening the Government laws and executive orders since the 1990s accelerated the need to coordinate energy, environment, vehicle fleet, and sustainable buildings policies and programs at the Department level. VA integrated these areas under the Green Management Program Service (GMPS) within the Office of Asset Enterprise Management in This integration is essential in helping VA optimize and prioritize green investments, as well as meet requirements of laws, executive orders, and presidential memoranda. In 2014, VA successfully carried out an ambitious green management program. Among other accomplishments, VA: Awarded 31 energy projects for design, construction, and installation. These projects included solar, geothermal, renewably-fueled combined heat and power plants, and energy and water conservation measures; and Undertook 32 contracts for commissioning, auditing, environmental assessments, and other requirements. In 2016 and 2017, VA plans to implement additional solar, ground source heat pump, and geothermal projects. Other planned initiatives include: Implementation of energy savings performance contracts (ESPCs) and utility energy savings contracts (UESCs); Constructing up to ten combined heat and power projects (renewably fueled where viable); Completion of building retro-commissioning in 25 percent of VA facilities; Energy assessments of up to 25 percent of VA facilities; Improvements to the functionality of VA s national utility metering data collection and analysis system; Obtaining green building certification for up to 100 existing buildings each year to meet the sustainable building goals; Conducting renewable energy feasibility studies at up to 30 sites; Continued funding of facility and regional level energy managers and environmental coordinators; and Continued focus on Presidential goals, such as using 20 percent renewable energy by 2020 and continued investment in energy performance contracting. See Chapter 9.2, Green Management Program, in Volume 4, for additional program information Congressional Submission VHA-247

250 Comprehensive Emergency Management Program (CEMP) Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease Obligations ($000)... $144,606 $174,395 $163,064 $176,540 $152,551 $152,551 ($10,513) $0 VA is committed to achieving the readiness necessary to meet its health care responsibilities in national emergencies in times of disaster or attack and ensuring continuity of care to its patients during any emergency. Emergency Management Strategic Health Care Group (EMSHG) manages, coordinates, and implements VHA s Comprehensive Emergency Management Program (CEMP) to help VA meet these mission requirements. CEMP includes preparedness and response actions as mandated through various Federal laws and regulations to ensure continuity of care and operation, supporting the DoD medical system in wartime, providing medical backup for national emergencies through the National Disaster Medical System, and providing support as requested under the National Response Framework. The major components of the VHA medical emergency preparedness budget include performance improvement funds to the VA medical facilities to meet the identified gaps in emergency preparedness, provide pharmaceutical supplies, support the decontamination program, provide personal protective equipment, ensure the availability of deployable clinics and environmental safety specialists/emergency coordinators, meet training needs, and secure the continuity of operations plans for essential functions and personnel. The major initiatives are recent programs that include Veterans Integrated Service Networks (VISN)-based patient evacuation capabilities, a Federal emergency regional coordination program, field evaluation, and contingency support for CEMP. Gulf War Programs Budget Current Advance Revised Advance Increase / Increase / Actual Estimate Estimate Approp. Request Approp. Decrease Decrease Obligations ($000)... $2,132,725 $2,385,500 $2,372,967 $2,652,800 $2,638,669 $2,940,768 $265,702 $302,099 VA s Gulf War Veteran programs provide a range of services, including Priority Level 6 eligibility for health care and no-cost clinical registry evaluations for Gulf War Veterans to access VA clinical care and the Gulf War Registry Program. The programs provide special clinical and diagnostic evaluations for combat Veterans with difficult-to-diagnose illnesses and world-class research on Veteran health issues. VA works to meet the special medical needs of Gulf War Veterans who served in Southwest Asia and are concerned about depleted uranium munitions or other forms of embedded-fragment wounds during combat. VA also conducts surveys of Gulf War Veterans to determine if they have any adverse health effects related to their deployment and develops effective outreach and educational tools for Gulf War Veterans with health concerns related to potential environmental exposures and their deployment. VHA-248 Selected Program Highlights

251 Health Care Sharing Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease Services Purchased by VA: Obligations ($000)... $1,165,551 $1,297,645 $1,212,173 $1,349,551 $1,260,660 $1,311,086 $48,487 $50,426 Services Provided by VA: Reimbursements ($000)... $49,423 $51,447 $51,399 $53,505 $53,455 $55,594 $2,056 $2,139 VA has been procuring health care resources with affiliated institutions and community providers based on authority included in title 38 United States Code (U.S.C.), section 8153, enacted in 1966 and last amended by the Veterans Health Care Eligibility Reform Act of 1996, Public Law (P.L.) VA also procures health care resources using Federal Supply Schedules. These authorities are the contracting mechanism of choice for VHA and non-department of Defense (DoD) health care entities, including medical specialists and the shared use of medical equipment. This authority, along with the use of competitive procurements, allows VHA facilities to maximize the effective use of internal and community resources to eliminate any diminution of services to Veterans. Procurements with affiliated institutions, such as medical schools, medical practice groups, and academic institutions, allow quality service and support VHA goals in education and training in accordance with 38 U.S.C The primary goal of the VA health care system is to furnish high quality medical care to our Veterans on a timely basis and at a fair and reasonable price. All revenue generated from the sale of services is used to enhance care for enrolled Veterans. VA/DoD Sharing Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease VA Services Purchased from DoD: Obligations ($000)... $101,800 $115,100 $104,900 $117,400 $108,000 $111,200 $3,100 $3,200 VA/DoD Sharings Svcs, VA Provided: Reimbursements ($000)... $119,000 $187,200 $116,600 $183,500 $114,300 $112,000 ($2,300) ($2,300) Section 721 of the 2003 National Defense Authorization Act (NDAA), P.L , required DoD and VA to establish a joint incentive program to identify, implement, fund, and evaluate creative coordination and sharing initiatives at the facility, intraregional, and national levels. Title 38 U.S.C., Section 8111 authorizes VA and DoD to enter into sharing agreements for the mutually beneficial coordination, use, or exchange of health care resources, with the goal of improving the access to, and quality and cost effectiveness of, the health care provided by VHA and the Military Health System to the beneficiaries of both Departments. The obligations and reimbursements shown here are the result of over 140 sharing agreements between VA and DoD facilities; they do not reflect the funding that the two Departments contribute to the two joint VA-DOD accounts, the DoD-VA Health Care Sharing Incentive Fund and the Joint DoD-VA Medical Facility Demonstration Fund. For more information on the joint accounts, see Part 2 of this Volume Congressional Submission VHA-249

252 Health Professionals Educational Assistance Program (HPEAP) Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease Obligations ($000) Education Debt Reduction Program (EDRP)... $13,249 $20,000 $21,200 $22,000 $27,400 $27,400 $6,200 $0 Employee Incentive Scholarship Program (EISP)... $2,030 $2,000 $2,000 $2,000 $2,000 $2,000 $0 $0 VA Nursing Education for Employees Program (VANEEP)... $8,836 $12,287 $12,287 $14,573 $12,287 $12,287 $0 $0 Nat'l Nursing Education Initiative (NNEI)... $13,667 $17,049 $17,049 $17,049 $17,049 $17,049 $0 $0 Health Professional Scholarship Program (HPSP)/1... $0 $0 $0 $0 $0 $5,400 $0 $5,400 Visual Impairment Education Assistance Program (VIOMPSP)... $0 $900 $0 $900 $0 $0 $0 $0 Total... $37,782 $52,236 $52,536 $56,522 $58,736 $64,136 $6,200 $5,400 1/Obligations in 2015 and 2016 for this program are funded through the Veterans Choice Act, Sec. 801 The Education Debt Reduction Program (EDRP) was authorized by the Veterans Programs Enhancement Act of 1998, P.L and implemented in The statute was amended by the Department of Veterans Affairs Health Care Programs Enhancement Act of 2001 (P.L ), the Caregivers and Veterans Omnibus Health Service Act of 2010 (P.L ), the Veterans Access, Choice, and Accountability Act of 2014 (P.L ), and the Department of Veteran Affairs Expiring Authorities Act of 2014 (P.L ). PL allows EDRP participants to receive education debt reduction payments up to a maximum of $120,000 for up to five years. As a result of PL , there is allowance for the Secretary to grant waivers to the maximum loan amount, which was extended in P.L from $60,000 to $120,000, for certain critical hires. In addition, P.L authorizes VA to pay the lender directly on behalf of EDRP participants. The VHA Workforce Succession and Strategic Plan ranks physicians and nurses, along with other allied health professionals, among the top 10 occupations experiencing the greatest shortages, which should receive priority attention from the agency in recruitment and retention efforts. Recruitment for these positions is highly competitive nationally due to significant increased demand, insurance reform initiatives, accelerated retirements of the baby boomer cohorts, and a decreased applicant pool size. EDRP serves as both a recruitment and retention tool. When recruitment and retention of qualified personnel is difficult, VHA has the authority to offer education debt reduction payments for employees who are in difficult to recruit/retain healthcare positions and who are providing direct patient care services or services incident to direct patient care. Local facilities prioritize hard-to-recruit and -retain occupations based on facility needs. The local facilities identify top occupations as part of the facility/visn workforce succession strategic planning process. Currently, at the conclusion of each 12-month service period, payments are made to EDRP participants equal to the student loan payments made by the participant during the service period not to exceed the award amount for that service period. P.L , however, authorizes VA to pay the lender directly. Once those processes are in place, it will allow for a more predictable distribution of funds and for more consistent use of program dollars because it won t be dependent on the participant s ability to pay their lender first. Participants receive education debt reduction payments while they remain employed by VHA in the position that was approved for EDRP for up to five years, thereby acting as a significant retention incentive. VHA-250 Selected Program Highlights

253 Employee Incentive Scholarship Program (EISP) was established by title VIII of P.L , the Department of Veterans Affairs Health Care Personnel Incentive Act of 1998, and codified in sections of Title 38 U.S.C. The statute was amended by P.L , the Department of Veterans Health Care Programs Enhancement Act of 2001, P.L , the Veterans Health Care, Capital Asset, And Business Improvement Act of 2003, and PL , the Veterans Health Programs Improvement Act of EISP authorizes VA to award scholarships to employees pursuing degrees or training in health care disciplines for which recruitment and retention of qualified personnel is difficult. The National Nursing Education Initiative (NNEI) and the VA Nursing Education for Employees Program (VANEEP) are policy-derived programs that stem from the legislative authority of EISP. EISP awards cover tuition and related expenses such as registration, fees, and books. The academic curricula covered under this program includes education and training programs in fields leading to appointments or retention in title 38 or Hybrid title 38 health care positions listed in 38 U.S.C. section The maximum amount of a scholarship that may be awarded to an employee enrolled in a full-time curriculum is $37,869 for the equivalent of 3 years of full-time coursework. Title 38 U.S.C. section 7631 allows for periodic adjustments in the amount of assistance whenever there is a general Federal pay increase. As of September 30, 2014, VA has awarded 15,236 scholarships to EISP, NNEI, and VANEEP participants since the program started in Educational assistance awarded to date totals $241 million, which includes future obligations of $24 million through Participants in EISP, NNEI, and VANEEP receive multi-year scholarships. To address rising out-year costs and increasing attrition rates in these programs, VHA implemented changes to these programs over the past three years. These changes included implementing NNEI funding distribution allocations for each medical facility and requiring Facility Director endorsements, justifications, and commitments to hire in new occupations after completion of programs. The cumulative effect of these changes initially reduced the number of applications due to revised selection criteria, decreased immediate funding requirements, and reduced out-year funding obligations. The previously reduced 2014 actual expenditures and the current 2015 estimates for EISP, NNEI, and VANEEP reflect a cumulative effect of those program changes. As a result of collaborative efforts with the Office of Nursing Services in supporting VHA initiatives, facility use of NNEI and VANEEP is again increasing with continual growth expected throughout VHA is ensuring that specific purpose scholarship program funding is allocated in a manner which responds to field-driven demands and funding requests, program office initiatives, and VHA mission priorities. VA Health Professional Scholarship Program (HPSP) and the Visual Impairment and Orientation and Mobility Professional Scholarship Program (VIOMPSP) were authorized under P.L This legislation allows VA to provide scholarship awards to VA and non-va employees in exchange for committing to a minimum two-year service obligation with VHA in a permanent, full-time position. Section 302 directs the Secretary to institute 2016 Congressional Submission VHA-251

254 a Visual Impairment Professional Education Assistance Program, to provide financial assistance to individuals pursuing a program of study leading to a degree or certificate in visual impairment or orientation and mobility. For VIOMPSP, each scholarship recipient would receive tuition (up to $15,000) for each year of a degree program (not to exceed a total of $45,000). HPSP allows VA to provide tuition assistance, a monthly stipend, and other required education fees for students pursuing education/training that would lead to an appointment in a title 38 or Hybrid title 38 occupation. For HPSP, each scholarship recipient would receive tuition, stipend, and other reasonable costs for each year of a graduate/training program. Regulations pertaining to VIOMPSP and HPSP became effective on September 19, Section 302 of P.L , the Veterans Choice Act, extended the HPSP sunset date until December 31, VA is working to incorporate the necessary program changes stipulated by the Veterans Choice Act, including resourcing the program and support staff for HPSP and VIOMPSP. Income Verification Match (IVM) Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease Obligations ($000) VHA Support... $12,392 $12,392 $12,392 $12,640 $12,640 $13,208 $248 $568 IT Support 1/... $4,069 $4,069 $7,114 $4,069 $7,114 $7,114 $0 $0 Total... $16,461 $16,461 $19,506 $16,709 $19,754 $20,322 $248 $568 1/ The IT support dollars come from the Office of Information Technology (OIT) Appropriaton fund. Eligibility for VA health care services, co-pay status, and enrollment priority is based, in part, on the Veteran s financial status. VA s Health Eligibility Center Income Verification Division verifies a Veterans self-reported gross household income to determine their eligibility for VA health benefits. Computer-matching agreements with Internal Revenue Service (IRS) and the Social Security Administration (SSA) authorize VA to receive Federal tax information for the income verification process. If a co-pay-exempt Veteran s income is verified as being above the applicable income threshold, the Veteran and the site(s) where the Veteran received care are notified and the Veteran is billed for co-pays for medical care received during that particular income year. Additionally, the Veteran s enrollment status may be impacted as a result. Non-VA Care* Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease Non-VA Care Total Obligations ($000) 1/... $7,012,292 $6,737,000 $6,737,000 $6,645,000 $6,645,000 $6,243,000 ($92,000) ($402,000) Emergency Care Obligations (Included Above)... $421,297 $379,976 $434,294 $370,812 $439,932 $455,421 $5,638 $15,489 * Excludes non-va care obligations for the Veterans Choice Program. 1/ Estimates for fiscal years 2016 and 2017 reflect the impact of Veterans Choice Program cost shift. The different types of care purchased Non-VA medical care that may be purchased through a non-va medical care provider is the same care as authorized to Veterans in a VA medical facility under Title 38 United States Code (U.S.C.) Specifically, the medical care purchased would be the same as afforded to eligible Veterans in the VA s comprehensive Medical Benefits Package to VHA-252 Selected Program Highlights

255 include all the necessary inpatient hospital care, outpatient services, maternity care, dental, and pharmaceutical services to promote, preserve, or restore health. Some of the top medical care purchased in2014 include: dialysis, skilled and unskilled home health services, radiation therapy, diagnostic testing, physical therapy, inpatient hospitalization and emergency care services (displayed as a subsection below). The different scenarios for why care is purchased VA may authorize a non-va health care facility or individual health care provider to perform necessary medical care services when such services are not routinely available at a VA health care facility, or VA determines that such services can be obtained outside the VA more economically or more appropriately due to geographic inaccessibility. Non-VA medical care must be authorized by VA in advance, unless the medical event is an emergency. Non-VA emergency medical care may be reimbursed for both service-connected Veterans (38 U.S.C. 1728) and non-service connected Veterans (38 U.S.C. 1725) when certain criteria has been met. The recent reorganization as a result of Veterans Choice Act The Veterans Access, Choice, and Accountability Act of 2014 (Public Law ) required that the Veterans Health Administration (VHA) consolidate non-va medical care claims processing operations into a centralized organization under Chief Business Office Purchased Care (CBOPC). Five Regions have been developed during the consolidation, with each region being represented by a Regional Officer. Below is the breakdown of Veteran Integrated Service Networks (VISNs) by regions: REGION 1 (VISN 1, VISN 2, VISN 3, VISN 4, VISN 10) REGION 2 (VISN 5, VISN 6, VISN 7, VISN 8) REGION 3 (VISN 9, VISN 11, VISN 12, VISN 15, VISN 16) REGION 4 (VISN 17, VISN 18, VISN 19) REGION 5 (VISN 20, VISN 21, VISN 22) Emergency Care (Veteran s Millennium Health Care Act, PL ) Under the Veteran s Millennium Health Care Act, PL , Veterans who are eligible for reimbursement of emergency services at non-va facilities are defined as individuals who are enrolled in the VA health care system; have received VA care within the 24- month period preceding the furnishing of such emergency treatment for a non-serviceconnected condition; and are financially liable to the provider of the emergency non service-connected treatment. Veterans who have health insurance coverage for emergency care, or entitlement to care from any other Department or Agency of the United States (Medicare, Medicaid, TRICARE, Workers Compensation, etc.), are not eligible for this provision. VA is the payer of last resort. VA Secretary has the authority to establish maximum amounts and circumstances under which payment is made Congressional Submission VHA-253

256 Non-VA Care Workload The following chart shows actual and anticipated Non-VA Care workload for fiscal years 2014 through 2017: Note: The above chart excludes workload from the Veterans Choice Program. Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease Obligations ($000)... $3,742,552 $4,204,500 $4,304,800 $4,737,200 $4,872,900 $5,485,500 $568,100 $612,600 Unique Patients , , , , , ,292 71,182 71,597 Cost Per Patient... $5,366 $5,549 $5,565 $5,751 $5,769 $5,987 $204 $218 Note: OEF/OIF/OND obligations reflect the total cost of medical care, including outreach services that are documented as medical encounters. These obligations do not include benefits or Readjustment Counseling. VA provides medical care to military personnel who served in OEF/OIF/OND. Veterans deployed to combat zones are entitled to five years of eligibility for VA health care services following their separation from active duty, even if they are not otherwise eligible to enroll in VA. VA is committed to ensuring a continuum of care for our injured Servicemembers and continues to support ongoing efforts to continuously improve this process while providing the necessary care to these returning Servicemembers. VA s outreach network ensures that returning Servicemembers receive full information about VA benefits and services. Each medical center and benefits office now has a point of contact assigned to work with returning OEF/OIF/OND Veterans. OEF/OIF/OND patients represent 11 percent of the overall VA patients served. The funding estimates reflect the anticipated costs associated with the scheduled withdrawal of troops. VHA-254 Selected Program Highlights

257 Rural Health Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease Obligations ($000) Rural Health Initiative... $248,289 $250,000 $250,000 $250,000 $250,000 $250,000 $0 $0 Rural Care and Outreach... $18,387,716 $18,832,902 $18,893,373 $19,524,026 $19,354,594 $19,826,846 $461,221 $472,252 Obligations for the Rural Health Initiative reflect specific purpose funding for the Office of Rural Health (ORH), whose mission is to improve access and quality of care for enrolled Veterans residing in geographically rural areas by developing evidence-based policies and innovative practices to support their unique needs. Obligations for Rural Care and Outreach reflect the total cost of health care and outreach services provided to Veterans who live in rural areas. In 2014, ORH has addressed the unique needs of over three million enrolled Veterans living in rural and highly rural areas, which make up approximately 33 percent of all Veteran enrollees. ORH collaborates with a range of internal and external stakeholders to conduct studies and analyses and to implement and evaluate innovative pilot projects. Through this data-driven and collaborative decision-making process, ORH translates findings and best practices into policy and facilitates broader execution among established VA program offices. ORH conducts its work around six core areas of focus: access; quality; workforce; education and training; technology; and collaborations. Through these areas, ORH identifies and implements initiatives that include: supporting rural clinics and rural homebased primary care; identifying and addressing barriers to access and quality of health care delivery in rural and highly rural areas; developing workforce recruitment and retention initiatives; expanding the use of distance learning for VA and community service providers to rural and highly rural Veterans; accelerating and expanding telehealth opportunities; operating the Rural Health Resource Centers to support implementation of innovative pilot projects; and collaborating with Federal and non-federal community partners to share resources and expand access to care for rural Veterans. ORH continues to partner internally with Office of Academic Affiliations, Office of Telehealth Services, Office of Specialty Care Transformation, Office of Geriatrics and Extended Care, Women s Health Services, Office of Mental Health Services, and others to improve the provision of primary and specialty care to Veterans living in rural and highly rural areas and enhance educational opportunities in rural communities. ORH collaborates with other federal agencies, including the U.S. Department of Agriculture and the Department of Health and Human Services to extend and improve health care services to rural and highly rural Veterans Congressional Submission VHA-255

258 Telehealth Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease Obligations ($000) Home Telehealth /1... $217,356 $246,027 $219,692 $259,047 $227,529 $239,104 $7,837 $11,575 Rural Telehealth Services Projects (Specific Purpose)... $70,292 $71,747 $71,747 $73,204 $73,204 $73,204 $1,457 $0 Rural Telehealth Medical Services /2... $246,000 N/A $298,441 N/A $357,630 $416,946 $59,189 $59,316 Non-Rural Telehealth Medical Services /2... $217,390 N/A $258,308 N/A $309,604 $386,828 $51,296 $77,224 T-21 (Telehealth)... $204,708 $208,945 $208,945 $213,187 $213,187 $213,187 $4,242 $0 Other Specific Purpose (Telehealth) /3... $10,279 $10,492 $10,492 $10,705 $10,705 $10,705 $213 $0 Teleradiology (Diagnostic Services)... $19,801 $30,000 $30,000 $32,000 $32,000 $32,000 $2,000 $0 Total Telehealth... $985,826 $567,211 $1,097,625 $588,143 $1,223,859 $1,371,974 $126,235 $148,115 1/ Also displayed under Non-Institutional Long-Term Services and Supports in the Medical Services chapter. 2/ Includes primary care, health promotion, mental health, specialty care, diabetes and retinal screening, dermatology, EKG, and other clinical Telehealth. 3/ Palo Alto Telehealth Centers. Telehealth delivers health care services remotely to patients, from clinicians situated at different geographic locations. Its value proposition lies in: increasing access to care, especially in rural and remote locations; making expert advice more available to Veterans; and reducing the costs and inconvenience of their travel. VA increasingly uses telehealth to reach Veterans in rural communities that are medically underserved. In 2014, VHA Telehealth Services provided 2.1 million consultations to more than 717,000 Veterans, 45 percent of whom were in rural areas. In addition to direct support of ambulatory care services for Veterans in rural clinics, telehealth maintains the viability of many small rural VA medical centers, ones where core services would be impossible to sustain without access to remote expertise such as Tele-Intensive Care, TeleAudiology, TelePathology, Teleradiology and TeleMental Health. Telehealth funding supports the critical clinical, technological, and administrative infrastructures necessary for VA to successfully deliver this volume of virtual care services to Veterans safely and cost-effectively. In 2016, VA expects to deliver telehealth based services to 1.1 million Veterans. Priorities The program office responsible for telehealth in VA is VHA s Telehealth Services, within the Office of Patient Care Services. In 2016, priorities for Telehealth Services are: serving 1.1 million Veterans by sustaining and expanding services developed in 2015; creating innovative new programs; an ongoing focus on increasing access to underserved rural populations; and monitoring the quality of clinical care to ensure its continued excellence. Currently telehealth services in VA are provided via three modalities that are distinguishable by the care they offer, and the technology platforms that support them. These modalities are: Clinical Video Telehealth (CVT), Home Telehealth (HT) and Store and Forward Telehealth (SFT). Areas of clinical care that new telehealth program development in 2016 will focus on to address priority areas of Veteran care include: VHA-256 Selected Program Highlights

259 TeleMental Health, including National Specialist Networks (see TeleMental Health subsection under Strategy) Clinical Video Telehealth expansion to Veterans in their homes TeleAudiology TelePathology TeleICU Services TeleWound Care Home Telehealth model for Veterans with low-complexity healthcare needs Women s Telehealth for gynecology, reproductive health and mental health TelePulmonology, including TeleSpirometry TeleRetinal Imaging for macular degeneration TeleSurgery for pre- and post-operative care, including transplant care TeleCardiology TeleNeurology Telehealth expansion with non-va sites to improve Veterans access to care, to include but not limited to the DoD and Indian Health Service. Through its sustainment/expansion of existing Telehealth services, and focus on new service development, VHA expects 19 percent of Veterans to receive an element of their healthcare via Telehealth (CVT, HT and SFT) during Overall Telehealth Strategy Accomplishing VA s Telehealth goals requires complex coordination of the associated clinical, technology, telecommunications, training and other supportive arrangements. VHA Telehealth Services monitors and project manages areas of routine operations and development to ensure telehealth programs deliver high quality services on robust infrastructures appropriate to expected levels of patient care. Core functions VHA Telehealth Services performs in support of this are: Strategic planning for telehealth; Integration of telehealth with other virtual care modalities; Enterprise program management; National contracting and technology support, to include national service and warranty agreements for telehealth equipment; National telehealth training, operations manuals, support for competency testing and related resources; Organizational development support for telehealth programs; National quality and performance management, business processes and related reports; and Enterprise-level coordination with other VA/VHA program offices and internal and external organizations Congressional Submission VHA-257

260 Traumatic Brain Injury (TBI) and Polytrauma Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease Obligations ($000) TBI - All Veterans... $229,059 $229,200 $233,600 $227,200 $231,800 $233,200 ($1,800) $1,400 TBI-OEF/OIF/OND... $54,643 $48,800 $60,800 $46,600 $59,300 $59,800 ($1,500) $500 *VA estimates the ten-year cost ( ) to be $2.2 billion for TBI-All Veterans and $0.5 billion for TBI-OEF/OIF/OND Veterans. VA s Polytrauma System of Care (PSC) is the largest integrated system of care dedicated to the medical rehabilitation of Veterans and Servicemembers with combat and noncombat related traumatic brain injuries (TBI) and polytrauma. PSC encompasses specialized rehabilitation programs at 110 medical facilities across the VA. These programs are organized into a four-tier system that ensures access to the appropriate level of rehabilitation services based on the needs of the Veteran and Servicemember. PSC has five regional Polytrauma Rehabilitation Centers (PRC) that serve as regional referral centers for acute medical and rehabilitation care and as hubs for research and education; 23 Polytrauma Network Sites that coordinate polytrauma services within the Veterans Integrated Service Networks; 87 Polytrauma Support Clinic Teams (PSCTs) providing specialized evaluation, treatment, and community re-integration services within their catchment areas; and, 39 Polytrauma Points of Contact (PPOC) that provide a more limited range of rehabilitation services and facilitate referrals to the other PSC programs, as necessary. VA s medical rehabilitation services for TBI and polytrauma are provided in partnership with Veterans and their families, and address the goals of recovery and community reintegration. They include: Mandatory TBI Screening for possible TBI for all Veterans of combat operations in Iraq and Afghanistan, upon their initial entry into VA for services Veterans with positive screening results are offered referral for a comprehensive evaluation with specialty providers. Veterans with TBI requiring rehabilitation services receive an Individualized Rehabilitation and Community Reintegration (IRCR) Plan of Care the computerized IRCR Plan of Care documents physical, cognitive, mental health and vocational problems that may affect the Veteran s progress toward successful community re-integration and outlines Veteran-directed goals for addressing those issues. The functional status of Veterans with an IRCR Plan of Care is measured using a validated tool that allows rehabilitation teams to track changes and to provide appropriate interventions at the right time to maximize the Veteran s independence and restore physical and cognitive function. Integrated interdisciplinary team approach to care VA includes specialists from psychiatry, nursing, psychology, social work, physical therapy, occupational therapy, speech-language pathology, recreational therapy, and other disciplines, as VHA-258 Selected Program Highlights

261 appropriate for the individual needs of the patient. Collaborative decision-making process decisions regarding the provision of rehabilitation services are made by the medical provider in collaboration with the Veteran and his/her family based on their individually-assessed needs. VA rehabilitation outcomes meet or succeed benchmarks outcomes data collected in PSC programs show that Veterans with TBI and polytrauma that receive rehabilitation in VA meet or exceed external non-veteran benchmarks in functioning, community participation, and satisfaction with life. These outcomes reflect the outstanding rehabilitative care, prosthetic services, benefits, and adaptive modifications to the home and automobile that help Veterans with these severe disabilities overcome common obstacles to achieve personal independence, positive life adjustment, and opportunities in meaningful areas of life. PSC partners with other VA services PSC provides access to a broad continuum of rehabilitation services for TBI and polytrauma, from acute inpatient rehabilitation to sub-acute and transitional rehabilitation, outpatient care, adult day programs, home based care, and community living centers. PSC collaborates with specialists in the DoD, academia, and private sector to develop and deploy clinical practice guidelines, consensus positions and guidance on best practices VA/DoD Clinical Practice Guidelines for the management of mild TBI have been widely disseminated to VA rehabilitation providers through educational and training opportunities and reinforced through information technology solutions in the computerized medical record. PSC leads the Nation in advancing rehabilitation care for TBI and polytrauma. developments in the PSC include: Recent Integration with the VA Amputation System of Care to provide acute and longterm medical, rehabilitation and prosthetic needs for individuals with amputations; Assistive Technology Labs at the PRCs offering comprehensive evaluation, prescription and training for the use of technology to optimize the Veterans independence and community participation goals; Emerging Consciousness Programs at the PRCs serving Veterans and Servicemembers who are slow to recover consciousness after severe brain injuries; and, Expanding telerehabilitation services to include standardized protocols for remote TBI evaluation, devices for in-home monitoring of TBI symptoms, and the upcoming release of the TBI Coach, an app for the self-management of TBI symptoms. Since 1982, VA has provided acute rehabilitation services for Veterans and military Servicemembers with TBI, amputations, and severe complex injuries secondary to accidents and service-connected incidents (e.g., combat operations, other missions, 2016 Congressional Submission VHA-259

262 training, etc.). As current combat operations subside, VA will continue to maintain the PSC to provide comprehensive evidenced-based rehabilitation services to improve and maintain the physical and cognitive function of all patients in its care. Additionally, VA will study the results of the pilot program providing assisted living services to eligible Veterans with TBI, as authorized by P.L This study will assess how the pilot impacted rehabilitation, quality of life, and community reintegration of Veterans with TBI. Electronic Health Record Interoperability and Veterans Integrated System Technology Architecture (VistA) Evolution 2014 Actual 2015 Budget Current Estimate Estimate 2016 Advance Revised Approp. Request Advance Increase / Increase / Approp. Decrease Decrease Obligations ($000)... $73,865 $123,074 $67,594 $208,265 $159,596 $208,265 $92,002 $48,669 VA s ability to provide the best care anywhere and health equity for Veterans is dependent upon a robust information technology (IT) infrastructure, coupled with a responsive and evolving health information technology (HIT) system. The VHA funding request will support the staff and operational resources needed for requirements development, functional design, content generation, deployment, and evaluation of HIT systems. Funding will also support training for clinicians on new IT applications resulting from these efforts. Healthcare change is rapid and unyielding. Advances in knowledge range from the routine (recommendations for initiating treatment for cholesterol) to the previously unimaginable (genomics, advanced prosthetics). Advances in care delivery models have also dramatically changed from physician-dominated practice to team-based, patient-centered care. Finally, there is increasing emphasis to provide seamless transitions of care from other healthcare systems. To meet current and future needs, HIT systems must respond to these changes with expanded standards for data, tools for electronic health record (EHR) interoperability, and new functionality for clinical decision making, teamwork, and patient goals. This budget request is designed to ensure that the HIT solutions developed or purchased meet the current and future needs of the VHA health care teams at the time of deployment. VistA is VA s EHR system. The Computerized Patient Record System (CPRS) is the current user interface that clinicians use at the point of care delivery. The enterprise Health Management Platform (ehmp) comprises new technology that modernizes and extends portions of VistA and will eventually replace CPRS. VistA Evolution is a joint VHA and Office of Information and Technology (OI&T) program, designed to continuously improve healthcare for Veterans through the continual improvement of VistA. In 2016, VA will nationally deploy an incrementally-improved version of VistA with development for this version occurring between fiscal year (FY) 2015 and This version will include additional ehmp functionality intended to replace much of CPRS, as well as functionality that supports Office of the National Coordinator (ONC) 2014-Edition VHA-260 Selected Program Highlights

263 EHR component certification. Examples include entry of structured data to support immunizations, family history, occupational history, women s health, and other specialty care; a substantially improved user experience that increases provider productivity and facilitates clinician recruitment to VHA; greatly expanded support for clinical decisions and a common plan of care from which all clinicians and the Veteran works to improve healthcare efficiency, safety, and quality; and explicit tracking of goals that Veterans choose to ensure that VHA is addressing what is important to Veterans. By deploying new tools as soon as they become available and supporting clinicians through a new user experience platform, VHA will be positioned to rapidly respond to changes in practice, policy, priorities, and patient needs as well as better able to integrate advances in technology. Expertise in clinical informatics is essential for requirements development, functional design, content generation, deployment, and evaluation of VistA systems. In 2016, VHA funding for VistA Evolution will support the clinical informatics staff carrying out these functions and managing interactions with the clinical community throughout the life cycle for software development and acquisition. Specifically, this investment ensures that business requirements are identified aligned with the Federal HIT business architecture and guidance from ONC. It supports work in software design to optimize HIT usability and support for clinical decisions and workflows. Informatics staff will also invest substantial effort in migrating and developing new rules and other content for clinical decision support and workflow management. As software is deployed, informatics staff will help train users in the use of the software and new business practices that promote improved Veterans experience, population health, and efficiency. Finally, informatics staff will lead and conduct business case analyses and evaluations of VHA HIT investments to ensure that they promote business goals. In addition to VistA improvements, the VHA 2016 investment supports our commitment to achieve interoperability with the Department of Defense s (DoD) EHR and community health care providers, including those who are participating in the new Veterans Choice Program. VHA staff will participate in standards creation and enhancement with national partners. They will also support more effective implementation of standards within our EHR in cooperation with the Interagency Program Office (IPO). These standards will help VHA address legislative mandates in the Veterans Choice Act, DoD-VA data sharing, and Veterans benefits assessments. Through the Veterans Lifetime Electronic Record (VLER) Health Program, VHA staff recruits external healthcare partners to use national standards and technical frameworks for data sharing. Through the Connected Health program and MyHealtheVet (VA s personal health record), VHA staff work to engage Veterans. This program will create and deploy functionality to help Veterans provide data for clinicians to use in VistA and for Veterans to access VistA data. In 2017, VA anticipates deploying another incrementally-improved version of VistA (the development for which occurs in late FY 2016 and early FY 2017) to all VHA sites. This software will include functionality that improves upon that listed above and additional functionality for collecting structured clinical data to support lean-style management of clinical micro-processes. Clinical micro-processes are the decisions and actions that 2016 Congressional Submission VHA-261

264 clinicians and Veterans undertake. Many of these are currently recorded in free text notes or not captured at all, and therefore cannot be managed. Current Status: In 2015, the VistA Evolution project is focused on developing ehmp functionality that delivers value to the Veteran and meets many of the 2014-Edition ONC EHR certification criteria. Critical Milestones: September 2015: Achieve deployment at additional 30 sites; consolidate multiple views of internal and external clinical data into ehmp. September 2016: Complete substantial, deployable ehmp functionality, which will include much of the functionality to achieve ONC EHR certification using 2014 Edition certification criteria. September : Certify components of VistA 4 as they are ready for production release to achieve ONC 2014 Edition certification : Complete retirement and decommission of the CPRS. Women Veterans Health Care Actual Budget Estimate Current Estimate Advance Approp. Revised Request Advance Approp. Increase / Decrease Increase / Decrease Obligations ($000) Gender-Specific Health Care... $379,978 $403,200 $411,800 $436,700 $446,100 $481,700 $34,300 $35,600 Total Care... $3,714,241 $4,624,200 $4,157,100 $5,737,500 $4,659,400 $5,222,200 $502,300 $562,800 Gender-Specific Unique Patients* , , , , , ,226 12,889 12,632 Women Veterans Total Unique Patients , , , , , ,282 27,284 28,929 *Included in Women Veterans Total Unique Patients. Women comprise 15 percent of today s active duty military forces and 18 percent of National Guard and Reserves. Correspondingly, women are enrolling for VA health care at record levels: the number of women Veterans using VA health care has doubled since Based on the upward trend of women in all service branches, the continued withdrawal of troops from Afghanistan, the decision to allow women in combat roles, and the increased number of women choosing VA for healthcare, the expected number of women Veterans using VA health care will rise rapidly, the complexity of injuries of returning troops is likely to increase, and the cost associated with their care will grow accordingly. VA is improving access, services, resources, facilities, and workforce capacity to make health care more accessible, more sensitive to gender-specific needs, and of the highest quality for the women Veterans of today and tomorrow. VA specifically wants to ensure that every eligible woman Veteran receives high-quality comprehensive care that includes reproductive health care (such as maternity and gynecology care) and treatment for all gender-specific conditions and disorders, as well as mental health care, basic preventive care, acute care, and chronic disease management. VHA-262 Selected Program Highlights

265 Most importantly, deployed women are sustaining injuries similar to those of their male counterparts, both in severity and complexity. VA is anticipating and preparing not only for the increase in the number of women Veterans but also for the accompanying complexity and longevity of treatment needs they will bring with them. Security and privacy for women Veterans is a high priority for VA. VA is training providers and other clinical staff, enhancing facilities to meet the needs of women Veterans, and reaching out to inform women Veterans about VA services. VA is redesigning women s health care delivery with models of care that ensure women receive equitable, timely, high-quality primary health care from a single primary care provider and team, thereby decreasing fragmentation and improving quality of care for women Veterans Congressional Submission VHA-263

266 This Page Intentionally Left Blank VHA-264 Selected Program Highlights

267 DoD-VA Health Care Sharing Incentive Fund DoD-VA Health Care Sharing Incentive Fund Budget Authority $ M i l l i o n s $ $ $ $ Actual 2015 Estimate Anticipated* 2016 Estimate Anticipated* *Funding contributions anticipated from VA and DoD. Program Description Congress created the DoD-VA Health Care Sharing Incentive Fund, regularly referred to as the Joint Incentive Fund (JIF), between the Department of Defense (DoD) and the Department of Veterans Affairs (VA) to encourage development of sharing initiatives at the facility, intra-regional and nationwide level. The JIF program has been very successful in fostering collaboration and new approaches to problem solving that mutually benefit both VA and DoD. Through the JIF, there is a minimum of $30,000,000 available annually to enable VA and DoD to identify and provide incentives to implement creative sharing initiatives at the facility, intra-regional, and nationwide levels. Section 8111(d) of title 38, United States Code (U.S.C.) requires each Secretary to contribute a minimum of $15,000,000 from the funds appropriated to that Secretary s Department. The DoD-VA Health Care Sharing Incentive Fund became effective on October 1, Public Law , the National 2016 Congressional Submission VHA-265

268 Defense Authorization Act for Fiscal Year (FY) 2010, section 1706, amended section 8111(d)(3) of title 38, U.S.C. to extend the program to September 30, This is a no-year account. VA and DoD propose to extend the DoD-VA Health Care Sharing Incentive Fund for five years until September 30, Extension of the JIF authority will ensure the continued development and implementation of joint projects that will benefit the delivery of health care to beneficiaries of both departments. Program Highlights (dollars in thousands) Budget Current 2016 Increase/ Description Actual Estimate Estimate* Estimate* Decrease Transfer from Medical Services... $15,000 $15,000 $15,000 $15,000 $0 Transfer from DoD... $15,000 $15,000 $15,000 $15,000 $0 Budget Authority Total... $30,000 $30,000 $30,000 $30,000 $0 Rescissions, P.L (From Unobligated Balance)... $0 $0 ($15,000) $0 $15,000 Total Budgetary Resources... $30,000 $30,000 $15,000 $30,000 $15,000 Obligations... $91,389 $70,000 $70,000 $70,000 $0 FTE** *Anticipates VA and DoD will each transfer the required minimum of $15 million to this fund. **In the past, VA generated estimates based on the projected number of FTE identified in the business cases for approved proposals. Therefore, these estimates were obtained through self-reported means from the field as opposed to a verifiable financial system. The new FTE count of 44 reflects the number reported in the VA financial management system (FMS) in FY 2014, and VA assumes a steady-state number of FTEs in FY 2015 and FY During FY 2015, VA will work to develop a reliable and valid system of tracking FTEs in this account. Administrative Provision An administrative provision related to the JIF will be included in the VA chapter of the President s Budget Appendix: Of the amounts available in this title for Medical services, Medical support and compliance, and Medical facilities, a minimum of $15,000,000, shall be transferred to the DOD-VA Health Care Sharing Incentive Fund, as authorized by section 8111(d) of title 38, United States Code, to remain available until expended, for any purpose authorized by section 8111 of title 38, United States Code. Governance and Accountability The VA-DoD Joint Executive Council delegated the implementation of the fund to the Health Executive Council (HEC). VHA administers the fund under the policy guidance and direction of the HEC and executes funding transfers for projects approved by the HEC. The VHA Chief Financial Officer (CFO) provides periodic status reports of the financial balance of the Fund to the Defense Health Agency (DHA) CFO and to the HEC. VHA-266 DoD-VA Health Care Incentive Fund

269 2015 JIF Projects The JIF program has been very successful in fostering innovative projects and proposed the following 2015 projects totaling $38,377,000. The remaining obligations for 2015 are for projects approved in prior years. JIF funding is considered to be an initial investment in the project to facilitate the mutually beneficial exchanges of health care resources, with the goal of improving the access to high quality and cost effective health care provided to beneficiaries of both departments. JIF funding is designed and programmed to cover the start-up costs during the initial two-year JIF financial support period, after which time sustainment funding will be provided by the designated Department(s) as appropriate. The first three proposed 2015 projects are national in scope and would have a systemwide impact on the DoD and VA health care systems. The remaining seven proposed 2015 projects are local or site-specific. DoD/VA National (Interagency Care Coordination Committee Training) This project seeks to expand Interagency Care Coordination and Case Management Programs assessment and corresponding pilots first launched in It proposes to roll out Lead Coordinator training across the Military Healthcare System and Veterans Health Administration at the facility level and provide support for the rapid design, planning, execution, communication, refinement and sustainment of the Lean Coordinator training program. This project also standardizes all processes and tools that care coordinator s use to enhance the delivery of healthcare, benefits, and services for active duty service members and Veterans during transition between the Departments. Cost: $3,150,000 DoD/VA National (Joint Centralized Credentials Quality Assurance System 2) The initial Joint DoD and VA Centralized Credentials Quality Assurance System (JCCQAS) JIF proposal approved in FY 2014 provides for the development of a Prototype for a single comprehensive health care provider credentialing and preparation of the platform for the single comprehensive system across VHA and the Military Healthcare System (MHS). DoD and VA are currently working on requirements and user stories for a prototype, with the goal of using a single credentialing platform by both departments. This will further ongoing VA/DoD collaboration, defining joint business requirements, establishing policy and standards, and helping to identify areas of unique collaboration. Cost: $9,200,000 DoD/VA National (Safety Event Reporting System) This initiative would enable the DoD and VHA to utilize the same enterprise-level, commercial-off-the shelf (COTS) Patient Safety Event Reporting System (PSR) that DoD has been using successfully since 2011 and interface it with the government-off-the-shelf (GOTS) tool that has been developed by VHA s National Center for Patient Safety for capturing initial patient safety incidents, as well as the root cause analysis (RCA) process, an in-depth review of patient safety events. As the primary benefactor of this joint 2016 Congressional Submission VHA-267

270 venture, VHA anticipates expansion and improved standardization in the reporting of initial patient safety events. Cost: $3,350,000 60th Medical Group (MedGrp) Travis/Northern California Veterans Affairs Health Care System (VANCHCS) (Medical Surgical Bed Expansion) The 60th MedGrp and VANCHCS will continue to grow services offered to Veterans and DoD beneficiary population by expanding medical/surgical bed capacity by five beds at 60th Medical Group. Expanding bed capacity with the appropriate staff would allow for the recapture of an average of 14 patients monthly and cost avoidance of $1.840 million in DoD and VA network care costs. Cost: $2,096,000 96th Medical Group (MedGrp) Eglin/VA Gulf Coast Health Care System (Orthopedic Spine Care) This project proposes to expand Orthopedics care services at the 96th Medical Group by hiring 1 FTE Physician Assistant and 1 FTE contract Nurse to provide follow-up outpatient care. This staff augmentation will allow the currently assigned orthopedic surgeon more time to perform surgery and maximize the use of two recently added operating rooms. This initiative is projected to increase surgical caseload from 135 in FY14 to approximately 228 by FY16, and reduce consultation to the private sector for orthopedic care. Cost: $1,117,000 Air Force Medical Support Agency (Tele-Intensive Care Unit) This project will allow for the continuous monitoring of 100 Intensive Care Units (ICU) beds (60 DoD / 40 VA) by a remote team of Intensivists from VISN 23 Tele-ICU monitoring center in Minneapolis. This initiative projects Intensive Care clinical expertise 24/7 to wherever it is needed via: high definition video monitoring of each patient; access to appropriate bedside diagnostic & telemetry waveforms; high quality audio communications with each bed; and continuous connectivity to DoD and VA information systems (Armed Forces Health Longitudinal Technology Application, Essentris, Picture Archiving, and Communication System). The overall savings from private sector care costs will result in more funding allowance for direct Military Treatment Facility care (outpatient and inpatient) and will increase access to care. Cost: $4,955,000 Naval Hospital Beaufort/ Ralph H. Johnson Charleston VA Medical Center (RHJVAMC) (Physical Therapy) This initiative will add two physical therapists, two physical therapy assistants, one medical services assistant and two prosthetics purchasing agents, who will provide services in the Physical Therapy Department at the Naval Hospital in Beaufort, SC. This project is projected to increase access to physical therapy services; decrease travel time for Veterans seeking services; decompress physical therapy services at RHJVAMC and expand the scope of clinical services currently at the RHJVAMC CBOC inside NHB. Cost: $918,000 VHA-268 DoD-VA Health Care Incentive Fund

271 Naval Medical Center Portsmouth/Hampton VA Medical Center (Continuity of Psychiatric Care) This proposal will fill the gap in outpatient mental health services to active duty Servicemembers with severe and persistent mental health diagnoses as they transition through the Integrated Disability Evaluation System into the VA health care system, by providing comprehensive community-based treatment modeled after the civilian treatment program Assertive Community Treatment (ACT). This Continuity of Psychiatric Care program will allow for daily one-on-one case management and close follow-up care by mental health providers at both facilities. Cost: $2,682,000 Naval Medical Center San Diego (NMCSD) /San Diego Veterans Affairs Health Care System (SDVAHCS) (Physical Therapy) This project proposes to eliminate shared space constraints and staffing shortfalls by modifying existing space in NMCSD s physical therapy department, purchasing new equipment, and increasing staff to increase access for both departments beneficiary. The project will also provide a seamless continuity of care for active duty Servicemembers receiving physical therapy as they transition into VA care, and provide a platform for future research projects and internship opportunities that can attract sub-specialists that are currently difficult to recruit. Cost: $8,421,000 Walter Reed National Medical Military Center (WRNMMC)/Martinsburg VAMC (Tele-Neurosurgery) This initiative proposes to replicate the successful JIF project approved in 2009 between Walter Reed Army Medical Center Neurosurgery Virtual Clinic (now WRNMMC Tele- Neurosurgery) and the Washington, DC, VA Medical Center Neurology Department. The initiative s goals are to reduce wait times and improve access for global neurosurgery services. Veterans will have access to neurosurgical sub-specialty care at WRNMMC by neurosurgeons who are using the latest neurosurgery technologies. This initiative will also help to ensure that the next generation of military neurosurgeons will possess strong clinical and surgical skills developed from treating complex cases. Cost: $2,488, Congressional Submission VHA-269

272 DoD-VA Health Care Sharing Incentive Fund Crosswalk (dollars in thousands) Budget Current 2016 Increase/ Description Actual Estimate Estimate* Estimate* Decrease Transfer from Medical Services... $15,000 $15,000 $15,000 $15,000 $0 Transfer from DoD... $15,000 $15,000 $15,000 $15,000 $0 Subtotal... $30,000 $30,000 $30,000 $30,000 $0 Budget Authority... $30,000 $30,000 $30,000 $30,000 $0 Adjustments to Obligations: Unobligated Balance (SOY): No-Year... $256,361 $216,361 $195,593 $140,593 ($55,000) Rescissions, P.L (From Unobligated Balance)... $0 $0 ($15,000) $0 $15,000 Unobligated Balance (EOY): No-Year... ($195,593) ($176,361) ($140,593) ($100,593) $40,000 Change in Unobligated Balance (Non-Add)... $60,768 $40,000 $40,000 $40,000 $0 Recovery Prior Year Obligations... $621 $0 $0 $0 $0 Obligations... $91,389 $70,000 $70,000 $70,000 $0 Outlays: Obligations... $91,389 $70,000 $70,000 $70,000 $0 Obligated Balance (SOY)... $38,473 $28,473 $73,184 $113,184 $40,000 Obligated Balance (EOY)... ($73,184) ($68,473) ($113,184) ($160,684) ($47,500) Recovery Prior Year Obligations... ($621) $0 $0 $0 $0 Outlays, Net... $56,057 $30,000 $30,000 $22,500 ($7,500) FTE** *Anticipates VA and DoD will each transfer the required minimum of $15 million to this fund. **In the past, VA generated estimates based on the projected number of FTE identified in the business cases for approved proposals. Therefore, these estimates were obtained through self-reported means from the field as opposed to a verifiable financial system. The new FTE count of 44 reflects the number reported in the VA financial management system (FMS) in FY 2014, and VA assumes a steady-state number of FTEs in FY 2015 and FY During FY 2015, VA will work to develop a reliable and valid system of tracking FTEs in this account. VHA-270 DoD-VA Health Care Incentive Fund

273 Joint Department of Defense-Department of Veterans Affairs Medical Facility Demonstration Fund DoD-VA Medical Facility Demonstration Fund Appropriation Transfers ($ in millions) $500.0 $400.0 $364.3 $399.2 $376.4 $386.7 $300.0 $123.0 $146.8 $117.1 $120.4 $200.0 $100.0 $241.4 $252.4 $259.3 $266.3 $ Actual 2015 Budget Estimate 2015 Current Estimate 2016 Estimate Department of Veterans Affairs (VA) Department of Defense (DoD) 2016 Congressional Submission VHA-271

274 Financial Highlights (dollars in thousands) Budget Current 2016 Increase/ Description Actual Estimate Estimate 3/ Estimate 3/ Decrease Appropriation, Transfers From: Medical Services... $176,831 $187,433 $190,185 $195,358 $5,173 Medical Support & Compliance... $24,740 $26,222 $26,608 $27,332 $724 Medical Facilities... $32,998 $31,743 $35,490 $36,455 $965 VA Information Technology... $6,789 $6,968 $6,968 $7,158 $190 Subtotal, VA Contribution... $241,358 $252,366 $259,251 $266,303 $7,052 Department of Defense (DoD) 1/... $122,986 $128,804 $117,125 $120,387 $3,262 Other DoD Contributions: MERHCF DoD reimbusement... $3,358 $3,358 $3,483 $3,615 $132 DoD "Stay Navy" (non-add) 2/... $16,025 $14,695 $14,695 $14,980 $285 Subtotal, DoD Contribution... $142,369 $146,857 $135,303 $138,982 $3,679 Total /4... $364,344 $399,223 $376,376 $386,690 $10,314 Collections 5/... $19,405 $17,072 $19,666 $21,110 $1,444 Reimbursements 6/... $8,472 $7,400 $8,500 $8,500 $0 Unobl Bal (SOY)... $5,128 $5,000 $5,950 $5,000 ($950) Unobl Bal (EOY)... ($5,950) ($3,500) ($5,000) ($5,000) $0 Lapse... ($2,668) Obligations... $388,731 $425,195 $405,492 $416,300 $10,808 FTE: Civilian... 2,082 2,136 2,162 2,167 5 DoD Uniformed Military 7/ Total FTE... 2,985 2,994 2,998 3, /The actual amount of the MERHCF reimbursement will impact DoD transfer amount. 2/ Non-add for Personal Services Contract funded by DoD for the East Campus. 3/FY 2015 and 2016 estimates are based upon the best available information at the time of the development. of the budget. These estimates are subject to revision as operational estimates are refined for the Captain James A. Lovell Federal Healthcare Center (FHCC). These estimates are in compliance with Public Law which established this fund. 4/Total does not include the Stay Navy contribution or MERHCF reimbursement. 5/Collections estimate provided by the Chief Business Office. 6/Includes estimated MERHCF reimbursement from DoD. 7/FY 2014 is corrected for actual on-board DoD Uniform Military FTE. FY 2015 is based on estimates from the Navy Manning Plan in FY 2015, and no change is expected in FY Estimates do not reflect the number of DoD Uniform Military FTE subject to Reconciliation in the FHCC Joint Areas. Program Description On May 27, 2005, the Department of Veterans Affairs (VA)/Department of Defense (DoD) Health Executive Council signed an agreement to integrate the North Chicago VA Medical Center (NCVAMC) and the Navy Health Clinic Great Lakes (NHCGL). This VHA-272 Joint DoD/VA Medical Facility Demonstration Fund

275 landmark agreement created an organization composed of all the medical and dental components on both VA and Navy property under the leadership of a VA Senior Executive Service (SES) Medical Center Director and a Navy Captain (O-6) Deputy Director. The leadership functions in concert with an Interagency Advisory Board and a local Stakeholder Advisory Board. To support the integration of NHCGL and NCVAMC, a $118 million DoD construction project was awarded to construct a new federal ambulatory care clinic and parking facilities co-located with NCVAMC. The project was completed on September 27, 2010, and the first multiple specialty clinic opened on December 20, The approved Governance Model, with VA as the Lead Partner, relies on an extensive Resource Sharing Agreement (RSA) between the current NCVAMC and NHCGL. This RSA ensures strict adherence to the title 38 requirement that one entity may not endanger the mission of the other entity engaged in a RSA. The integrated organization the Captain James A. Lovell Federal Health Care Center (FHCC) is comprised of two campuses. The West Campus has 48 buildings on 107- acres of land between Green Bay Road and Buckley Road in North Chicago, Illinois. The East Campus has four medical facilities on Naval Station Great Lakes, Illinois. There are two Community Based Outpatient Clinics (CBOCSs) in Evanston and McHenry, Illinois, and one in Kenosha, Wisconsin. The FHCC has 369 available beds and treated 892,030 outpatients and 4,572 inpatient admissions in The FHCC began using a single unified budget in 2011 to operate the integrated facility and execute funding using the VA Financial Management System (FMS). An account under the Department of Veterans Affairs, Joint Department of Defense - Department of Veterans Affairs Medical Facility Demonstration Fund (referred to as the Fund ), was effective beginning in 2011 (4 th Quarter). VA and DoD determine the FHCC expenses that can be attributed to VA and DoD, based on cost, workload, and the consumption of resources by each Department s beneficiaries. This reconciliation model is used as the basis for preparing future budgets. The reconciliation methodology uses agreed-upon full costing methods and execution data to determine the costs attributable to each Department. The reconciliation methodology uses industry standard measurements such as Relative Value Units (RVUs) and Relative Weighted Products (RWPs) for the determinations of workload values to be compared to VA s Decision Support System (DSS) full costs. Both Departments will continue to work together to improve upon an equitable reconciliation process and ensure respective Department financial controls are implemented. Per statute, the Secretary of Defense, in consultation with the Secretary of the Navy, and the Secretary of Veterans Affairs shall jointly provide for an annual independent review of the Fund at least three years after the date of the enactment of National Defense Authorization Act (NDAA) of FY 2010, P.L Altarum Institute conducted the independent review, which began in March 2014 and was completed in October Altarum is a nonprofit health systems research and consulting organization serving government and private-sector clients. Altarum did an assessment of the uses of the funding issued for support of the FHCC and an evaluation of the adequacy of the 2016 Congressional Submission VHA-273

276 proportional share contributed to the Fund by the Secretary of Defense and Secretary of Veterans Affairs. Altarum determined that the FHCC ensured that the funding issued for support of health care delivery under the fund was spent appropriately and the Reconciliation Model appropriately calculated the proportional share that each Department should contribute to the Fund. In addition, P.L requires the Secretaries to jointly submit a final report on the exercise of the authorities in the law not later than 180 days after the fifth anniversary of the date of the execution of the executive agreement. The report must include the following: a. A comprehensive description and assessment of the exercise of the authorities in NDAA b. The recommendation of the Secretaries as to whether the exercise of the authorities of NDAA 2010 should continue. The Departments anticipated submitting this report to the appropriate committees of Congress in the fall of The authorities to use this Fund shall terminate on September 30, VA and DoD propose that this authority be extended by one year, through September 30, 2017, to allow the Departments sufficient time to analyze the recommendations and conclusions in the final report and develop an informed consideration for the future direction of the joint endeavor. Administrative Provisions VA is proposing continuing the following administrative provisions in accordance with P.L , NDAA FY 2010, for FY 2016, as included in the President s Budget: Sec Of the amounts appropriated to the Department of Veterans Affairs for fiscal year 2016 for "Medical Services'', "Medical Support and Compliance'', "Medical Facilities'', "Construction, Minor Projects'', and "Information Technology Systems'', up to $266,303,000, plus reimbursements, may be transferred to the Joint Department of Defense-Department of Veterans Affairs Medical Facility Demonstration Fund, established by section 1704 of the National Defense Authorization Act for Fiscal Year 2010 (P.L ; 123 Stat. 3571) and may be used for operation of the facilities designated as combined Federal medical facilities as described by section 706 of the Duncan Hunter National Defense Authorization Act for Fiscal Year 2009 (P.L ; 122 Stat. 4500): Provided, That additional funds may be transferred from accounts designated in this section to the Joint Department of Defense-Department of Veterans Affairs Medical Facility Demonstration Fund upon written notification by the Secretary of Veterans Affairs to the Committees on Appropriations of both Houses of Congress: Provided further, That section 223 of Title II of Division I of Public Law is repealed. VHA-274 Joint DoD/VA Medical Facility Demonstration Fund

277 Sec Such sums as may be deposited to the Medical Care Collections Fund pursuant to section 1729A of title 38, United States Code, for health care provided at facilities designated as combined Federal medical facilities as described by section 706 of the Duncan Hunter National Defense Authorization Act for Fiscal Year 2009 (P.L ; 122 Stat. 4500) shall also be available: (1) for transfer to the Joint Department of Defense-Department of Veterans Affairs Medical Facility Demonstration Fund, established by section 1704 of the National Defense Authorization Act for Fiscal Year 2010 (P.L ; 123 Stat. 3571); and (2) for operations of the facilities designated as combined Federal medical facilities as described by section 706 of the Duncan Hunter National Defense Authorization Act for Fiscal Year 2009 (P.L ; 122 Stat. 4500). Also in accordance with P.L , NDAA FY 2010, DoD is proposing the following general provision, for FY 2016, as included in the President s Budget: Section From within the funds appropriated for operation and maintenance for the Defense Health Program in this Act, up to $121,000,000 shall be available for transfer to the Joint Department of Defense-Department of Veterans Affairs Medical Facility Demonstration Fund in accordance with the provisions of section 1704 of the National Defense Authorization Act for Fiscal Year 2010, P.L : Provided, That for purposes of section 1704(b), the facility operations funded are operations of the integrated Captain James A. Lovell Federal Health Care Center, consisting of the North Chicago Veterans Affairs Medical Center, the Navy Ambulatory Care Center, and supporting facilities designated as a combined Federal medical facility as described by section 706 of P.L : Provided further, That additional funds may be transferred from funds appropriated for operation and maintenance for the Defense Health Program to the Joint Department of Defense-Department of Veterans Affairs Medical Facility Demonstration Fund upon written notification by the Secretary of Defense to the Committees on Appropriations of the House of Representatives and the Senate. Justification for VA Administrative Provisions: The first VA provision (Sec. 219) is required to permit the transfer of funds from specific VA appropriations to the Fund, which was established by P.L , section Section 1704(a)(2)(A) and (B) specify that the Fund will consist of amounts transferred from amounts authorized and appropriated for the DoD and VA specifically for the purpose of providing resources for this Fund. The VA s 2016 budget request includes funding to be appropriated and transferred to the Fund within the appropriations request for Medical Services, Medical Support and Compliance, Medical Facilities, and Information Technology Systems. The second provision (Sec. 221) will permit the transfer of funds from the Medical Care Collections Fund to the Fund. Section 1704 of P.L allows VA and DoD to deposit medical care collections to this Fund. Section 1704(b)(2) specifies that the availability of funds transferred to the Fund under subsection (a)(2)(c) shall be subject to 2016 Congressional Submission VHA-275

278 the provisions of 1729A of title 38, United States Code (U.S.C). Title 38, U.S.C., section 1729A(e), requires that: (e) amounts recovered or collected under the provisions of law referred to in subsection (b) shall be treated for the purposes of sections 251 and 252 of the Balanced Budget and Emergency Deficit Control Act of 1985 (2 U.S.C. 901, 902) as offsets to discretionary appropriations to the extent that such amounts are made available for expenditure in appropriations Acts for the purposes specified in subsection (c). To treat the collections as offsets to discretionary appropriations, language is needed in the appropriations act regarding the authority to use collections to pay for the expenses of furnishing health care at the Captain James A. Lovell Federal Health Care Center located in North Chicago, Illinois. VHA-276 Joint DoD/VA Medical Facility Demonstration Fund

279 Medical and Prosthetic Research Leading 21 st Century Medical Research/ Transforming VA Care Summary of Budgetary Resources (dollars in millions) M i l l i o n s $2,500 $2,000 $1,500 $1,000 $500 $0 $1,794 $1,775 $1,775 $1,832 $586 $589 $589 $622 $498 $501 $501 $525 $515 $500 $500 $500 $195 $185 $185 $ Budget Estimate 2015 Budget Estimate 2015 Current Estimate 2016 Request Other Non-Federal Resources Federal Resources Medical Care Support Research Appropriation Language For necessary expenses in carrying out programs of medical and prosthetic research and development as authorized by chapter 73 of title 38, United States Code, [$588,512,641] $621,813,000, plus reimbursements, shall remain available until September 30, [2016] (Military Construction and Veterans Affairs, and Related Agencies Appropriations Act, 2015.) Executive Summary The VA Research and Development (R&D) program plays a key role in advancing the health and care of Veterans and is uniquely positioned to continue to lead a national transformation of American health care. As part of the largest integrated health care system in the United States, VA R&D draws upon Veteran patients and families who continue the spirit of service by volunteering to participate in research studies across the Nation. These participants, along with VA s committed clinician-scientists and national 2016 Congressional Submission VHA-277

280 health care delivery structure, form the bedrock of a VA research program that has advanced care for Veterans and the public for nearly 90 years. These resources allow VA to deliver the best health care and develop cutting-edge medical treatments for Veterans, their families, and the Nation. Although the VA research program focuses on benefiting current and future Veterans, the outputs of VA research ultimately affect the entire Nation. VA is committed to using evidence-based results to address the needs of the entire Veteran population. Through VA s focused mission to advance health care for Veterans, VA research serves as a 21 st -century model for how American medicine can be transformed through scientific inquiry and innovative thought, leading to evidence-based treatments successfully implemented into practice. Because more than 60 percent of VA researchers are also clinicians who take care of patients, VA is uniquely positioned to move scientific discovery from investigators laboratories to patients care. In turn, VA clinician investigators identify new research questions for the laboratory at the patient s bedside, making the research program one of VA s most effective tools to improve the care of Veterans. VA research is a valuable investment with remarkable returns. VA research has developed new technologies and products of benefit to the economy, and is facilitating and expanding collaborations between VA researchers and private pharmaceutical, biomedical, and biotechnology companies. Innovative products spawned by such creative partnerships include, for example, the shingles vaccine Zostavax, which was brought to market by Merck after a successful clinical trial conducted by the VA Cooperative Studies Program that benefits all senior citizens. The VA research program plays a critical role in attracting and retaining top-quality physicians in VA. A program evaluation conducted by Abt, Associates found that 79 percent of VA clinicians cited the research program as a factor in coming to VA, while over 90 percent cited it as a reason for staying. VA research works continually to ensure that the research portfolio is appropriately rebalanced to meet the most pressing needs of Veterans. In 2016, VA s research priorities will emphasize ensuring continued care for Veterans throughout their life span. A robust health services research program will continue to improve the way VA delivers health care and the methods through which Veterans can access VA services. VA will also support a wide array of research and development in engineering and technology to improve the lives of Veterans with disabilities. Work includes both prosthetic systems that replace lost limbs and those that activate residual or paralyzed nerves, muscles, and limbs. Enhancing research on genomic medicine and continuing the Million Veteran Program (MVP) remain major goals for VA Research in MVP, a groundbreaking genomic medicine program, seeks to collect genetic samples and general health information from one million Veterans in the next five years. The program is on track to establish one of the largest genomic and health information research resources available in the world, which will help provide answers to many pressing medical questions and lead to improvements in care and disease prevention to Veterans and the Nation. As of December 31, 2014, MVP had enrolled more than 336,900 Veterans, and is conducting initial genetic analysis VHA-278 Medical & Prosthetic Research

281 of these specimens at the rate of more than 10,000 per week. These data will be available to VA investigators starting in 2015; studies that will use these data concentrate on posttraumatic stress disorder and other chronic diseases/conditions prevalent in Veterans. Further information is provided later in the discussion. A comprehensive research program supports VA s commitment to the health and care of the increasing number of women Veterans. Recent areas of inquiry include studying how VA provides for women Veterans general and gender-specific health care needs, and understanding the experiences of women Veterans while in service and their health risk factors later in life. Research to benefit Gulf War Veterans will remain a priority for VA in VA issues Requests for Applications specifically for Gulf War research two times per year and, over the past several years, the number of projects funded and the level of funding have increased each year. As directed by Senate Report , the VA research program ensures that no less than $15 million is available for Gulf War research each year; the actual amount spent on such research is highly dependent upon the quantity and quality of research proposals submitted. Funding is estimated at $15 million in VA works closely with other federal research agencies to assure effective use of scarce taxpayer resources in executing its research mission. We carry out joint programmatic reviews with the Department of Defense (DoD) and National Institutes of Health (NIH) to ensure that our research efforts are complementary and not duplicative. Under the auspices of the President s National Research Action Plan, VA has worked with DoD to create two research consortia for traumatic brain injury and posttraumatic stress disorder, at a combined investment of $107 million over five years. This tight coordination has become routine for all three agencies, with benefits that accrue to Veterans and the American public at large. To fulfill the commitment to provide superior health care to our Veterans and their beneficiaries, VA is requesting $622 million in direct appropriations in 2016, which is an increase of $33 million, or six percent, over the 2015 level. Additional program resources are estimated at $1.2 billion and consist of private and Federal grants, including the NIH, DoD, and Centers for Disease Control and Prevention. VA estimates total resources will exceed $1.8 billion in The estimated direct research program and reimbursable employment level is 3,551 full-time equivalents (FTEs); all VA researchers are VA employees. The budget request reflects a civilian pay raise of 1.3 percent It is estimated that VA R&D will support 2,254 projects during Congressional Submission VHA-279

282 Appropriation and Other Federal Resources - Medical and Prosthetic Research (dollars in thousands) % Change Actual Current Request Estimate Medical and Prosthetic Research $585,664 $588,513 $621,813 6% Medical Care Support $498,000 $501,000 $525,000 5% Other Federal and Non-Federal Resources 710, , ,000 0% Reimbursements 25,051 40,000 40,000 0% Total Budgetary Resources $1,818,715 $1,814,513 $1,871,813 3% FTE 3,446 3,491 3,551 2% Appropriation Highlights - Medical and Prosthetic Research (dollars in thousands) 2015 Budget Current Actual Estimate Estimate Request Inc/Dec Appropriation... $585,664 $588,922 $588,513 $621,813 $33,300 Obligations... $613,866 $637,911 $656,520 $661,813 $5,293 Total Projects... 2,224 2,224 2,224 2, Average Employment... 3,446 3,491 3,491 3, Employment Distribution Direct FTE... 3,305 3,010 3,350 3, Reimbursable FTE Total... 3,446 3,491 3,491 3, VHA-280 Medical & Prosthetic Research

283 Description Budget Authority Original FY 2015 President's Budget... $588,922 Rescission P.L ($409) Adjusted FY 2015 Budget Estimate... $588, Request: Net Change Medical and Prosthetic Research 2016 Summary of Resource Requirements (dollars in thousands) Pay Raise (1.3%) Starting January 1, $4,145 Non-Payroll Inflation (1.5%)... $3,836 Strategic Initiative... $10,200 Inflation - Biomedical Research and Development Price Index (2.5%) $15,119 Subtotal... $33, Budget Estimate... $621,813 Strategic Initiative We propose a $10.2 million strategic initiative to support improvements in VA medical care through research. Learning Health Care System research initiative. A learning health care system is one that is responsive to new information, adapts to implement more effective clinical practices, and is committed to an ongoing mission of excellence, supported by a culture of self-reflection and continuing education.. This initiative proposes to further develop existing research by scaling up evidence-based decision-making as the lessons from each care experience are systematically captured, assessed, and translated into improved methods of delivering of care to veterans. VA R&D proposes five interlocking research streams: measurement science, operations research, point of care research, provider behavior, and randomized program implementation. 1. Measurement science: This workstream will develop methods for accurately assessing quality metrics, including timeliness and uniform delivery of VA medical care using currently collected data. Special focus will be placed on optimizing tools that are capable of creating accurate data sets using administrative and health records data to assess performance in the delivery of primary care, specialty care, and mental health services. To encourage VA researchers to pursue investigations in this area, direct research support will be provided; additionally VA research will support the career development of investigators who are focused 2016 Congressional Submission VHA-281

284 on improving the quantitative assessment of medical care and medical care delivery systems. 2. Operations research: This workstream will build upon the measurement science work stream by using health system data to develop mathematical models of health systems functions. Special focus will be on supply chain management and industrial engineering techniques to optimize the delivery of medical care. VA compares itself to a logistical system that depends on having a variety of resources properly positioned to come together in the right place at the right time for efficient and effective operation. Using developed models, with evidence from an adequately powered sample size, VA will focus on answering a multitude of questions currently facing the operations of the health care system. The ultimate goal is to improve the administrative, logistical, and operational conduct of health care delivery. 3. Point of Care Research: This workstream supports the full implementation of pilot studies that have successfully embedded research directly into clinical care. Clinical trials that compare different widely accepted treatments can be conducted in routine primary and specialty care settings, rather than carried out by independent study teams working parallel to the health care system. This initiative will reduce the time required to carry out randomized clinical trials, and increase the generalizability of their results, supporting a health care system that can more quickly determine the most effective treatment options and implement results into clinical care. 4. Provider behavior: Health care providers sometimes make puzzling decisions recommending an expensive therapeutic approach when a less expensive approach with apparently similar outcomes is available, for example. This workstream will focus on the use of neurobiological methods and behavioral economics techniques to further understand the decision-making process for VA health care providers. Additionally, utilizing developments and techniques from the measurement science workstream, VA research will use data analytics to mine VA s electronic health records to better determine provider behavior and healthcare outcomes. 5. Randomized Program Implementation: Block randomization or step-wedge design techniques, is a method by which one can assess the efficacy of a program during and after implementation, which is the strength of randomized clinical trials. This technique, if it can be made to work on a large scale, is much more reliable as a program assessment tool than the use of historical controls or pilot projects. This research work stream will attempt to use randomized-program implementation in several program rollouts to determine feasibility and barriers to implementation of this approach in the VA healthcare system. The function of assessment tools will depend upon the output of the Measurement Science work stream; and the rollout strategy employed may benefit from output of the Operations Research work stream. Medical and Prosthetic Research Program Description The VA Office of Research and Development (ORD) consists of four main research services that together address the full spectrum of Veterans health needs. In support of VHA-282 Medical & Prosthetic Research

285 VA research in the field, these four services work together to perform a wide range of essential functions: solicitation and coordination of proposal submissions and oversight of the scientific peer-review process, portfolio management, administrative oversight, compliance and infrastructure management, and many other tasks necessary to ensure VA is pursuing the highest-priority and most productive research for Veterans and their families. The four services are: Biomedical Laboratory (BLR&D): BLR&D supports preclinical research to understand life processes from the molecular, genomic, and physiological level in regard to decisions affecting Veterans. Clinical Science (CSR&D): CSR&D administers investigations, including human subject research, to determine the feasibility or effectiveness of new treatments such as drugs, therapy, or devices. This is done in small clinical trials or multisite studies, conducted by the Cooperative Studies Program (CSP), aimed at learning more about the causes of disease and providing the evidence base for more effective clinical care. Health Services (HSR&D): HSR&D supports studies to identify and promote effective and efficient strategies to improve the organization, cost-effectiveness, and delivery of quality of health care for Veterans. Rehabilitation (RR&D): RR&D develops novel approaches to restore full and productive lives to Veterans with traumatic amputation, central nervous system injuries, loss of sight or hearing, or other physical and cognitive impairments. I. Care for Returning Service Members VA researchers are pursuing ways to address Iraq and Afghanistan Veterans most pressing mental and physical health issues. These include posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), traumatic limb loss, sensory dysfunction and loss, pain, and polytrauma. The work VA researchers do in these areas also benefits Veterans of all ages with similar issues. Mental Health VA supports a range of studies on post-deployment mental health concerns such as PTSD, depression, anxiety, substance abuse, and suicide. Research aims to describe the incidence and prevalence of mental health disorders, identify their risk factors, quantify their effect on health outcomes, understand the basic mechanisms of individual disorders, identify effective treatments, and develop models of care that will deliver effective treatments more quickly, widely, and reliably to Veterans in need Congressional Submission VHA-283

286 Approximately one in five Veterans of the wars in Iraq and Afghanistan has been diagnosed with PTSD, often co-occurring with another mental disorder or a physical illness. One major effort is the Marine Resiliency Study (MRS), involving some 2,600 Marines who deployed to Iraq and Afghanistan. Beginning in 2008, the research team conducted clinical interviews on Marine bases and collected psychological, social, and biological data before deployment and then multiple times after deployment. Researchers are analyzing the data to identify risk and resilience factors for combat-related PTSD. The team recently published two articles in JAMA Psychiatry. One shows deployment-related brain injury to be a significant risk factor for PTSD. Another implicates high levels of inflammation in the body as a PTSD risk factor. The Health of Vietnam Era Veteran Women s Study (CSP #579 Health ViEWS) is examining factors associated with mental and physical health and represents the largest study to date of women Vietnam Veterans. Early findings indicate that, compared to the general population of U.S. women, women in all three Vietnam cohorts (those who served in Vietnam, in areas near Vietnam, and in the United States) have lower mortality from all causes combined, as well as from causes such as diabetes, heart disease, chronic obstructive pulmonary disease, and nervous system disease. However, women who served in Vietnam appear to have higher rates of death from pancreatic and brain-related cancers, a linkage that is now being studied further by VA. Other studies that focus on Veteran cohorts include the National Vietnam Veterans Longitudinal Study, the Vietnam Era Twins Registry (CSP #569), and a longitudinal study of the neuropsychological and mental outcomes of Veterans of the Iraq war (CSP #566). VA will soon have large datasets to characterize health status and changes over time for Vietnam, Iraq, and Afghanistan Veterans, which will be a rich resource for researchers. Suicide among Veterans is a critical concern for VA researchers. In 2007, VA established the Center of Excellence for Suicide Prevention. Center-affiliated researchers and other VA investigators are developing national surveillance systems for data management relating to suicide, attempted suicide, and suicide re-attempts. These systems will generate a framework for characterizing risk and protective factors for suicidal behavior among Veterans. New research is underway in collaboration with VA s national suicide hotline to directly improve Veterans use of appropriate VA services. VA s CSP is initiating a new clinical trial (CSP #590) to look at whether the drug lithium is effective in preventing suicide attempts among those who have previously made an attempt. VA clinical trials provided much of the evidence that cognitive processing therapy (CPT) and prolonged exposure therapy are effective treatments for PTSD. In 2013, VA researchers demonstrated that Veterans using either therapy not only showed reductions in their PTSD symptoms, but also used VA s mental health services considerably less than in the year before they began therapy. Now, a head-to-head comparison of CPT and prolonged exposure therapy is underway (CSP #591 CERV PTSD) to learn more about which type of therapy is better for a patient. VHA-284 Medical & Prosthetic Research

287 Additional areas of PTSD research include studies of alternative treatments, such as meditation and yoga, and studies to increase the use of evidence-based treatments. Other researchers are working on projects to improve Veterans' access to and engagement in evidence-based PTSD treatments. Large-scale investigations promise additional insight into risk factors for PTSD that could prevent or mitigate onset following traumatic exposure. VA is also studying the use of service dogs for Veterans with PTSD. A multisite study will provide eligible Veterans with either an emotional support dog or a service dog that has been specifically trained to perform tasks that mitigate PTSD. Researchers will look for improvements in participants PTSD symptoms, quality of life, participation in society, and employment status. Another study will examine the impact of dogs adopted from an animal shelter on PTSD symptoms. During the last 18 months, VA and other federal research funding agencies have worked together to address the mental health needs of Veterans through the National Research Action Plan (NRAP), developed in response to President Obama s Executive Order The plan outlines the vision for PTSD, TBI, and suicide prevention research and describes requirements intended to help the agencies successfully reach important research goals over the next few years. One major result of the plan has been the establishment of new research consortia devoted to PTSD and TBI. These consortia were jointly developed by VA and DoD and approved for funding for five years at the beginning of FY The overall funding level is estimated at $107 million from the two departments. PTSD consortium studies focus on potential biomarkers (e.g., indicators that can be determined from a laboratory test) and the use of advanced brain imaging to gain a deeper understanding of the condition. VA also participates in developing cross-agency priority goals for Veterans mental health. These goals, coordinated by the Office of Management and Budget ( will establish common data elements for PTSD and suicide prevention, which will improve the coordination of research efforts across Federal agencies. Earlier efforts produced common data elements for TBI and substance use. Major depressive disorder (MDD) is among the most disabling and widespread of all mental disorders, affecting more than 300,000 VA patients per year. Thousands of Veterans with MDD do not respond adequately to initial treatments. Several second-line treatments are available, but it is unclear which is best. CSP #576 (VAST-D) will evaluate the effectiveness of treatment options for Veterans with MDD who fail to satisfactorily improve with their initial antidepressant and will help providers understand whether switching or augmenting antidepressant treatment is more effective. Schizophrenia and bipolar disorder can cause lifelong disability, resulting in significant burdens on patients and their caregivers. VA scientists are investigating genetic risk factors for these disorders in a large, multisite, observational study (CSP #572) Congressional Submission VHA-285

288 TBI/Neurotrauma/Polytrauma TBI s annual cost to the Nation is estimated to be $76.5 billion. VA researchers are examining screening approaches to detect TBI (which can be difficult in mild cases), looking for biomarkers of mild TBI, and using imaging techniques to evaluate long-term structural and functional changes to the brain after TBI. Researchers are also looking at injury-specific treatments and medications that improve recovery of function. VA is collaborating with the Department of Education and the TBI Model Systems National Data and Statistical Center to develop the Veterans Traumatic Brain Injury Health Registry. The registry will provide military and civilian researchers with data on cases of TBI in Iraq and Afghanistan Veterans. It will also provide longitudinal follow-up of Veterans with diagnoses related to TBI. VA has increased funding for TBI research from $14.5M in 2009 to $36.8M in 2014; the number of VA-funded studies increased from 79 in 2009 to 133 in VA also established a Center of Excellence for TBI in Boston, and other ORD centers conduct interdisciplinary research on TBI. In addition, VA and DoD, as part of the NRAP, have created the Chronic Effects of Neurotrauma Consortium to study the after-effects of mild TBI. VA s neuroscience portfolio supports collaborations focused on standardizing a type of MRI called diffusion tensor imaging to make better use of this technology to track disease progression and treatment efficacy. In 2014, VA funded more than $4.3 million in research related to brain imaging and mapping to better understand the effects of TBI. VA s electronic medical record system reminds clinicians to screen Veterans who have been deployed to Iraq or Afghanistan for mild TBI. Researchers found that VA s TBI screening process, which includes an initial TBI screen and a comprehensive examination for those who screen positive, is inclusive and useful in referring patients for appropriate care. In 2013, an international team including VA researchers discovered chronic traumatic encephalopathy, or CTE, in the brains of four Veterans after their deaths. CTE is a degenerative disease linked to repeated head traumas, such as concussions, and has been identified in the brains of football players who have committed suicide. It is possible that some of the symptoms of PTSD in Veterans are caused by CTE. VA researchers are studying this possible link. Some VA investigators are developing a screening tool for the TBI-related vision problems common among returning Veterans. Others are reviewing best practices for insomnia treatment in Veterans with TBI. Still another effort is evaluating the practice of involving families in clinical decision-making, care plans, and educational efforts for their loved ones with TBI. Investigators are also hoping to increase reintegration of Veterans with TBI into the community by developing and testing the Community Participation through Self-Management Skills Development (COMPASS) program. This program tracks changes in functioning and community participation over time. VHA-286 Medical & Prosthetic Research

289 VA s Polytrauma and Blast-Related Injuries Quality Enhancement Research Initiative (PT/BRI-QUERI) promotes the successful rehabilitation, psychological adjustment, and community reintegration of those who have sustained polytrauma and blast-related injuries. While working closely with VA s polytrauma system of care, PT/BRI-QUERI focuses on all care settings in which Veterans receive services for TBI and polytrauma. Military Sexual Trauma Military Sexual Trauma (MST) is associated with a wide range of physical and mental health conditions among both male and female Veterans. PTSD is the most common condition associated with MST. VA researchers have been assessing VA s MST screening program, determining the impact of MST on mental and physical health, and ascertaining how MST affects women Veterans use of VA care and the quality of care they receive. VA and DoD researchers examined official reporting of sexual assault in the military by both active duty and Reserve and National Guard. Among other findings, the researchers determined that there remain reporting concerns related to confidentiality, adverse treatment by peers, and beliefs that no action will be taken both in restricted and unrestricted reporting in the military. Prosthetics and Sensory Loss The number of Veterans accessing VA health care for prosthetics, sensory aids, and related services has increased by more than 70 percent since VA supports research to improve the lives of all Veterans who require these services. VA s Center of Excellence for Limb Loss Prevention and Prosthetic Engineering in Seattle investigates methods and devices to improve the quality of life and functional status of Veterans who are at risk for or have undergone lower extremity amputation. The Center for Functional Electrical Stimulation in Cleveland investigates functional electrical stimulation, a technique that uses small electrical currents to activate paralyzed muscles. The Center of Excellence in Wheelchairs and Associated Rehabilitation Engineering in Pittsburgh improves the mobility and function of people with disabilities through advanced engineering, and contributed to the design of wheelchairs, seating systems, and other technology. A noteworthy study in this area is the evaluation of an advanced prosthetic arm developed by DEKA Research and Development Corporation through funding from the Defense Advanced Research Projects Agency (DARPA). The DEKA arm was initially tested and refined in a multiyear, multisite, VA-funded study. More than three dozen study volunteers at four VA Medical Centers (VAMC) and one Army facility tested the prototype prosthesis. The study used virtual reality to allow users to practice controlling the arm in a simulated environment before being fitted with it. In the latest phase of this VA-funded research project, participants are bringing home the newest prototype of the arm for three months of use and scientific evaluation, which will 2016 Congressional Submission VHA-287

290 help DEKA engineers further refine the prototype. The VA-DARPA collaboration is the first time large-scale clinical testing has played an integral part in the final design and development of a prosthetic device. The Food and Drug Administration approved the DEKA arm in May 2014, paving the way for commercialization, marketing, and ultimately delivery to Veterans. Other VA research is underway to test if brain-computer systems may one day enable users of robotic arms to control the devices using only their thoughts. The Providence VAMC is one site testing the BrainGate2 system, which is developing better communication interfaces and improved accuracy and consistency of control over robotic and prosthetic limbs for those with limb loss or conditions resulting in paralysis, such as amyotrophic lateral sclerosis (ALS). VA researchers are also looking at how to best match prosthetic components with the needs of amputees, including those with very active lifestyles. They are investigating different wound-care strategies for residual limbs after surgery, and evaluating computed tomography (CT) scans of diabetic feet to identify foot types at highest risk for ulcers. One team is developing a program to teach caregivers complementary and alternative medicine techniques shown to lessen anxiety and pain associated with traumatic limb loss. Hearing loss affects some 28 million Americans and is the number one service-connected disability in the VA health care system. VA researchers, engineers, and clinicians are studying ways to prevent, diagnose, and treat hearing loss. They are also addressing a wide range of technological, medical, rehabilitative, and social issues associated with hearing loss. Much of this work takes place at VA s National Center for Rehabilitative Auditory Research (NCRAR) in Portland, Oregon. In 2010, NCRAR researchers published a management protocol for tinnitus, defined as a ringing, buzzing, or other type of noise that originates in the head. The protocol offered ways for clinicians to help patients with the ailment to self-manage their condition, especially if the condition is causing other health problems, such as depression and anxiety. VA is currently conducting a clinical trial of repetitive transcranial magnetic stimulation (rtms), a means of using magnetic fields to normalize brain activity in the parts of the brain responsible for hearing, to see if it provides relief for those with tinnitus. VA estimates that nearly one million Veterans may be coping with severe visual impairments. In older Veterans, major causes of vision loss include age-related macular degeneration, glaucoma, cataracts, stroke, and diabetes. Among Iraq and Afghanistan Veterans, blast-related brain injuries can be followed by problems such as blurred vision, double vision, sensitivity to light, and difficulty reading. In addition to developing visionrestoring treatments, VA investigators are designing and improving assistive devices for those with visual impairments and developing more accurate and efficient methods of vision testing. VHA-288 Medical & Prosthetic Research

291 New Models for Post-Deployment Care VA issued a solicitation in 2014 for studies to advance understanding of the health care provided to Gulf War Veterans and their long-term health outcomes. These studies will help VA understand Gulf War Veterans experiences of health care in and outside VA and identify promising models for improving care for this cohort. Moreover, insights from the care of Gulf War Veterans will help improve care for all Veterans with deployment-related health problems. Employment/Vocational Rehabilitation One of VA s most important responsibilities is to help disabled Veterans prepare for, find, and keep suitable jobs. Some Veterans with spinal cord injuries (SCI) have taken part in a VA program that provides integrated treatment along with job search help, a focus on competitive employment, and ongoing employment support. Findings from an ongoing study have shown that Veterans with SCI receiving this level of support are 2.4 times more likely to obtain employment, compared with peers receiving usual care. This trial is also examining the cost-effectiveness of such services, and how their level and intensity affects employment outcomes. A few pilot studies have found that Veterans with TBI or PTSD also benefit from supported employment, and researchers are now gathering more data. CSP #589 (VIP STAR), begun in 2013 at several sites, aims to enroll 540 Veterans with PTSD to compare VA s vocational rehabilitation strategies. Researchers are also examining supported employment for Veterans with mental health or substance dependence diagnoses who have felony convictions. Depression has been linked with poorer work outcomes, including unemployment, missing work, and performance limitations. New research is looking at ways to ease depression in Veterans, specifically with an eye toward improving work outcomes. A randomized trial will enroll 250 Veterans with major depression who work at least 15 hours per week. Half of these will take part in the Veterans Work and Health Initiative (V-WHI), which will provide them with counseling sessions focused on addressing employment barriers. The expected outcomes include improved work performance, a decrease in work absenteeism, and improvement in health-related quality of life and depression symptoms. VA Research has also recently approved a study to better understand the experiences of Veterans with moderate to severe TBI as they transition to living in communities. This four-year study will provide a roadmap for designing and testing interventions to maximize community reintegration in employment, independent living, and social relationships. Homelessness VA s homelessness research initiative is developing strategies for identifying and engaging homeless Veterans and ensuring they receive proper housing, a full range of physical and mental health care, and other relevant services. Research focuses on using existing data to better identify and engage Veterans who are currently homeless, and to 2016 Congressional Submission VHA-289

292 develop strategies to identify and intervene with Veterans who are at risk for becoming homeless. Other projects are studying ways to assist homeless Veterans in need of palliative care and to improve care management so that homeless Veterans can maintain safe housing. Primary care is a key priority for homeless Veterans. Chronic diseases typically managed in primary care, such as diabetes, hypertension, and heart disease, are widespread among homeless Veterans and especially challenging to manage in this population. Life expectancy for the homeless is 30 years less than the average for other Americans. Recent studies have shown that primary care for homeless Veterans works best when it is integrated with other VA homeless services. Researchers are now looking at how to accomplish that goal, by assessing the value of incorporating formal peer support from formerly homeless Veterans and testing the outcomes of Homeless Patient Aligned Care Teams (H-PACTs) designed specifically to meet needs of homeless Veterans. Women Veterans are up to four times more likely than civilian women to experience homelessness. VA researchers have found that unemployment was the biggest single risk factor for homelessness among women Veterans. Military sexual trauma is another risk factor for homelessness, and sexual trauma rates differ between women Veterans and non- Veterans. VA is also looking at the special challenges homeless women with children face. Research has shown, for example, that they often place the safety and well-being of their children first, even if it means they may end up homeless and unable to live with their children. Family/Caregiver Issues Caring for an injured, disabled, or ill family member causes emotional, physical, and financial strain on caregivers. The Program of Comprehensive Assistance for VA Family Caregivers provides support for both Veterans and family caregivers, as well as a series of benefits including training and education. Several VA studies are looking at the impact of caregiver education and stress-reduction programs on the health of both Veterans and caregivers. Other studies are focusing on the short- and long-term needs of caregivers, because many of these individuals will be providing care for years. The PT/BRI-QUERI has developed educational and supportive services for caregivers of severely injured Veterans. VA research has partnered with the Veterans Health Administration (VHA) Caregiver Support Program and Social Work Services to establish a Caregiving Support Evaluation Center. The center will measure various aspects of VA s caregiving services, including outcomes of both Veteran and caregiver groups, providing information needed to revise current caregiver programs and plan new ones. Pain Management Safe and effective treatment of pain has become a critical health issue in VA, driven by the high prevalence of musculoskeletal pain in Iraq and Afghanistan Veterans, the variable management of pain in older Veterans with chronic diseases, and concerns about excessive use of opiates and resultant overdose deaths in Veterans with chronic pain. VA VHA-290 Medical & Prosthetic Research

293 has a National Pain Management Strategy to provide a system-wide standard of care to reduce suffering from preventable pain. VA researchers have played an integral role in shaping the strategy, which in turn helps to set the course for VA research and innovation in pain care. As part of this strategy, VA researchers helped establish the VA Stepped Care Model of Pain Management. A recently funded multisite study will evaluate the effects of pain screening and assessment approaches in primary care settings. Researchers are also identifying and helping to address any disparities in Veterans access to opioid therapy, non-medication treatments such as cognitive behavioral and physical therapies, and complementary and alternative approaches to treat or manage pain. In one recently completed study, researchers examined an Internet-mediated, pedometerbased intervention designed to increase walking and improve pain-related function among patients with chronic back pain. Another study is testing a mechanism to expand access to cognitive behavioral therapy through interactive voice response technology that allows patients to report and receive information via their telephone. The treatment may prove to be an option for rural Veterans and others with limited access to care. Other researchers are creating a longitudinal study of Veterans with musculoskeletal diagnoses, to examine pain-management issues that can inform quality-improvement efforts. This study will implement a pain screening and assessment tool that addresses gaps in existing approaches to routine screening for the presence and intensity of pain. VA is represented on the Interagency Pain Research Coordinating Committee (IPRCC), a federal advisory committee created by the Department of Health and Human Services to enhance pain research efforts and promote collaboration across the government. Addictive Disorders Substance abuse disorders such as problem drinking are prevalent among returning Veterans and are often complicated by co-existing disorders such as PTSD, chronic pain, or other mental health problems. Researchers are looking at treatment-seeking patterns: why and when Veterans ask for help, and why many don t. Treatment strategies, including cognitive behavioral strategies and Web-based approaches, are being reviewed. Other researchers are looking at the most effective therapies for Veterans with cooccurring disorders, such as depression and PTSD, and trying to determine if early intervention improves outcomes, and also examining how best to provide treatment for multiple issues (e.g., integrating care or sequencing therapy). Research has documented a higher risk of overdose death among individuals receiving high opioid dosages and multiple opioid prescriptions. VA researchers developed an Opioid Dashboard to track and help reduce the number of patients receiving high-dose prescriptions or multiple opioid prescriptions. At the request of the Office of Ethics, VA Research is soliciting studies to examine the implementation of new informed consent processes for patients being prescribed long-term opiate medications for pain Congressional Submission VHA-291

294 II. Continued Care for the Veteran VA Research s mission is to advance health care for Veterans of all ages, across their entire life span. Beyond immediate post-deployment concerns, VA research invests in studies of chronic diseases, reproductive health, and preventative care to ensure continued high-quality care for Veterans as they age. Cancer VA researchers are conducting a broad array of research on cancers common in the Veteran population. These include prostate, lung, colorectal, bladder, kidney, pancreatic, esophageal, and breast cancer, as well as lymphomas and melanomas. Researchers are conducting lab experiments aimed at discovering the molecular and genetic mechanisms involved in cancer. Researchers also conduct studies looking at the causes of the disease, clinical trials to evaluate new or existing treatments, and research focused on improving end-of-life care, or bolstering caregiver support. One highlight of these efforts is a new study that aims to enroll 50,000 Veterans to compare colorectal cancer screening strategies. Colorectal cancer is among the most preventable of cancers. While colonoscopy is seen as the gold standard for screening, some recent findings raise questions about its effectiveness at preventing colorectal cancer deaths. A cooperative study (CSP #577 - CONFIRM) is comparing the value of screening colonoscopy to annual non-invasive fecal immunochemical testing for the prevention of colorectal cancer deaths over 10 years. Cardiovascular Disease Cardiovascular disease (CVD), which includes heart disease, stroke and other vascular disease, is the leading cause of death for both men and women, Veterans and non- Veterans alike. As a result, VA investigators devote considerable resources toward optimizing treatment for Veterans suffering from heart and other cardiovascular diseases and improving efforts to prevent CVD through better treatment of risk factors such as high blood pressure, obesity, and diabetes. Diabetes Diabetes affects some 26 million people in the United States. Type 2 (adult onset) diabetes affects nearly one in four VA patients. Moreover, diabetes is the leading cause of kidney failure, non-traumatic lower-limb amputations, and new cases of blindness among adults. Up to 80 percent of patients with diabetes will develop macrovascular disease, such as heart attack and stroke. VA researchers are studying innovative strategies and technologies to enhance access to diabetes care and to improve outcomes for patients. They are also working to develop better ways to prevent or treat diabetes, and exploring its relationship to other medical conditions, such as kidney disease, heart disease, and mental illness. Diabetes has a strong genetic basis that is also susceptible to environmental factors. VA researchers are conducting linkage studies to identify genes associated with various diseases, including diabetes. Technological advances now permit investigators to search VHA-292 Medical & Prosthetic Research

295 for common genetic patterns in affected families, or in large groups of individuals who do not have a family history of the disease. Using these approaches, researchers have identified several regions in the human genome that harbor risk for type 1 diabetes and type 2 diabetes. Recently, VA researchers compared diabetes care among Medicare-eligible Veterans who obtained their health care from VA and those receiving care from Medicare s fee-forservices program. They focused on Medicare patients who had ongoing interactions with providers that occurred in the same place with the same medical record. They found reliance on VA care was a stronger predictor of appropriate care than continuous receipt of care from the same non-va provider. Current studies are examining the incidence of pre-diabetes among Veterans in the VA health care system. A QUERI-funded initiative is also evaluating the implementation of a large-scale diabetes prevention program for those at risk of diabetes that involves tailored self-management strategies focused on weight loss, healthy diet, and exercise that could yield significant benefits for the VA population overall. Women s Health Recognizing the dramatic increase in the number of women Veterans, VA Research established the Women s Health Research Network to accelerate research that addresses needs of women Veterans. This innovative network is building capacity to develop research that will benefit women Veterans of all ages, including studies on women s health during and after deployment, reproductive health, primary care, and prevention. The network also fosters large multisite studies through a group of 37 VA Medical Centers that work together to facilitate research-clinical partnerships. The overall goal is to develop, test, implement, and disseminate effective innovations in care. In 2014, VA researchers published studies on women Veterans reproductive health issues, the use of VA maternity benefits, and infertility rates. New research has also been published on lifetime major depression among women Veterans and intimate partner violence. Yet other newly published studies describe access to VA care among women Veterans in rural areas, and the implications of changes in DoD policy on women Veterans exposure to combat and their disclosure of sexual minority status. VA research is also examining satisfaction with VA care and potential gender disparities, and is continuing to explore gender differences in post-deployment health and reintegration. Gulf War Veterans Some Gulf War Veterans are affected by a debilitating cluster of medically unexplained chronic symptoms that may include fatigue, headaches, joint pain, indigestion, insomnia, dizziness, respiratory disorders, and memory problems referred to by VA as chronic multisymptom illness (CMI). VA researchers are dedicated to learning more about these problems and identifying the best ways to diagnose and treat them. VA contracted with the National Academy of Sciences Institute of Medicine (IOM) to develop a consensus case definition for chronic multisymptom illness in Gulf 2016 Congressional Submission VHA-293

296 War Veterans. A number of different case definitions for chronic multisymptom illness are currently in use, making it difficult to compare the results from different studies. A consensus definition will help research move forward. IOM completed their report and briefed VA in March 2014 with recommendations for which case definitions to use. Two new studies that may benefit this cohort involve functional magnetic resonance imaging of the brains of Gulf War Veterans. One study is designed to understand the mechanism of cognitive fatigue by giving memory tests to patients while the images are being collected. The other will examine patients with cognitive difficulties who might have been exposed to nerve agents in Iraq and compare their brain images with those from Gulf War Veterans who are unlikely to have been exposed. In other work, researchers are studying blood plasma in mice in the hopes of discovering biomarkers that could ultimately be useful for diagnosing Gulf War Veterans with chronic multisymptom illness. Other projects involving animal models will address brain changes related to free radicals, therapies that target nerve tissue in the brain, and paternal reproductive risks. In addition to these basic studies, two new treatments for ill Gulf War Veterans are being tested. In the first, a neurosteroid called pregnenolone will be given to a group of these Veterans to treat their pain, cognitive symptoms, and fatigue. A control group of study volunteers will receive a placebo. In another treatment trial, duloxetine and pregabalin will be used to treat chronic pain. These drugs are currently used to treat fibromyalgia, a condition with many of the same symptoms displayed by Gulf War Veterans. The drugs will also be evaluated for their efficacy in treating fatigue, sleep problems, and mood disorders. VA s Gulf War Registry program, which began in August 1992, offers a health examination at any VA health care facility to any Veteran with Gulf War service. As of June 2014, about 140,000 Gulf War Veterans had undergone a registry exam, allowing their health concerns to be evaluated by VA physicians, and enabling them to be referred for additional care when needed. Since 2001, VA s War-Related Illness and Injury Study Centers (WRIISC) have used information from the registry and other data to support specialized care for Gulf War Veterans, and to conduct cutting-edge research and treatment programs specifically tailored to their needs. VA is also creating and using research infrastructure in support of a range of epidemiologic and clinical studies. One example is the establishment of the Gulf War Era Cohort and Biorepository (CSP #585). Through this new project, epidemiological, survey, clinical, and environmental exposure data, along with blood specimens, will be collected to enable studies of conditions common among these Veterans. CSP #585 is currently identifying best approaches to engaging Veterans and building the structure for a largescale effort. A complementary effort, the Gulf War Veterans Illnesses Biorepository, will collect and store brain and spinal cord tissue for the future study of neurological diseases. This project is also in its pilot phase and is recruiting participants now. Both these efforts VHA-294 Medical & Prosthetic Research

297 will work collaboratively with the Million Veteran Program, which is designed to identify relationships between reported illnesses and genetic variations. Amyotrophic Lateral Sclerosis Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig s disease, is a progressive neurodegenerative disease that affects the central nervous system, specifically the brain and spinal cord. Researchers are studying environmental, toxic, traumatic medical, genetic, and occupational influences as possible contributors to the development of this disease. ALS is almost twice as prevalent among Veterans who were deployed to the Persian Gulf region in 1990 and 1991, compared with non-deployed Gulf War-era troops. Several current research projects focus on improving quality of life for Veterans with ALS. The data from CSP #567, A Clinical Demonstration of an EEG Brain-Computer Interface for ALS Patients, are being analyzed and results should be available in The long-term goal of another study, titled Feasibility of the BrainGate System for Veterans with ALS, supported in part by VA, is to create a system that turns thoughts into actions to help Veterans with ALS communicate and do things for themselves. Other studies and resources are aimed at determining the causes of ALS so that treatments can be developed. VA s Biorepository Brain Bank collects, processes, stores, and distributes specimens for future research studies. The Brain Bank accepts after-death neurologic tissue donations from Veterans with ALS and collected specimens are made available to qualified investigators. Additionally, more than 600 blood samples from a registry of Veterans with ALS will be analyzed to hunt for genetic mutations that contribute to the disease. Complementary and Alternative Medicine A growing number of VAMCs are offering complementary and alternative (CAM) therapies to their patients, including yoga, acupuncture and meditation training. VA researchers are committed to filling in scientific gaps relating to these treatments to determine which CAM therapies are truly effective, and for which conditions and populations. Studies cover a range of common and promising therapies across a range of mental and physical health problems. VA is also collaborating with the NIH to support studies on effective nonpharmacological approaches to pain and symptom management in Veterans with comorbid physical and mental conditions. This effort will provide a better understanding of how complementary approaches can be effectively integrated with regular care. One study is examining the feasibility of conducting a trauma-sensitive hatha yoga intervention in female Veterans with military sexual trauma and PTSD. Early findings showed that yoga may be acceptable to and preferred by many participants as an alternative to trauma-focused psychotherapy. Two other randomized controlled trials are underway to test mindfulness-based therapies: one targets suicidal thoughts, the other looks at reducing the risk of cardiovascular disease in women. Two additional PTSD studies are looking at the effectiveness of Mindfulness-Based Stress Reduction Congressional Submission VHA-295

298 Preventive Care and Health Promotion Multiple Risk Factor Behavior Change Interventions The major causes of complex chronic illness among Veterans such as heart disease, diabetes, and cancer are associated with multifactorial behavioral risks (e.g., smoking, diet, physical activity). VA conducts research to reduce multiple health risks through behavior change interventions that focus on common clinical objectives. These innovative programs incorporate Veterans social networks, including spouses and peer coaches, and employ the Veterans personal health record and online tool kits. Smoking Cessation Veterans smoke cigarettes at higher rates than their civilian counterparts. VA researchers are working to find a specific nicotine receptor in the brain that plays a key role in certain cravings and then develop a medicine that delivers a targeted strike against those cravings. VA has also used the online virtual world Second Life, combined with traditional treatments and psychotherapy, to improve quit rates and get Veterans to smoke less. Transcranial magnetic stimulation, a treatment program involving the application of an electromagnetic field to specific areas of the brain, is also being investigated. Peer Support Following up on a promising pilot study, researchers at VA s Center for Health Equity Research and Promotion (CHERP) are conducting a trial of peer mentors to help Veterans control their diabetes. The study will compare the impact of peer mentoring versus usual care on blood sugar levels, blood pressure, cholesterol levels, quality of life, and depression. Other innovative peer support studies have involved the National Guard, notably the QUERI-funded Buddy to Buddy program that is focused on enhancing access to mental health and support services for returning Veterans, as well as a recent initiative to combine peer support with Web-based cognitive behavioral therapy programs to improve mental health outcomes among Veterans. A VA study published in 2013 found that maintaining the social support of military peers after active duty is associated with better physical health among women Veterans, regardless of whether or not they have PTSD. Obesity More than seven in 10 Veterans who receive VA care are either overweight or obese. VA research on obesity looks at the biological processes of weight gain and weight loss, compares the safety and effectiveness of obesity treatments, and identifies ways to help Veterans stay at their optimal weight. VA MOVE! programs throughout the Nation help Veterans adopt positive lifestyle changes and develop weight-management skills. VA researchers recently studied weightloss outcomes among 120 Veterans to see if these classes can be delivered effectively via telehealth. The study found that those who took part in a series of 12 classes via video teleconference lost weight, while those who took neither video nor in-person classes VHA-296 Medical & Prosthetic Research

299 gained weight. The average weight difference between the groups was about 12 pounds, and the MOVE! participants kept their weight off a year after their weight was first measured. Another research team found that self-monitoring of diet and physical activity is associated with weight-loss success, and can be performed conveniently using handheld devices. Immunization In the United States, vaccines have greatly reduced or eliminated many infectious diseases. However, the viruses and bacteria that cause vaccine-preventable disease and death still exist and can be passed on to people who are not protected by vaccines. VA invests in research on the development of new or improved vaccines to prevent and treat diseases, and on strategies to optimize vaccine use among Veterans. VA research is responsible for several notable developments in immunization, including development of the shingles vaccine, which is now widely available to Veterans and U.S. adults in general. One recent study found that VA patients are more likely than the general population to be vaccinated for seasonal influenza and the H1N1 (swine flu) virus. Another found that VA facilities that care for Veterans with spinal cord injury may need additional expert guidance to ensure effective influenza infection control among these patients and their caregivers. Chronic Pain VA s Center for Restoration of Nervous System Function focuses on neuropathic pain due to traumatic nerve injury, traumatic limb amputation, burn injury, and peripheral neuropathy. Studies are shedding light on variations in how Veterans with nerve injuries experience severe neuropathic pain, and how they respond to pain treatments. Researchers at VA s Center of Innovation (COIN) on Pain Research, Informatics, Multimorbidities and Education (PRIME) study the interactions between pain and behavioral health factors. PRIME s projects are exploring a variety of technologies, including interactive voice response, the Internet, smartphone applications, and video conferencing, as potential tools for pain management. The aim is to develop and enact approaches that are individualized and patient-centered. Osteoarthritis (OA) is one of the most common causes of pain and disability among Veterans. A recently completed study showed the effectiveness of a combined intervention for patients and providers for improving multiple OA-related outcomes, such as pain, stiffness, and function. The intervention involved exercise, weight management, and cognitive behavioral pain management for patients, and customized guidelines for providers. It is low-cost and can be disseminated widely in the VA. Another study of musculoskeletal spine pain (including neck pain and low back pain) found that patients who received physical medicine services during the first 30 days of treatment were significantly more likely to recover than those who did not receive such services Congressional Submission VHA-297

300 III. Care for the Golden Veteran VA researchers are pursuing new treatments, care models, and preventive strategies to improve aging Veterans quality of life, and to support their caregivers. Aging Working with the National Institute on Aging, VA is gathering a Veteran cohort from the NIH-funded longitudinal Health Retirement Study (HRS). VA health data will be merged with information that has been provided to the HRS over the years to answer key questions about the health and well-being of Veterans, including those who do not use VA for care. The data will include information about income, work, assets, pension plans, health insurance, disability, physical health and functioning, cognitive functioning, and health care expenditures. These data will be available to qualified researchers in Neurodegenerative Disease Alzheimer s disease Alzheimer s disease is a progressive, degenerative brain disease with no known cure. It is the most common cause of dementia, and eventually leads to death. Dementia is a prevalent chronic condition in Veterans treated by VA. The Department projects that roughly 218,000 Veterans will be diagnosed with dementia in 2017, an increase of more than 40,000 such diagnoses from In patients with Alzheimer s disease, a protein called beta amyloid clumps up and forms hard plaques between neurons in the brain. Until recently, these amyloid clumps could be seen only after a patient died and underwent an autopsy, when brain tissue could be sliced and viewed under a microscope. VA researchers associated with the Alzheimer s Disease Neurological Initiative (ADNI) are developing new tests to determine beta amyloid levels in the body, and several such tests are already in use in clinical trials. The goal is to enable early detection, which will become more important as new treatments become available. ADNI is led by a VA researcher and funded mainly by the National Institute on Aging. VA's Cooperative Studies Program recently completed a trial of vitamin E and the drug memantine for Veterans with mild to moderate Alzheimer's disease (CSP #546 TEAM- AD). Findings published in JAMA indicated individuals taking Vitamin E had slower cognitive decline than those who took placebos. Because of the decline of cognitive function that occurs in Alzheimer s disease, patients eventually need care either part-time or around the clock for the rest of their lives. Research is essential to provide caregivers of dementia patients with the resources, tools, and emotional support they need so they can better manage their caregiving experience, and continue to provide care for Veterans. VA offers a program for caregivers called Resources for Enhancing Alzheimer s Caregiver Health in VA (REACH VA). The project provides caregivers for Veterans with Alzheimer s with 12 individual in-home and telephone counseling sessions, and five VHA-298 Medical & Prosthetic Research

301 telephone support group sessions. Caregivers are also given a quick guide covering 48 behavioral and stress topics, plus education on safety and patient behavior management, and training for their individual health and well-being. VA research has documented the effectiveness of the program, which has been expanded to address other conditions, such as spinal cord injury and TBI. VA researchers have also created an online education and support program for caregivers of Veterans with Alzheimer s disease. It includes a website, streaming videos, online education, and discussion forum. Previous studies have suggested that such education and support may not only benefit caregivers but also lessen negative behaviors on the part of those with Alzheimer s. Parkinson s Disease In 2001, VA created six specialized centers known as the Parkinson s Disease (PD) Research, Education, and Clinical Centers (PADRECCs). These centers of excellence serve the estimated 60,000 Veterans affected by PD through research, clinical care, education, outreach, and advocacy. In 2012, VA researchers published the results of a 36-month VA cooperative study (CSP #468) of 159 patients that found patients with Parkinson s disease who undergo deep brain stimulation (DBS) a treatment in which a pacemaker-like device sends pulses to electrodes in the brain can expect stable improvement in their muscle symptoms for at least three years. The trial, based at the PADRECCs and conducted in collaboration with the National Institute of Neurological Disorders and Stroke, resulted in some of the strongest evidence to date worldwide on the pros and cons of DBS. A longer-term followup study is underway. Research has shown that people with PD can benefit greatly from exercise. Not only do exercise programs improve motor function and reduce the risk of falls, but they also improve overall quality of life and may slow the course of the disease. However, exercise programs that involve supervision in the home are expensive, and programs that require travel to a central site often result in non-compliance over time because of difficulty getting to the site, or they may simply exclude those who live too far away. A VA research team is evaluating a safe, home-based exercise program for people with PD, in the hope it can eventually be implemented on a wide scale to help affected Veterans. The program focuses on remote, real-time instruction utilizing smartphone technology. Studying Long-Term Health Outcomes VA s three Epidemiology Research and Information Centers design and conduct longterm studies that track risk factors and health outcomes as Veterans age. In one such study, CSP #569, investigators are assessing the prevalence of PTSD and other mental and physical health conditions for Vietnam-era Veterans and exploring the relationship between PTSD and other conditions. VA has invited about 10,000 members of the Vietnam Era Twin Registry to participate, in hopes of understanding the impact of wartime deployment on health and mental health outcomes nearly 40 years later. (The 2016 Congressional Submission VHA-299

302 registry consists of approximately 7,000 middle-aged male-male twin pairs who served during the Vietnam War.) Diseases Prevalent in the Elderly Stroke Stroke is a common and costly problem in the Veteran population. Some 6,500 Veterans are hospitalized in VA with an acute ischemic stroke every year. VA is now developing a comprehensive system to provide optimal acute stroke care to all eligible Veterans. Little is known about transitions in care that occur in the post-stroke period for Veterans who survive strokes. VA researchers are examining care trajectories and associated cost and use of care after discharge for VA stroke patients. This will inform our understanding of health care following hospitalization for ischemic stroke. The results will also teach us more about how rehabilitation or other interventions improve post-stroke outcomes. Heart Failure Among Veterans, heart failure is the most frequent cause for hospital admission and one of the most frequent causes of unplanned hospital readmission. More than 90 percent of Veterans with congestive heart failure are discharged on guideline-recommended medications, yet many do not receive optimal doses. The optimal dose of these medications (especially beta blockers) has been shown to improve cardiovascular outcomes. A new project that leverages natural language processing will provide key clinical data to Patient-Aligned Care Team (PACT) members during outpatient visits to support timely, guideline-based use of beta-blockers at the point of care. The end goal is to reduce patient readmissions and boost overall patient outcomes. Additionally, a newly approved study (CSP #592) will study whether implantable cardioverter defibrillators can prevent heart failure in the elderly. A recent QUERI-funded initiative evaluated the Hospital to Home (H2H) coordinated care program for Veterans with heart failure, which resulted in reduced hospital days over time. Subsequently, the Heart Failure Network of VA providers was established to more rapidly translate effective heart failure programs into clinical practice. Another recent study demonstrated that a nurse-led intervention also resulted in fewer readmissions compared to usual care, and emerging research is focused on using peer support to further enhance the care of these individuals. Palliative and End-of-Life Care At life's end, most people experience physical suffering, as well as significant emotional, spiritual, and social distress. During this time, appropriate palliative care treatment plans can improve the quality of end-of-life care. The recently completed "Best Practices for End-of-Life Care for Our Nations' Veterans" (BEACON) trial was a multicenter trial to improve the quality of end-of-life care in VAMCs. It consisted of preparatory site visits, a staff training program, a newly VHA-300 Medical & Prosthetic Research

303 developed comfort care order (a decision-support tool), and follow-up consultation. This intervention has led to statistically significant changes in several processes of care. Among the homeless, mean age at death ranges from 34 to 47 years. VA research seeks to improve care and extend life for homeless Veterans. Additionally, a recently funded project is studying unmet need for palliative care among homeless Veterans, and the barriers and facilitators to providing them excellent end-of-life care. Most older Veterans and their surrogate decision-makers will eventually face complex, ongoing decisions in connection with the Veterans chronic illnesses. A team of researchers has developed an easy-to-use, culturally appropriate preparation guide called PREPARE. It is designed to teach Veterans how to choose a surrogate and discuss surrogate decision-making, clarify personal values for specific health states, and ask clinicians questions to make informed choices. The researchers are conducting a randomized control trial to determine PREPARE s impact. Long-Term Care and Health Outcomes Prompted by the rising costs of institutional care and the preferences of most Veterans who require these services to remain in the community, VA long-term-care services have been shifting from institutional to community-based care. VA Geriatrics and Extended Care (GEC) staff has promoted cultural transformation in VA nursing homes, renaming them VA Community Living Centers (CLCs), issuing a handbook for culture change implementation, and emphasizing short-stay rehabilitative care over long-stay custodial care. Several projects aim to bolster workplace learning systems in VA CLCs by studying the transfer of learning to practice, and developing and implementing a toolkit for measuring and promoting CLC cultural transformation. A study is examining changes in the length of stay at CLCs over time, and looking at factors associated with shortened length of stay and successful discharge to the community. GEC leadership will use the results of this study to refine CLC policies, particularly in crafting incentives to adopt effective practices. IV. Ensuring Access and High-Quality Care/Special Initiatives Ensuring access to timely and high-quality care is one of VA s highest priorities. VA Research works to identify and evaluate innovative strategies that can improve access and quality, especially for those Veterans that may face barriers to such care (for example, rural Veterans or racial or ethnic minorities). Access to Care/Rural Health Many Veterans who rely on VA for health care live in remote areas. VA researchers have been instrumental in understanding these Veterans health care needs and developing and evaluating new initiatives to fill gaps in care. These efforts include defining and understanding Veteran preferences and perceptions of access and barriers to care, developing new models for providing access to specialty care, and advancing telehealth innovations Congressional Submission VHA-301

304 Researchers have been examining and exploring ways to reduce wait times and improve scheduling for rural Veterans. One such study has examined no-shows for scheduled colonoscopy appointments and found that certain patient variables predict a missed appointment. The study suggested improved ways of scheduling to increase efficiency. Another study is using innovative methods and predictive modeling techniques to schedule patients in operating rooms. The approach is being compared to traditional methods of scheduling to see if patient satisfaction and surgical outcomes improve. Four recently funded studies regarding mental health care for rural Veterans include: developing a patient-centered survey to measure Veterans' perceived access to mental health services; testing interventions to increase engagement in mental health care at VA community-based outpatient clinics (CBOCs); testing clinical and technology interventions to improve quality and outcomes of mental health care at CBOCs; and testing Web-based interventions and evidence-based training to enhance access to PTSD care for women Veterans and Veterans using CBOCs. Other recently funded studies aim to improve access and outcomes for rural Veterans, including those with HIV, depression, or diabetes. Another study will compare PTSD care utilization patterns among Iraq and Afghanistan Veterans with PTSD and identify individual- and community-level factors associated with choosing VA or non-va care settings. Researchers conducting a study at 22 VA CBOCs found that implementing telemedicinebased collaborative care in small rural clinics that lack on-site psychiatrists and psychologists increases the percentage of Veterans who take the medications they are prescribed, and improves treatment response rates. In another analysis, researchers found Veterans with prostate cancer who live in rural settings have less access to comprehensive cancer resources than do Veterans living in urban settings. Also, on average, those in rural areas have to travel five times further for care. However, despite these differences in access, rural patients received similar or better quality of care on four of five measures, and the time between diagnosis and the initiation of treatment was similar for rural and urban Veterans. Next Generation of Quality Performance Measures Clinical quality performance measures are often criticized for failing to take into account individual patient factors, such as age, health status, lifestyle, values, and goals. VA studies have identified the potential harms of one-size-fits-all performance measures in cancer screening, blood pressure treatment, and diabetes management. VA Health Services Research and Development recently worked with the VA Office of Clinical Analytics and Reporting in a virtual state-of-the-art conference to speed progress toward performance measures that are more effective and patient-centered. These efforts identified the need for research in four areas: making measures more personalized; incorporating patient preferences; measuring and promoting value through performance measurement; and implementing performance measurement strategies. VHA-302 Medical & Prosthetic Research

305 VA has funded related work on innovative performance measurement systems to provide feedback to VA clinicians, such as an automated approach to improve the quality of care for complex chronic disease and heart failure, and a program to streamline overly complex clinical performance information. Improving Patient Safety VA Research emphasizes improving patient safety and health care quality. Research has documented how electronic health records, and proliferation of electronic reminders, may actually contribute to errors. One study is using data from the electronic medical record to develop an automated surveillance tool to improve the diagnosis and care of five common cancers in primary care practice. This tool will determine the value of automated interventions in identifying and reducing cancer-related diagnostic delays. Other studies are examining how information can be extracted from the medical record to support more appropriate use of antibiotics to reduce drug-resistant infections. Patient-Aligned Care Teams Patient-Aligned Care Teams (PACTs) are transforming how primary care is delivered in VA. These integrated teams aim to deliver care that is patient-driven, team-based, comprehensive, and coordinated. Researchers in a number of studies have examined the implementation and results of such care on Veteran outcomes. One such study evaluated the impacts of the PACT model on quality of care and determined which elements were most effective. Other studies have examined how to apply the model to specialty care settings. This work is ongoing. Dual or Multiple Use of Health Systems Approximately three-quarters of Veterans enrolled in VA also have another form of health coverage. While this raises the possibility of better, more comprehensive care, it could also lead to incomplete communication among providers; duplicative, competing, or incomplete diagnosis and treatment plans; and unnecessarily high costs. Much remains to be learned about the scope of multisystem health care use, its impact on the quality and efficiency of patient care, and the extent of the extra costs. A recent call for studies has been issued to assess the scope and quality of information exchanged between VA and non-va health care providers; the level of patient-care coordination between these providers; the level of health benefit coordination between VA and Medicare; and the level of satisfaction among VA patients, and among VA and non-va providers. Connected Health The prevalence of high-speed Internet access and mobile technologies give Veterans multiple options for connecting with their VA health care team. VA researchers have led the way in exploring how care can be enhanced by use of the telephone, Internet, videoconferencing, , and text messaging. Researchers have conducted a number of studies comparing the use of these technologies to standard care. The ehealth Quality Enhancement Research Initiative is studying how to enhance and increase the use of secure messaging and other Veteran-facing technologies Congressional Submission VHA-303

306 Among key findings on connected health that were reported in 2014: VA is learning to successfully cope with a nationwide shortage of intensive-care physicians through the use of tele-intensive care services. Innovations including team-based telehealth collaborative care for patients with HIV; collaboration with local health systems, including campus health services; and home-based cardiac rehabilitation can all bring a broad range of health services closer to Veterans homes. Smartphone applications can deliver or augment provider-delivered, evidencebased psychotherapies, as can other connected-health methods. Genomic Medicine/Million Veteran Program Genomic medicine uses information on a patient s genetic make-up to tailor prevention and treatment for that individual. VA s Million Veteran Program (MVP) is a national, voluntary research program to better understand how genes, lifestyle, and military exposures affect health. Genetic information from Veteran volunteers is linked to information from VA s electronic health records and surveys. The goal of the program is to understand the relationship between genes, environment, and health and to use that information to benefit Veterans. Veterans who are users of VA s health care system are invited by mail to join MVP. Those interested complete and mail a short survey related to their health, military service, and family history. They then go to a scheduled, one-time study visit, where they complete the informed consent process, discuss any questions they may have, and provide a small blood sample. They also receive a longer, optional survey that contains detailed questions about their military exposures and lifestyle. Veterans may also enroll in the program at their local VAMC, or call the MVP information center for more information. MVP, with more than 336,900 enrolled Veterans, is now the largest genetic cohort in North America. Many studies in the near future will use MVP samples and data to help answer pressing questions about physical and mental health conditions affecting Veterans. One study already underway is examining how genomic information is integrated into colorectal cancer care within VHA, particularly for a hereditary form of the disease. MVP will also soon provide samples for the purpose of examining risk for PTSD. This cutting-edge research program highlights the need for genomics education among VA's health care professionals, especially VA nurses who comprise over 70 percent of the VHA workforce. In collaboration with the VA Office of Nursing Services and the VA Employee Education System, MVP staff developed a series of five educational modules that became available to all VA nurses in June Infrastructure The physical condition of VA s research facilities is an important factor in recruiting and retaining world-class researchers. Since more than 60 percent of VA researchers are also clinicians taking care of patients, recruiting and retaining high-caliber researchers is essential to patient care. VHA-304 Medical & Prosthetic Research

307 In 2006, Congress directed VA to undertake a comprehensive review of its research facilities, and to report deficiencies and provide recommendations for correcting them. In response, VA conducted a detailed review of the physical structures housing research laboratories and support spaces, as well as plumbing, mechanical, electrical, and fireprotection systems supporting research spaces. The 2010 report, based on an assessment of 74 sites, indicated a widespread need for repairs and improvements, estimated to cost $774 million (in 2010 dollars). VA has since corrected many of the deficiencies and has increased funding for this purpose. New research space is also being constructed at several sites. Phase II of the modernization project, expected to be completed in 2015, will reassess research space at 25 stations to determine the effect of recent improvements. In addition, approximately 15 additional stations are expected to receive administrative follow-up visits. The infrastructure program will thus continue to support state-of-the art research laboratories Comparative Effectiveness Research Comparative effective research helps to shape the evidence base that providers and patients rely on to choose the best treatment strategies. VA s Comparative Effectiveness Research (CER) program is unique because it is embedded within a national health system. VA has the resources to support large, rigorous, well-designed multicenter clinical trials that provide solid evidence to guide treatment. A major part of VA s CER effort is the Cooperative Studies Program (CSP). As highlighted throughout this document, CSP provides a platform to collaboratively address comparative effectiveness research questions on a large scale. CSP sponsors, develops, and executes multisite clinical trials, epidemiological and population research, and genomic research. One particularly influential VA CER study was the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial. Published in 2007, the trial showed that the majority of patients with optimal medical therapy had substantial improvements in their health status for more than four years, meaning that patients with stable angina did not need to have stents implanted. The study has been widely cited in the medical literature and has influenced practice not only in VA, but worldwide. Reducing Research Cycle Time A preliminary review of 121 VA health services research studies funded from 2006 through 2009 found that on average, it takes more than six years between the time a study is funded and when its findings are published. VA Research is expanding methods for moving promising ideas forward, such as providing pilot funding so that researchers can begin collecting preliminary data while finalizing their proposals. VA also offers sequential funding when timing is critical, funding the first phase of data collection with an implicit promise to fund subsequent research phases if the initial data address Veterans needs. VA uses a service directed 2016 Congressional Submission VHA-305

308 research mechanism, helping reviewers to work with applicants to ensure that proposals are written in a scientifically sound and fundable format. In clinical trials research, VA is promoting adaptive designs to allow researchers to adjust sample size and other elements in response to data accumulated during the trial itself. VA hopes this approach may also serve health services researchers, who may hesitate to study rapidly changing processes or models. VA is also examining ways to streamline approvals for research studies that pose only very minimal risk to participants. For example, studies collecting data on patient preferences and satisfaction with new processes pose virtually no risk to patients, as opposed to studies of new health care interventions. VA is considering ways to fast track such low-risk research and expedite reviews in these cases. Network of Dedicated Enrollment Sites A recent enhancement to the Cooperative Studies Program is VA s Network of Dedicated Enrollment Sites (NODES), a consortium of VAMCs that have teams, or nodes, in place to optimize the conduct of CSP studies. NODES sites share best practices and provide local insights on quality study design and management. Each node will also create a stronger local community of clinicians and Veterans involved in research. A recent report in JAMA Surgery highlighted this innovation as a promising approach to increase the efficiency of clinical trials both in and outside VA. COIN, CREATE, and Partnered Research The Collaborative Research to Enhance Transformation and Excellence (CREATE) initiative encourages closer collaboration between Health Service Research and Development investigators and others in VHA on high-priority issues. CREATE is defined by a group of coordinated research projects conducted by collaborating investigators and their VHA partners. Each individual project is scientifically meritorious in its own right and addresses a distinct area, but all the projects within a CREATE complement each other and build synergy. The program is designed to accelerate the pace of VA research in critical areas, promote more effective partnerships between research and VA health systems, enhance research collaborations, and speed the implementation of findings. CREATE projects target critical areas of interest to Veterans, including PTSD, long-term care, women s health, pain management, patient-aligned care teams, prevention, value, access, quality and safety, mental health, and substance use disorders. VA s Center of Innovation (COIN) initiative further promotes innovative research and facilitates collaboration across multidisciplinary research teams. The mission of the COIN program is to engage VA s clinical and operations partners, and to increase the impact of health services research on specific areas of central importance to the health and health care of Veterans. Nineteen COINs have been funded to address research on VA priorities such as health equity, rural health, primary care, quality, pain, long-term care, and disability and rehabilitation research. The initiative also facilitates partnerships between research and those who implement VA research findings. VHA-306 Medical & Prosthetic Research

309 QUERI The mission of VA s Quality Enhancement Research Initiative (QUERI) is to improve Veterans health care by studying and facilitating the adoption of new treatments, tests, and models of care into routine clinical practice. Each of QUERI s 10 centers focuses on a disease or condition that is common among Veterans, such as heart disease, mental health, substance abuse, and polytrauma. In collaboration with VA s Central Office, Veterans Integrated Service Networks, and individual VAMCs, QUERI centers conduct a diverse portfolio of implementation and research projects in their respective area of expertise. The ultimate goal is to improve Veterans outcomes and promote cost-effective care. QUERI also supports four Evidence-based Synthesis Program (ESP) Centers, located at the West LA, Durham, Minneapolis, and Portland VAMCs. These centers generate evidence syntheses on health care topics of particular importance to Veterans. In 2013, ESP, released 17 new systematic reviews and ongoing reviews on topics including interventions for hospital readmissions, CAM therapies, online self-help programs for alcohol misuse, and screening for hepatocellular cancer in chronic liver disease VA s Office of Nursing Services has partnered with QUERI to form two evaluation centers to improve access to and quality of nursing-related services. Each center is evaluating nursing-specific strategic initiatives around staffing methodology and hospitalacquired pressure ulcers. QUERI has established similar partnered evaluation centers with three VA offices: Specialty Care; Patient Centered Care and Cultural Transformations; and Social Work and Caregiving. Health Informatics and Big Data The Health Information Technology (HIT) landscape is changing rapidly as a result of increased computing power, changing computer platforms, and new expectations on the part of patients, providers, and other stakeholders. To capitalize on this digital environment, Health Services Research and Development invests significant resources in supporting health care informatics and Big Data research. A critical foundation to HIT research is the Veterans Informatics and Computing Infrastructure (VINCI). Funded by VA Research and the Office of Information and Technology, VINCI provides a high-performance computing environment and access to comprehensive VHA data. This infrastructure supports researchers access to national data on the entire VA population and facilitates the creation of sophisticated analytic tools, which are transformed into robust research products to address a broad array of issues. Research has supported development of tools that use natural language processing techniques to extract data from unstructured data such as radiology and microbiology reports so that they can be analyzed more efficiently for research or clinical care. A recently funded group of five projects, Improving Therapeutic Decision-Making through Veteran-Centered Population Analytics, seeks to use population informatics methods and tools to make VA medication management data accessible to clinical 2016 Congressional Submission VHA-307

310 providers. The projects within this program will leverage data within the EHR and administrative records to help improve diagnosis and prescribing. Technology Transfer Program VA researchers have invented many notable new drugs and technologies. But these inventions have little value unless they are made available to those who would be helped by them. VA s Technology Transfer Program (TTP) works to protect intellectual property developed at the Department. The program finds private industry partners willing to invest in the new technology and conduct further development and commercialization activities. One example of such successful development efforts is a new device for measuring oxygen saturation in the blood. It was invented and developed by a VA researcher in Pittsburgh. TTP patented the device and found a company willing to work with VA to test the device under a Cooperative Research and Development Agreement. After the study, the technology will be ready for commercialization. A second example involves a new tissue preservation solution formulated by VA scientists, to be used for the stabilization of veins and arteries in coronary bypass surgeries or other procedures. VA has licensed the technology and the company is conducting clinical trials required for FDA approval. Public Access to Research Data A White House directive in February 2013 required VA to develop plans to make the published results of its research freely available to the public within one year of publication. VA has begun work on a new policy to ensure that peer-reviewed full-text articles resulting from ORD-funded research are available to the public through PubMed Central, a National Library of Medicine database. Additionally, pilot work has begun to establish requirements, procedures, and policies for enabling broader access to study data. VA Research has always encouraged and promoted the free exchange of scientific and medical information. Investigators are expected to report their results at professional meetings and in scientific and medical journals. Those results will now be more accessible to the general public. Designated Research Areas Designated Research Areas (DRA) represent areas of particular importance to our Veteran patient population. The methodology for calculating the table has been modified so that VA is consistent with other Federal research agencies. Previous reports of DRA projects counted each project in only one category. The table has been adjusted such that the amounts shown for these research areas are not mutually exclusive. Research projects that span multiple areas may be counted in several categories. Thus, amounts depicted within this table total to more than the VA research appropriation and accurately reflect amounts by DRA. VHA-308 Medical & Prosthetic Research

311 Description Amounts by Designated Research Areas (dollars in thousands) 2014 Estimate Budget Estimate* Current Estimate 2016 Request Inc/Dec Acute & Traumatic Injury... $20,197 $20,606 $20,298 $21,313 $1,015 Aging... $146,125 $39,808 $146,856 $154,199 $7,343 Autoimmune, Allergic & Hematopoietic Disorders... $27,561 $13,441 $27,699 $29,084 $1,385 Cancer... $54,757 $51,699 $55,031 $57,783 $2,752 CNS Injury & Associated Disorders... $88,598 $48,693 $89,041 $93,493 $4,452 Degenerative Diseases of Bones & Joints... $30,092 $19,934 $30,242 $31,754 $1,512 Dementia & Neuronal Degeneration... $24,714 $26,243 $24,838 $26,080 $1,242 Diabetes & Major Complications... $34,835 $32,652 $35,009 $36,759 $1,750 Digestive Diseases... $20,577 $14,931 $20,680 $21,714 $1,034 Emerging Pathogens/Bio-Terrorism... $954 $520 $959 $1,007 $48 Gulf War Veterans Illness... $8,549 $15,000 $9,528 $15,000 $5,472 Health Systems... $62,156 $43,652 $62,467 $72,667 $10,200 Heart Disease/Cardiovascular Health... $62,012 $48,626 $62,322 $65,438 $3,116 Infectious Diseases... $32,878 $29,342 $33,042 $34,694 $1,652 Kidney Disorders... $20,810 $16,170 $20,914 $21,960 $1,046 Lung Disorders... $26,856 $12,858 $26,990 $28,340 $1,350 Mental Illness... $107,885 $86,042 $110,310 $115,826 $5,516 Military Occupations & Environ. Exposures... $13,419 $2,319 $14,045 $16,633 $2,588 Other Chronic Diseases... $4,859 $1,255 $4,883 $5,127 $244 Prosthetics... $15,000 ** $15,075 $15,829 $754 Sensory Loss... $17,000 $17,945 $17,085 $17,939 $854 Special Populations... $19,491 $23,591 $19,588 $20,567 $979 Substance Abuse... $29,259 $23,595 $29,405 $30,875 $1, *Estimated using a different method where each project was only included in a single Designated Research Area. Estimates for 2014 were recalculated using the new methodology. **Prosthetics was added as a DRA in FY 2015 and therefore was not reflected in the FY 2015 budget estimate Congressional Submission VHA-309

312 Because many research activities involve more than one particular subject (e.g., a study about diabetes may also involve aging), many individual research projects involve more than one DRA. Therefore, the sum of the projects shown in the Number of Projects by Designated Research Areas table below exceeds the number of distinct projects actually supported. Number of Projects by Designated Research Areas Budget Current Description Estimate Estimate Estimate Request Inc/Dec Acute & Traumatic Injury Aging Autoimmune, Allergic & Hemaptopoietic Disorders Cancer Central Nervous System Injury & Associated Disorders Degenerative Diseases of Bones & Joints Dementia & Neuronal Degeneration Diabetes & Major Complications Digestive Diseases Emerging Pathogens/Bio-Terrorism Gulf War Research Illness Health Systems Heart Disease Infectious Diseases Kidney Disorders Lung Disorders Mental Illness Military Occupations & Environ. Exposures Other Chronic Diseases Prosthetics * Sensory Loss Special Populations Substance Abuse * Prosthetics was added as a DRA in FY 2015 and therefore is not reflected in the FY 2015 budget estimate. VHA-310 Medical & Prosthetic Research

313 Obligations by Sub-Activity (dollars in thousands) Budget Current Description Estimate Estimate Estimate Request Inc/Dec Research Programs (Investigator Initiated)... $371,509 $388,164 $410,410 $ 413,520 $3,110 Career Development... $83,260 $85,861 $84,000 $ 84,251 $251 Centers of Excellence... $65,696 $74,670 $74,670 $ 75,324 $654 Service Directed/Service Specific Research... $13,739 $10,816 $10,816 $ 11,032 $216 Research Compliance... $4,193 $5,124 $5,124 $ 5,186 $62 R&D Specific Costs... $75,468 $73,276 $71,500 $ 72,500 $1,000 Total Obligations... $613,865 $637,911 $656,520 $ 661,813 $5,293 Appropriation... $585,664 $588,922 $588,513 $621,813 $33,300 Projects by Sub-Activity Budget Current Description Estimate Estimate Estimate Request Inc/Dec Research Programs (Investigator Initiated)... 1,638 1,638 1,638 1, Career Development Centers of Excellence Service Directed Research Total Projects... 2,224 2,224 2,224 2, Congressional Submission VHA-311

314 Employment Summary, FTE by Grade GS Grade or Title 38 Estimate Estimate Estimate Inc/Dec SES Title or higher Wage Board Total Number of FTE... 3,446 3,491 3, Analysis of FTE Distribution Headquarters/Field GS Grade or Title 38 HQ-Actual Field-Actual SES Title or higher Wage Board Total Number of FTE ,423 VHA-312 Medical & Prosthetic Research

315 Obligations by Object Classification (dollars in thousands) Budget Current Description Actual Estimate Estimate Request Inc/Dec 10 Personal Services... $325,327 $333,201 $332,000 $336,813 $4, Travel & Transportation of Persons: Employee Travel... $3,971 $2,989 $3,971 $3,971 $0 All Other... $54 $586 $29 $29 $0 Subtotal... $4,025 $3,575 $4,000 $4,000 $0 22 Transportation of Things... $88 $276 $50 $50 $0 23 Communication, Utilities & Misc... $2,821 $852 $2,911 $2,911 $0 24 Printing & Reproduction... $543 $580 $1,000 $1,000 $0 25 Other Services: Medical Care Contracts & Agree. w/insts. & Orgs. $77,285 $71,500 $82,000 $82,000 $0 Fee Basis - Medical & Nursing Services, On-Station $347 $415 $415 $415 $0 Consultants & Attendance... $5,028 $14,100 $14,100 $14,100 $0 Scarce Medical Specialist... $347 $504 $504 $504 $0 Repair of Furniture & Equipment... $3,744 $1,665 $1,665 $1,665 $0 Maintenance & Repair Services... $572 $712 $712 $712 $0 Administrative Contractual Services... $119,911 $129,573 $138,998 $139,478 $480 Training Contractual Services... $1,026 $1,126 $1,126 $1,126 $0 Subtotal... $208,260 $219,595 $239,520 $240,000 $ Supplies & Materials... $34,390 $40,500 $36,000 $36,000 $0 31 Equipment... $38,373 $39,000 $41,000 $41,000 $0 32 Lands & Structures... $39 $332 $39 $39 $0 Total Obligations... $613,866 $637,911 $656,520 $661,813 $5, Congressional Submission VHA-313

316 Medical and Prosthetic Research Summary (dollars in thousands) Budget Current Appropriation Actual Estimate Estimate Request Inc/Dec Medical research and support... $585,664 $588,922 $588,513 $621,813 $33,300 Budget Authority... $585,664 $588,922 $588,513 $621,813 $33,300 Reimbursements... $25,051 $40,000 $40,000 $40,000 $0 Budget Authority (Gross)... $610,715 $628,922 $628,513 $661,813 $33,300 Adjustments to obligations: Unobligated balance (SOY): No-year... $560 $0 $1,125 $0 ($1,125) 2-year... $80,721 $43,989 $76,882 $50,000 ($26,882) Supplemental... $0 $0 $0 $0 $0 Emergency Designation... $0 $0 $0 $0 $0 Subtotal unobligated balance (SOY)... $81,281 $43,989 $78,007 $50,000 ($28,007) Unobligated balance (EOY): No-year... ($1,124) $0 $0 $0 $0 2-year... ($76,882) ($35,000) ($50,000) ($50,000) $0 Supplemental... $0 $0 $0 $0 $0 Subtotal unobligated balance (EOY)... ($78,006) ($35,000) ($50,000) ($50,000) $0 Change in Unobligated balance (non-add)... $3,275 $8,989 $28,007 $0 ($28,007) Unobligated balance expiring (lapse)... ($124) $0 $0 $0 $0 Obligations... $613,866 $637,911 $656,520 $661,813 $5,293 Obligations... $613,866 $637,911 $656,520 $661,813 $5,293 Obligated Balance (SOY)... $267,626 $283,540 $240,526 $278,521 $37,995 Obligated Balance (EOY)... ($240,526) ($302,635) ($278,521) ($296,646) ($18,125) Adjustments in Expired Accounts... $15,876 $0 $0 $0 $0 Chg. Uncol. Cust. Pay Fed. Sources (Unexp.)... ($12,663) $0 $0 $0 $0 Chg. Uncol. Cust. Pay Fed. Sources (Exp.)... ($11,587) $0 $0 $0 $0 Outlays, Gross... $632,592 $618,816 $618,525 $643,688 $25,163 Offsetting Collections... ($24,249) ($40,000) ($40,000) ($40,000) $0 Outlays, Net... $608,343 $578,816 $578,525 $603,688 $25,163 Full-Time Equivalents (FTE): Direct FTE... 3,305 3,010 3,350 3, Reimbursable FTE Total FTE... 3,446 3,491 3,491 3, VHA-314 Medical & Prosthetic Research

317 Revolving and Trust Activities Veterans Canteen Service Revolving Fund Millions Fund Highlights Obligations $500 $450 $400 $350 $300 $250 $200 $150 $100 $50 $0 $ $ $ $ Actual 2015 Budget Estimate 2015 Current Estimate 2016 Estimate Program Description The Veterans Canteen Service (VCS) was established by Congress in 1946 to furnish, at reasonable prices, meals, merchandise, and services necessary for the comfort and wellbeing of Veterans in hospitals and domiciliaries operated by the Department of Veterans Affairs (Title 38 U.S.C ). It has since expanded to provide reasonably priced merchandise and services to America s Veterans enrolled in VA s Healthcare System, their families, caregivers, VA employees, volunteers, and visitors. Congress originally appropriated a total of $4,965,000 for the operation of the VCS and no additional appropriations have been required. Funds in excess of the needs of the Service totaling $12,068,000 have been returned to the U.S. Treasury. However, provisions of the Veterans Benefits Act of 1988 (Public Law ) eliminated the requirement that excess funds be returned to the Treasury and authorized such funds to be invested in interest-bearing accounts, specifically Treasury Bills and Notes. Gains are used to fund business operations. However, currently VCS has no interest bearing investments. Creating an environment where patrons can truly enjoy their shopping or dining experience has become a necessity for modern businesses. Providing VA customers the 2016 Congressional Submission VHA-315

318 same high quality service found outside the work environment has been, and will continue to be, necessary for VCS. This philosophy will take VCS into the budgeted fiscal year 2016 and beyond Fund Highlights* (dollars in thousands) to Budget Current 2016 Increase/ Description Actual Estimate Estimate Estimate Decrease Total revenue... $450,000 $460,000 $496,000 $500,000 $4,000 Obligations... $453,981 $455,150 $475,078 $490,078 $15,000 Outlays (net)... ($20,437) $3,000 $3,000 $3,000 $0 FTE... 3,258 3,425 3,425 3, * The numbers in the chart above reflect an estimate of the activity during the Federal Government Fiscal Year (October September), as the Veterans Canteen Service uses a retail industry fiscal year (February January) used by similar private sector retailers to enhance their ability to compare their operations to their private sector peers. In Fiscal Year 2009, VCS management changed reporting to a retail calendar fiscal year which resulted in an 11 month reporting period. This reporting cycle has been adopted in order to better align VCS operations with the financial reporting structure of the retail industry. The calendar uses a (4-5-4) weekly cycle for the monthly reporting schedule. The retail accounting calendar divides the year, beginning with the month of February, into quarters with the first and last month of each quarter consisting of 4 weeks each and the middle month of each quarter consisting of 5 weeks. Although VCS uses the retail accounting calendar for its management purpsoes, VCS will continue to report to VA on a Federal Fiscal Year basis. Summary of Budget Request No appropriation by Congress will be required for the operation of the VCS during The VCS is a self-sustaining, revolving fund activity that obtains its revenues from non- Federal sources; therefore, no Congressional action is required. The VCS functions independently within VA and has primary control over its major activities including sales, procurement, supply, finance, and personnel management. VHA-316 Revolving & Trust Activities

319 Changes From 2015 Budget Request (dollars in thousands) 2015 Budget Current Increase/ Description Estimate Estimate Decrease Total revenue... $460,000 $496,000 $36,000 Obligations... $455,150 $475,078 $19,928 Outlays (net)... $3,000 $3,000 $0 FTE... 3,425 3,425 0 Summary of Employment In the area of personnel management, the VCS uses techniques that are generally applied in commercial retail chain store, food and vending operations. Primary consideration is given to salary expenses in relation to sales. Salary expense data are provided to management personnel for each department in each Canteen, as well as VCS in total. These data are compared to the corresponding period from the previous year and to productivity goals and standards prior to making decisions regarding employment increases or decreases. Productivity is the standard by which VCS measures personnel cost management. The following chart reflects the full-time equivalent employment (FTE) for 2014 through 2016: Summary of Employment to Budget Current 2016 Increase/ Actual Estimate Estimate Estimate Decrease FTE... 3,258 3,425 3,425 3, Congressional Submission VHA-317

320 Revenues and Expenses (dollars in thousands) to Budget Current 2016 Increase/ Actual Estimate Estimate Estimate Decrease Sales Program: Revenue... $450,000 $460,000 $496,000 $500,000 $4,000 Less operating expenses... ($453,981) ($455,280) ($475,078) ($495,280) ($20,202) Net operating income-sales... ($3,981) $4,720 $20,922 $4,720 ($16,202) Nonoperating income or loss (-): Proceeds from sale of equipment... $50 $50 $50 $50 $0 Net book value of assets sold... ($125) ($125) ($125) ($125) $0 Net Gain or (Loss)... ($75) ($75) ($75) ($75) $0 Interest income... $0 $0 $0 $0 $0 Miscellaneous income/(loss)... ($4,350) ($4,350) ($4,350) ($4,350) $0 Net non-operating income... ($4,425) ($4,425) ($4,425) ($4,425) $0 Net income for the year... ($8,406) $295 $16,497 $295 ($16,202) Financial Condition The schedule below reflects the anticipated financial condition of the VCS through Changes from year to year are the result of anticipated changes in revenues, obligations, and outlays previously portrayed. Financial Condition (dollars in thousands) to Budget Current 2016 Increase/ Actual Estimate Estimate Estimate Decrease Assets: Cash with Treasury, in banks, in transit... $22,000 $22,000 $22,000 $22,000 $0 Accounts receivable (net)... $40,202 $42,000 $42,404 $44,404 $2,000 Inventories... $40,000 $43,000 $43,000 $43,000 $0 Real property and equipment (net)... $50,368 $49,433 $49,433 $47,376 ($2,057) Other assets... $492 $371 $371 $372 $1 Total assets... $153,062 $156,804 $157,208 $157,152 ($56) Liabilities: Accounts payable including funded accrued liabilities... $62,702 $65,371 $65,371 $65,000 ($371) Unfunded annual leave and coupons books... $7,000 $7,980 $7,980 $8,000 $20 Total liabilities... $69,702 $73,351 $73,351 $73,000 ($351) Government equity: Unexpended balance: Unobligated balance... $3,541 $19,902 $34,902 $35,000 $98 Undelivered orders... $6,286 $8,919 $4,323 $4,789 $466 Invested capital... $62,000 $54,632 $44,632 $44,363 ($269) Total Government equity (end-of-year)... $71,827 $83,453 $83,857 $84,152 $295 VHA-318 Revolving & Trust Activities

321 Government Equity (dollars in thousands) to Budget Current 2016 Increase/ Actual Estimate Estimate Estimate Decrease Retained Income: Opening Balance... $71,827 $83,158 $72,324 $72,821 $497 Transactions: Net Operating Income... $4,922 $4,720 $4,922 $4,720 ($202) Net Operating Gain... ($4,425) ($4,425) ($4,425) ($4,425) $0 Closing Balance... $72,324 $83,453 $72,821 $73,116 $295 Total Government Equity (end-of-year)... $72,324 $83,453 $83,857 $84,152 $ Congressional Submission VHA-319

322 This Page Intentionally Left Blank VHA-320 Revolving & Trust Activities

323 Medical Center Research Organizations Program Description The Veterans Benefits and Services Act of 1988 (Public Law ) authorizes "Medical Center Research Organizations" to be created at Department of Veterans Affairs Medical Centers (VAMC). These nonprofit corporations (NPCs) provide flexible funding mechanisms for the conduct of VA-approved research and educational activities. They administer funds from non-va Federal and private sources to operate various research and educational activities in VA. These corporations are private, state-chartered entities. They are self-sustaining and funds are not received into a government account. No appropriation is required to support these activities. Prior to June 1, 2004, 93 VAMCs had received approval for the formation of nonprofit research corporations. Presently, 83 are active. Most of the corporations have indefinite, ongoing operations. However, recent changes in the law permit NPC mergers. This may result in a decrease in the number of NPCs overall. All 83 NPCs have received their authority from the Internal Revenue Service Code of 1986, under Article 501(c)(3) or similar Code Sections. The fiscal years for these organizations vary, with most having year-ends at September 30 th or December 31 st. The table below reflects estimated revenues and expenses from 2014 to Contribution Highlights (dollars in thousands) Budget Current 2016 Increase/ Actual Estimate Estimate Estimate Decrease Contributions... $240,250 $252,812 $239,313 $239,014 ($299) Expenses... $237,079 $246,636 $236,853 $236,288 ($565) * 2015 and 2016 estimates have been updated from what is shown in the MAX database 2016 Congressional Submission VHA-321

324 The following table is a list of research corporations that have received approval for formation along with their estimated 2014 contributions from the non-va Federal and private sources. In addition, NPCs with no contributions have been approved for operation. Some have received contributions in the past, others have not, to date, received any contributions: Estimated Revenues (Contributions) City State Albany Research Institute, Inc... Albany NY $726, Asheville Medical Research and Education Corporation... Asheville NC $77, Atlanta Research and Education Foundation, Inc... Atlanta GA $8,694, Augusta Biomedical Research Corporation... Augusta GA $30, Baltimore Research and Education Foundation... Baltimore MD $2,438, Bedford VA Research Corporation, Inc... Bedford MA $196, Biomedical Research and Education Foundation of Southern Arizona... Tucson AZ $1,000, Biomedical Research Foundation... Little Rock AR $344, Biomedical Research Foundation of South Texas, Inc... San Antonio TX $1,740, Biomedical Research Institute of New Mexico... Albuquerque NM $10,600, Boston VA Research Institute, Inc... Boston MA $12,000, Brentwood Biomedical Research Institute... Los Angeles CA $10,599, Bronx Veterans Medical Research Foundation... Bronx NY $2,500, Buffalo Institute for Medical Research, Inc... Buffalo NY $440, Carl T. Hayden Medical Research Foundation... Phoenix AZ $2,878, Central New York Research Corporation... Syracuse NY $1,524, Central Texas Veterans Research Foundation... Temple TX $263, Charleston Research Institute, Inc... Charleston SC $1,122, Chicago Association for Research and Education in Science... Hines IL $5,000, Cincinnati Education & Research for Veterans Foundation... Cincinnati OH $1,811, Clinical Research Foundation, Inc... Louisville KY $705, Veterans Education and Research Ass'n. of Northern New England, Inc... White River Junction CT $792, Dallas VA Research Corporation... Dallas TX $2,960, Dayton VA Research and Education Foundation... Dayton OH $300, Denver Research Institute... Denver CO $5,443, Dorn Research Institute... Columbia SC $450, East Bay Institute for Research and Education... Martinez CA $600, Great Plains Medical Research Foundation... Sioux Falls SD $0 VHA-322 Revolving & Trust Activities

325 Estimated Revenues (Contributions) City State Houston VA Research and Education Foundation... Houston TX $2,752, Huntington Institute for Research and Education... Huntington WV $0 31. Indiana Institute for Medical Research, Inc... Indianapolis IN $300, Institute for Clinical Research, Inc... Washington DC $7,811, Institute for Medical Research, Inc... Durham NC $2,150, Idaho Veterans Research and Education Foundation... Boise ID $252, Iowa City VA Medical Research Foundation... Iowa City IA $325, Lexington Biomedical Research Institute, Inc... Lexington KY $300, Loma Linda Veterans Association for Research and Education, Inc... Loma Linda CA $665, Louisiana Veterans Research and Education Corporation... New Orleans LA $50, McGuire Research Institute, Inc... Richmond VA $2,900, Metropolitan Detroit Research and Education Foundation... Detroit MI $400, Middle Tennessee Research Institute, Inc... Nashville TN $765, Midwest Biomedical Research Foundation... Kansas City MO $2,000, Minnesota Veterans Research Institute... Minneapolis MN $4,100, Missouri Foundation for Medical Research... Columbia MO $367, Mountain Home Research and Education Corporation... Mountain Home TN $100, Mountaineer Education and Research Corporation... Clarksburg WV $0 47. Narrows Institute for Biomedical Research, Inc... Brooklyn NY $250, Nebraska Educational Biomedical Research Association... Omaha NE $600, North Florida Foundation for Research and Education, Inc... Gainesville FL $1,535, Northern California Institute for Research and Education, Inc... San Francisco CA $41,876, Ocean State Research Institute, Inc... Providence RI $246, Overton Brooks Research Corporation... Shreveport LA $55, Pacific Health Research and Education Institute... Honolulu HI $2,800, Palo Alto Institute for Research and Education, Inc... Palo Alto CA $22,830, Philadelphia Research and Education Foundation... Philadelphia PA $249, Portland VA Research Foundation, Inc... Portland OR $6,000, Congressional Submission VHA-323

326 Estimated Revenues (Contributions) City State Research! Mississippi, Inc... Jackson MS $310, Research, Incorporated... Memphis TN $1,470, Salem Research Institute, Inc... Salem VA $575, Salisbury Foundation for Research and Education... Salisbury NC $37, Seattle Institute for Biomedical and Clinical Research... Seattle WA $13,000, Sepulveda Research Corporation... Sepulveda CA $2,400, Sierra Veterans Research and Education Foundation... Reno NV $676, Sociedad de Investigacion Cientificas, Inc... San Juan PR $303, South Florida Veterans Affairs Foundation for Research and Education... Miami FL $2,398, Southern California Institute for Research and Education... Long Beach CA $3,700, Tampa VA Research and Education Foundation... Tampa FL $1,500, The Bay Pines Foundation, Inc... Bay Pines FL $650, The Cleveland VA Medical Research and Education Foundation... Cleveland OH $975, The Research Corporation of Long Island, Inc... Northport NY $355, Tuscaloosa Research and Education Advancement Corporation... Tuscaloosa AL $190, VA Black Hills Research and Education Foundation... Fort Meade SD $0 73. VA Connecticut Research and Education Foundation... West Haven CT $1,200, Veterans Research and Education Foundation of St. Louis... St Louis MO $473, Veterans Bio-Medical Research Institute, Inc... East Orange NJ $2,097, Veterans Education and Research Association of Michigan... Ann Arbor MI $3,385, Veterans Medical Research Foundation of San Diego... San Diego CA $22,000, Veterans Research and Education Foundation... Oklahoma City OK $690, Veterans Research Foundation of Pittsburgh... Pittsburgh PA $1,888, VISTAR, Inc... Birmingham AL $250, Western Institute for Biomedical Research... Salt Lake City UT $2,087, Westside Institute for Science and Education... Chicago IL $350, Wisconsin Corporation for Biomedical Research... Milwaukee WI $381,000 Total... $240,250,000 VHA-324 Revolving & Trust Activities

327 General Post Fund Budgetary Resources* $50.00 M i l l i o n s $40.00 $30.00 $20.00 $10.00 $ $ $ $ $ Actual 2015 Budget Estimate 2015 Current Estimate 2016 Estimate *Fund consists of gifts, bequests and proceeds from the sale of property. Program Description This trust fund consists of gifts, bequests, and proceeds from the sale of property left in the care of Department of Veterans Affairs facilities by former beneficiaries who die leaving no heirs or without having otherwise disposed of their estate. Such funds are used to promote the comfort and welfare of Veterans at hospitals and other facilities for which no general appropriation is available. Also, donations from pharmaceutical companies, non-profit corporations, and individuals to support VA medical research can be deposited into this fund (title 38 U.S.C., Chapters 83, Acceptance of Gifts and Bequests, and 85, Disposition of Deceased Veterans Personal Property). The resources from this trust fund are for the direct benefit of the patients. Expenditures from this fund are for recreational and religious projects; specific equipment purchases; national recreational events; the vehicle transportation network; television projects; and other items as outlined in Veteran Health Administration Directive 4721, General Post Fund. In addition, Public Law authorizes the receipts from the sale of a property acquired for transitional housing to be deposited in the General Post Fund and used for the acquisition, management and maintenance of other transitional housing properties Congressional Submission VHA-325

328 Summary of Budget Request Operations of this trust fund are financed from fund receipts. Congress has provided permanent, indefinite budget authority for this fund and no appropriation is required. Fund Highlights (dollars in thousands) to Budget Current 2016 Increase/ Description Actual Estimate Estimate Estimate Decrease Budget Authority (permanent, indefinite)... $28,539 $33,200 $29,300 $30,400 $1,100 Obligations: Trust Fund and Donation... $19,105 $25,000 $24,100 $25,000 $900 Therapeutic Residences... $993 $1,000 $1,000 $1,000 $0 Total Obligations... $20,098 $26,000 $25,100 $26,000 $900 Outlays... $19,507 $21,100 $20,000 $20,800 $800 Changes From Original 2015 Budget Estimate (dollars in thousands) 2015 Budget Current Increase/ Description Estimate Estimate Decrease Budget Authority (permanent, indefinite)... $33,200 $29,300 ($3,900) Obligations: Trust Fund and Donation... $25,000 $24,100 ($900) Therapeutic Residences... $1,000 $1,000 $0 Total Obligations... $26,000 $25,100 ($900) Outlays... $21,100 $20,000 ($1,100) VHA-326 Revolving & Trust Activities

329 Program Activity Trust Fund and Donations Estimates of trust fund obligations revised for 2015 and 2016 are $25,100,000 and $26,000,000 respectively. The obligations are consistent with the purposes for which proceeds from this fund may legally be expended (Comptroller General's Decision B , November 10, 1955) and the intent of the donors. Donors usually specify that their donations be used for designated recreational or religious purposes, research projects, or equipment (e.g., televisions, medical equipment and physical therapy equipment) purchases. Cash receipts from donations and estates for both fiscal years 2015 and 2016 are estimated to reach $24,100,000 and $25,000,000 respectively. The invested reserve for 2015 and 2016 is estimated to be approximately $89,811,000 and $91,834,000 respectively. This level of investment exceeds the requirement to retain at least five times the total amount paid to heirs during the preceding five year period. Compensated Work Therapy - Therapeutic Residences (CWT-TR) Per title 38, U.S.C. Section 1772(h), funds received through the operation of the Therapeutic Housing Program are to be deposited in the General Post Fund. The Secretary has the discretionary authority to expend up to an additional $500,000 from the fund above the amount credited to the fund in a fiscal year from proceeds of this program Congressional Submission VHA-327

330 Financial Actions and Conditions (dollars in thousands) to Budget Current 2016 Increase/ Actual Estimate Estimate Estimate Decrease Balance beginning of year: Cash... $11,365 $25,964 $18,689 $26,845 $8,156 Investments... $87,240 $70,691 $88,288 $89,811 $1,523 Property, Plant, Equipment & Other Assets... $28,032 $22,964 $50,103 $72,480 $22,377 Total... $126,637 $119,619 $157,080 $189,136 $32,056 Increase during period: Cash... $78,668 $74,300 $79,500 $80,300 $800 Investments... $51,925 $39,200 $52,400 $52,900 $500 Property, Plant, Equipment & Other Assets... $26,094 $2,700 $26,400 $26,700 $300 Total... $156,687 $116,200 $158,300 $159,900 $1,600 Decrease during period: Cash... $71,344 $59,000 $71,344 $71,344 $0 Investments... $50,877 $56,000 $50,877 $50,877 $0 Property, Plant, Equipment & Other Assets... $4,023 $7,118 $4,023 $4,023 $0 Total... $126,244 $122,118 $126,244 $126,244 $0 Balance at end of year: Cash... $18,689 $41,264 $26,845 $35,801 $8,956 Investments... $88,288 $53,891 $89,811 $91,834 $2,023 Property, Plant, Equipment & Other Assets... $50,103 $18,546 $72,480 $95,157 $22,677 Total... $157,080 $113,701 $189,136 $222,792 $33,656 VHA-328 Revolving & Trust Activities

331 Information and Technology TABLE OF CONTENTS Appropriations Language Explanation of Language Change Appropriation Highlights Executive Overview Improve Veteran Access to VA Benefits and Services Eliminate the Disability Claims Backlog Eliminate Veteran Homelessness Information Security Veterans Access Choice, and Accountability Act of Maintain the IT Infrastructure Other Development Programs Staffing and Administration Subaccount VistA Evolution/Interoperability and VLER Health Accomplishments Budget Appendices Development, Modernization, and Enhancement Subaccount Congressional Report Detail Operations and Maintenance Subaccount Operations and Maintenance Detail Amounts Available for Obligation Obligations by Object Class and Funding Sources Information Technology Systems Appropriations History Office of Information Technology Organization Chart Congressional Submission IT-329

332 This Page Intentionally Left Blank 2016 Congressional Submission IT-330

333 Information and Technology Information and Technology Budget Authority $4.8 B i l l i o n s $3.703 $3.903 $3.902 $4.133 $ Actuals 2015 Budget Estimate 2015 Current Estimate 2016 Budget Request Appropriations Language For necessary expenses for information technology systems and telecommunications support, including developmental information systems and operational information systems; for pay and associated costs; and for the capital asset acquisition of information technology systems, including management and related contractual costs of said acquisitions, including contractual costs associated with operations authorized by section 3109 of title 5, United States Code, [$3,903,344,000]$4,133,363,000, plus reimbursements: Provided, That [$1,039,000,000]$1,115,757,000 shall be for pay and associated costs, of which not to exceed [$30,792,000]$34,800,000 shall remain available until September 30, [2016]2017: Provided further, That [$2,316,009,000]$2,512,863,000 shall be for operations and maintenance, of which not to exceed [$160,000,000]$175,000,000 shall remain available until September 30,[2016]2017: Provided further, That [$548,335,000] $504,743,000 shall be for information technology systems development, modernization, and enhancement, and shall remain available until September 30, [2016: Provided further, That amounts made available for information technology systems development, modernization, and enhancement may not be obligated or expended until Secretary of Veterans Affairs or the Chief Information Officer of the Department of Veterans Affairs submits to the Committees on Appropriations of both Houses of Congress a certification of the amounts, in parts or in full, to be obligated and expended for each development project:]2017:provided further, That amounts made available for salaries and expenses, operations and maintenance, and information technology systems development, modernization, and enhancements may be transferred among the three subaccounts after the Secretary of Veterans Affairs [requests form] 2016 Congressional Submission IT-331

334 submits notice thereof to the Committees on Appropriations of both Houses of Congress the authority to make the transfer and an approval is issued: Provided further, That amounts made available for the Information Technology Systems account for development, modernization, and enhancement may be transferred among projects or to newly defined projects: Provided further, That no project may be increased or decreased by more than [$1,000,000]$3,000,000 of the cost prior to submitting [a request] notice thereof to the Committees on Appropriations of both Houses of Congress [to make the transfer and an approval is issued, or absent a response, a period of 30 days has elapsed: Provided further, That funds under this heading may be used by the Interagency Program Office through the department of Veterans Affairs to develop a standard data reference terminology model: Provided further, That of the funds made available for information technology systems development, modernization, and enhancement for VistA Evolution, not more than 25 percent may be obligated or expended until the Secretary of Veterans Affairs submits to the Committees on Appropriations of both Houses of Congress, and such Committees approve, a report that describes: (1) the status of and changes to the VistA Evolution program plan (hereinafter referred to as the Plan ), VistA 4 product roadmap ( Roadmap ), or the VistA Evolution cost estimate, dated March 24, 2014; (2) any changes to the scope or functionality of project within the VistA Evolution program as established in the Plan; (3) any refinements to the cost estimate presented in the Plan, including those based on actual costs incurred; (4) a Project Management Accountability System resourced schedule for every development project within the VistA Evolution program, including a testing methodology schedule; (5) progress toward developing and implementing all levels of interoperability, including semantic interoperability, between the electronic health record systems of the Department of Defense and the Department of Veterans Affairs; (6) a detailed governance structure for the VistA Evolution program, including the establishment of a single program director and integrator who shall have responsibility for the entire program: Provided further, That funds made available under this heading for information technology systems development, modernization, and enhancement, shall be for the project, and in the amount, specified under this heading in the explanatory statement described in section 4 (in the matter proceeding division A of this consolidated Act)]. (Consolidated and Further Continuing Appropriations Act, 2015.) Explanation of Language Change VA is proposing that the threshold at which a request is required be made from both Houses of Congress prior to the transfer of funds between projects be raised to $3,000,000. In the above language, project refers to the VA s congressional development, modernization enhancement (DME) projects report located in the budget appendix Congressional Submission IT-332

335 Information and Technology Appropriation Highlights Appropriation Hightlights (Dollars in Thousands) / Actuals Carryover Budget Estimate Current Estimate Budget Request Increase / Decrease Subaccounts: Development 495, , , , ,743-43,592 Sustainment 2,181, ,333,217 2,316,009 2,512, ,854 Pay & Administration 1,026,400 15,156 1,039,000 1,039,000 1,115,757 76,757 Rescission -1,066 1,066 Emergency Supplemental 2,057 Appropriation 1/ $3,703,344 $168,390 $3,903,344 $3,902,278 $4,133,363 $231,085 Funding Sources: Appropriation 3,703,344 3,903,344 3,902,278 4,133, ,085 Transfers 2/ -6,789-6,968-6,968-7, Reimbursements (+) 39,322 96,720 54,915 56,837 1,922 Available Balance SOY (+) 3/ 139, , ,400 5,010 Available Balance EOY (-) -168, , ,400 Unobligated Balance (Expiring) Lapse -1,250 PL The Choice Act 376, ,600 Total Obligations $3,706,052 $3,993,096 $4,321,815 $4,356,442 $34,627 Total Full Time Equivalents (FTE) 7,291 7,427 7,515 7, Direct 7,208 7,325 7,325 7,325 Direct (PL The Choice Act) Reimbursement Numbers may not add due to rounding 1/ Numbers include prior year carryover but exclude reimbursements and transfers. 2/ In FY2014, $6.789M was transferred from OIT to the North Chicago facility. This line also reflects North Chicago transfers in FY2014, FY2015 and FY / In FY2016, this line represents anticipated carryover for Veterans Access Choice and Accountability Act (Choice Act) 2016 Congressional Submission IT-333

336 Information and Technology Strategic Priorities Executive Overview The Office of Information and Technology (OIT) of the Department of Veterans Affairs (VA) provides information technology support across VA to ensure that the mission, vision, and strategic objectives of VA s Agency Priority Goals (APGs) are met. The current three VA APGs are to: Improve Veteran access to VA benefits and services; Eliminate the disability claims backlog; and Eliminate Veteran homelessness. In alignment with these goals, OIT s mission is to provide available, adaptable, secure, and cost effective information technology products and services to VA customers, enabling VA staff to provide mission-critical support to the Nation s Veterans. The technology and the resources required to support the APGs underpin every aspect of the care, benefits, and services that are delivered to Veterans. Information Technology (IT) is a vehicle that enables VA to support critical areas such as: Healthcare; improved benefits processing; provision of enhanced customer care and service to Veterans; maintenance of the Department s information security posture; and maintenance and enhancement of the IT Infrastructure. The 2016 Budget request focuses on the following critical areas: Improving Veteran Access to Benefits and Services Eliminating the Disability Claims Backlog Eliminating Veteran Homelessness Expanding Information Security ImplementingVeterans Access Choice, and Accountability Act of 2014 (the Veterans Choice Act) Maintaining the IT Infrastructure Other Development Programs Improving Interoperability/VistA Evolution (Veterans Health Information Systems and Technology Architecture) 2016 Congressional Submission IT-334

337 Access to Care VA is committed to providing Veterans and other eligible beneficiaries timely and highquality accessible health services. The Veterans Health Administration (VHA) leads the effort in health care services including: (1) inpatient and outpatient services; (2) pharmacy; (3) prosthetics; and (4) long-term care, as well as other programs. OIT provides crucial technical connectivity nationwide to hospitals, Community-Based Outpatient Clinics (CBOC), domiciliary facilities, Vet Centers, and other VHA facilities. These joint VHA-OIT efforts improve technology necessary for new medical treatments, the security of patient data, and business operations at medical facilities. OIT also prioritizes state-of-the-art technology and ensures its availability to Veterans in rural America. VA is also focused on delivering seamless and integrated services while increasing the efficiency and effectiveness of access to care. Eliminating the Claims Backlog Reducing the length of time it takes to process disability claims are integral to VA's mission of providing benefits to eligible Veterans in a timely, accurate, and compassionate manner. In 2013, Veterans Benefits Administration (VBA) began measuring the accuracy of individual issues for each claim ( issue-based accuracy ), as it provides a more detailed measure of workload proficiency. However, VBA will continue to monitor and report out on claim-based accuracy as a key indicator for this Agency Priority Goal. To improve benefits delivery, VA is transitioning to an electronic claims process that will reduce processing time and increase accuracy. Information technology solutions, such as VBMS, VETSNET and Appeals Modernization will drive automation, improve the quality of work, reduce variance, and speed efforts to complete claims electronically. These innovative technologies will also integrate business processes to take into account electronic filing of claims, national workload distribution, as well as the receipt of complete and certified medical, dental, and personnel records from the military services. As of September 2014, over 93 percent of VBA s inventory is in electronic format and is being processed electronically by VBA employees using the Veterans Benefits Management System (VBMS). Eliminate Veterans Homelessness VA has taken decisive action toward its goal of ending homelessness among Veterans. The Eliminate Veteran Homelessness (EVH) initiative is intended to prevent Veterans and their families from entering homelessness and to assist those who are homeless in exiting as safely and quickly as possible. VA s expanded access philosophy will ensure that homeless and at risk for homeless Veterans have timely access to appropriate housing and services. As Veteran come seek VA services to - at a medical center, a regional office, or a community organization - they all will lead to the tools to offer Veteran assistance. Eliminating homelessness among Veterans will advance the mission of VA by ensuring that all Veterans and their families achieve housing stability. Information Technology systems such as, Health Management Information System (HMIS) and Veteran Re-entry Identification System (VRIS), support the EVH program s efforts by automating processes to gather data needed to provide services to Veterans that are in need of homelessness services Congressional Submission IT-335

338 Information Security VA is committed to meeting the highest standards in protecting sensitive Veteran and employee information. OIT is making advancements in information security in the areas of: (1) Network Operations; (2) Security Operations; (3) Business Continuity Support; (4) Field Security Services; (5) and Information/Data Security to meet ever involving and increasingly sophisticated attacks. Veterans Access Choice and Accountability Act (the Veterans Choice Act) On August 7, 2014, President Obama signed into law the Veterans Access Choice, and Accountability Act of 2014, Public Law (P.L.) Section 801 of the Veterans Choice Act provides $5 billion to increase Veterans access to health care and to improve the physical infrastructure of the Department. Of the $5 billion total, $2.34 billion (46.8 percent) will support Veterans' Medical Care; $2.28 billion (45.7 percent) will support capital infrastructure; and $376.6 million (7.5 percent) will support information technology (IT) infrastructure and development. Section 802 of the Choice Act provides $10 billion to support the Veterans Choice Program, of which VA has identified $64 million in IT requirements so far and that may increase as more requirements become known. VA submitted a funding plan to Congress in December 2014 that describes how the Office of Information Technology plans to obligate Veterans Choice Act funding for years 2015 and The section on the Veterans Choice Act provides a detailed breakout of the funding plan. Maintain and Enhance the IT Infrastructure OIT works closely with its stakeholders (Veterans and their families, VHA, VBA, the National Cemetery Administration (NCA), Veterans Service Organizations (VSO), and non-va medical providers) to meet their technology needs. In order to keep pace with these needs, OIT has developed new systems, platforms, and applications. Now that these technology assets have deployed to the enterprise, OIT must allocate funds to maintain these new technologies in addition to existing technology. This investment in development has necessitated a growth in OIT s sustainment costs, as reflected in the 2016 budget request. The delivery of medical care and benefits, and protection of the security and privacy of sensitive Veteran information depend on: (1) a reliable and accessible IT infrastructure; (2) a high-performing IT workforce; and (3) modernized information systems that are flexible enough to meet both existing and emerging service delivery requirements. Other Development Programs OIT works closely with all the Administrations and Staff Offices to provide specific IT development requirements that are variable in nature and do not fit within the other IT programs described above. For example, these programs would include Memorials development, Mental Health, VLER Health, VHA Research, Registries, etc Congressional Submission IT-336

339 Improving Interoperability/VistA Evolution Veterans health Information Systems and Technology Architecture (VistA) Evolution is a joint program of the VA OIT and VHA and will provide interoperability with Electronic Health Record (EHR) systems of the Department of Defense (DoD) and other healthcare partners to promote improved outcomes in quality, safety, efficiency, and satisfaction in healthcare for Veterans, Servicemembers, and their dependents. The Interobility portion of the 2016 budget supports the electronic exchange of health information among caregivers and other authorized parties, allowing clinicians to access and view multisourced patient data. Improving cross-departmental interoperability and interoperability with industry will provide improved access to a more comprehensive and integrated patient health history from multiple sources where care originally occurred Budget Request OIT is one of the largest consolidated IT enterprises in the government. OIT s technology profile consists of over 424,000 desktop computers, 69,000 laptops, 31,000 mobile devices, and 539,000 accounts. To meet VA s health and benefit delivery commitments, OIT relies upon a large, secure, and complex technology infrastructure. VA s annual information technology investment request is important to sustain the provision of benefits and services to Veterans and their beneficiaries. For 2016, the OIT is requesting $4.133 billion, an increase of $231 million (6 percent) above the 2015 level. The request is separated into three subaccounts, as follows: Development Modernization Enhancement (DME) The request of $504.7 million is $43.6 million (8 percent) below the 2015 request; it represents the highest priority development projects for VA. The funds will support development of programs such as the Veterans Benefits Management Systems (VBMS), VistA Evoulution (VE), Veterans Relationship Management (VRM)/Veterans Customer Experience(VCE), Clinical Research initiatives, Medical Registries and Repositories, Innovative IT solutions, and other continuing development. Operations and Maintenance (OM) The request of $2.513 billion is $196.9 million (8.5 percent) above the 2015 level. The funds will provide for the operation and maintenance of existing infrastructure systems and marginal sustainment for development efforts, which supports newly deployed projects that have not fully matured into mandatory sustainment. It also includes funding for activating medical facilities, protecting Veterans personal information, and implementing projects that contribute to cost efficiencies. Staffing and Administration The request of $1.116 billion is $76.8 million (7.4 percent) above the 2015 level. The majority of this funding is to support the hospital and regional office IT support staff that are responsible to keep systems functioning. These funds will also support program and project administrative expenses (including hiring Digital Service experts) for such areas as enterprise architecture, engineering standards, etc. In addition to the appropriated level, VA OIT anticipates $30.3 million in non-pay reimbursements from other Federal agencies, credit reform programs and non-appropriated insurance benefits programs. The increase in non-pay reimbursements of $1.03 million is 3 percent over the 2015 level Congressional Submission IT-337

340 Anticipated pay reimbursements of $26.5 million will fund reimbursement 98 FTE. The increase in pay reimbursements of $0.9 million is 3.5 percent above the 2015 level. Budget Category Perspective The 2016 request is broken down into the following categories: staffing and administration; mandatory sustainment; information security; activations (equipment and licensing requirements for new facilities); discretionary sustainment; and continuing development. The largest category of the IT budget is mandatory sustainment, which accounts for $2.225 billion (54 percent) of the total 2016 request. The second largest category of spending in 2016 is staffing and administration, which will support 7,325 FTE in headquarters, regional and field offices, and VA hospitals (24x7 coverage) nationwide. The 2016 budget categories are prioritized to determine funding allocations among IT projects. Mandatory sustainment includes must pay one-time and/or recurring costs, such as software licensing, telecommunications, IT support contracts, and hardware maintenance; discretionary sustainment includes necessary but non-critical sustainment efforts to continue or enhance OIT operations; marginal sustainment supports newly deployed projects that have not fully matured into mandatory sustainment; and development covers development, modernization and enhancement (DME) of projects. The table below provides a budget category view of the 2016 IT budget request Budget by Category (Dollars in Thousands) / Actuals Carryover Budget Estimate Current Estimate Budget Request Increase / Decrease Development $ 388,137 $ 150,432 $ 531,127 $ 548,335 $ 504,743 $ (43,592) Marginal Sustainment $ 56,587 $ - $ 124,990 $ 124,990 $ 107,931 $ (17,059) Discretionary Sustainment $ 273,735 $ - $ 240,000 $ 240,000 $ 180,000 $ (60,000) Activations* $ 68,126 $ - $ 84,000 $ 84,000 $ 90,000 $ 6,000 Information Security* $ 144,635 $ - $ 156,000 $ 156,000 $ 179,501 $ 23,501 Mandatory Sustainment $ 1,591,503 $ 2,802 $ 1,728,227 $ 1,711,019 $ 1,955,431 $ 244,412 Staffing and Administration** $ 1,006,966 $ 15,156 $ 1,039,000 $ 1,037,934 $ 1,115,757 $ 77,823 Total $ 3,529,690 $ 168,390 $ 3,903,344 $ 3,902,278 $ 4,133,363 $ 231,085 * Information Security and Activations are categorized as mandatory sustainment but is not included in the Mandatory Sustainment budget line above ** 2015 Current Estimate Staffing and Administration is reduced by a rescission of $1.066M 2016 Congressional Submission IT-338

341 Information and Technology Improve Veteran Access to VA Benefits and Services Improve Veteran Access to VA Benefits and Services (Dollars in Thousands) / Obligations Carryover Budget Estimate Current Estimate Budget Request Increase / Decrease DME OM DME OM DME OM DME OM DME OM DME OM Veteran Customer Experience (aka Veterans Relationship Management) $ 126,637 $ 63,291 $ 9,916 $ - $ 76,600 $ 23,016 $ 76,600 $ 23,016 $ 67,233 $ 114,550 $ (9,367) $ 91,534 TeleHealth/Connected Health/ TeleHealth Expansion $ - $ - $ - $ - $ - $ 32,000 $ - $ 32,000 $ 4,070 $ 45,980 $ 4,070 $ 13,980 Access to Care $ 4,128 $ 3,740 $ 2,156 $ - $ 9,686 $ 8,138 $ 9,686 $ 8,138 $ 17,970 $ 13,780 $ 8,284 $ 5,642 Health Administrative Systems $ - $ 1,515 $ - $ - $ 14,645 $ 8,192 $ 14,645 $ 8,192 $ 27,800 $ 1,200 $ 13,155 $ (6,992) New Models of Care (NMOC) $ 27,617 $ 12,109 $ 6,186 $ - $ 30,551 $ 15,663 $ 30,551 $ 15,663 $ 25,430 $ 250 $ (5,121) $ (15,413) Enrollment System Modernization $ - $ 1,765 $ - $ - $ - $ - $ - $ - $ 13,900 $ 5,000 $ 13,900 $ 5,000 Mobile Development - Health Apps $ - $ - $ - $ - $ - $ - $ - $ - $ 11,000 $ 1,725 $ 11,000 $ 1,725 Memorials Development $ - $ - $ - $ - $ - $ - $ - $ - $ 10,000 $ 1,496 $ 10,000 $ 1,496 Disability Exam Assessment Program (DEAP) $ - $ - $ - $ - $ - $ - $ - $ - $ 6,100 $ 250 $ 6,100 $ 250 Health Provider Systems (Medical Core) $ - $ 4,817 $ - $ 2,057 $ 7,632 $ 11,054 $ 7,632 $ 11,054 $ 6,000 $ - $ (1,632) $ (11,054) Mental Health (Strategic Programming Initiative) $ - $ - $ - $ - $ - $ - $ - $ - $ 2,050 $ 2,270 $ 2,050 $ 2,270 International Classification of Diseases (ICD-10) $ 2,522 $ - $ 2,078 $ - $ - $ - $ - $ - $ - $ - $ - $ - Computerized Patient Records System (CPRS) $ 4,219 $ - $ 300 $ - $ - $ - $ - $ - $ - $ - $ - $ - Camp Lejeune $ 2,579 $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - Class III to I Testing (Medical Legacy) $ 629 $ 2,152 $ 571 $ - $ - $ - $ - $ - $ - $ - $ - $ - Surgical Quality and Workflow Management $ 617 $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - Healthcare Reform / Affordable Care Act $ 1,562 $ - $ 297 $ - $ - $ - $ - $ - $ - $ - $ - $ - Bar Code Expansion $ 274 $ - $ 1,107 $ - $ - $ - $ - $ - $ - $ - $ - $ - Strategic Capital Investment Planning (SCIP) $ - $ 748 $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - Vocational Rehabilitation & Employment (VR&E) $ - $ 4,065 $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - Compensation and Pension (C&P) - include Application Maintenance $ - $ 10,078 $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - Chapter 33 $ - $ 7,101 $ - $ - $ - $ 16,131 $ - $ 16,131 $ - $ - $ - $ (16,131) VA Medication Reconciliation $ - $ - $ 1,000 $ - $ - $ - $ - $ - $ - $ - $ - $ - TeleCounseling National Rollout $ - $ - $ 500 $ - $ - $ - $ - $ - $ - $ - $ - $ - Total $ 170,784 $ 111,380 $ 24,111 $ 2,057 $ 139,114 $ 114,194 $ 139,114 $ 114,194 $ 191,553 $ 186,501 $ 52,439 $ 72,307 TOTAL DME and OM $ 282,164 $ 26,168 $ 253,308 $ 253,308 $ 378,054 $ 124,746 Improve Veteran Access to VA Benefits and Services - $378.1 million The 2016 request of $378.1 million funds VA s IT Access to Care programs which will support the development and proliferation of an organizational approach that is personalized, proactive, and patient-driven. VA health services use technology and health informatics to provide Veterans with better access and more effective care management. Advances in services, such as virtual care, expands access to health care services, reduce the need for travel to medical facilities, and transforms VA s delivery of health care and its effect on patients health outcomes. Improved access to care through telehealth and 2016 Congressional Submission IT-339

342 other virtual services is of particular benefit to rural Veterans, as well as those with chronic conditions and/or impaired mobility. In 2016, funding will support the following programs that support improved access to care. Veteran Customer Experience (VCE) - $181.8 million Veteran Customer Experience (VCE), formerly called Veterans Relationship Management (VRM), will deliver and execute an enterprise-wide scalable, commercialized, Veterancentric, services-based technology environment that will be the foundation for how Veterans are served and how benefits and services are delivered. This new model will provide VA not only an integrated services delivery platform with the approach of placing the Veteran at the center, but will provide best-in-class and industry standard customer service with clear satisfaction and delivery measures. Continuing the work that began by the Veterans Relationship Management (VRM) Program Management Office, VCE will improve Veteran, beneficiary, and partner access to VA using state of the art Customer Relationship Management (CRM) and self-service tools enabled by an enterprise platform that provides Veterans their choice of access methods. VCE will eliminate the potential for redundant and duplicative capabilities under VCE s purview reducing IT development and maintenance costs. By investing in VCE, VA will be able provide access to self service capabilities for over 5 million ebenefits registered users, support over 3,500 VSO partners in serving our Veterans, and provide VA frontline call center employees with Customer Relationship Management (CRM) and knowledge management tools in providing excellent customer service. This investment will help VA in expanding and improving access for additional stakeholders and partners Request: The 2016 request of $181.8 million is broken down into $67.23 million in development, $98.7 million in mandatory sustainment, and $15.9 million in marginal sustainment funds. VCE will establish and maintain an integrated framework allowing VA customers to reliably access and obtain authoritative and uniform data information on VA benefits and services. VCE will provide a single authoritative Veteran view for use across VA. VCE will provide interactive and technical support to helpdesks and those that directly support VA customers and serve as a liaison between VA Lines Of Business and VA clients (those external to VA). The VCE organization will combine business and IT staff working towards common goals and metrics to support world-class customer service (agent-assisted and self-service) common reusable platforms, allowing for greater integration across the enterprise and enabling all systems to consistently provide a single view of the Veteran within VA and a single view of VA to the veteran. VCE will provide one View of VA with multiple access methods for Veterans to interact and get what they need easily, quickly, and consistently. Through the VCE identity and access management tools, VA will be able to direct theveteran to specific service that are available to them via self-service, agent-assisted call centers, onsite kiosks or mobile applications. VCE will support the streamlining of VA business processes via virtual access for our veterans, Servicemember and their families including electronic claims submission, automation of enrollment and letter generation,. Achieving VCE s strategic goals and objectives is critical to establishing a foundation for integrated service delivery. To ensure long-term support and adherence to VCE s strategic 2016 Congressional Submission IT-340

343 plan, additional and ongoing phases of work will include planning operations, ensuring staff has the support and motivation to execute strategy, and continuous monitoring and refinement of implemented initiatives through annual reviews of VCE s goals and objectives. The strategy map below ties together the VA/VCE mission, vision, strategic themes, strategic goals and objectives Deliverables: In 2015, OIT will deliver both Agent-Assisted and Self-Service platforms across the enterprise, additional services and common capabilities developed for Call Centers, Identity and Access Management, and the catalog of data and web services that can be reused by all organizations. Telehealth/Connected Health/Telehealth Expansion - $50.1 million VA must make use of emerging technologies to increase access to care and more efficiently perform associated services such as appointment scheduling. Connected Health oversees the following programs: My HealtheVet, Web & Mobile Solutions, Telehealth, Veterans Point of Service (including kiosks), and VHA Innovation. Each of these programs uses technology to provide a virtual connection between the Veteran and their health care providers which expands the Veteran access to care and allows the Veteran to more efficiently manage their health care. The Connected Health program maintains an 2016 Congressional Submission IT-341

344 organized and seamless experience for the Veteran as they make use of these virtual services Request: The 2016 request of $50.1 million is consists of $4.1 million in development, $40.0 million mandatory sustainment, and $5.98 million in marginal sustainment funds. This request will expand Veteran access to care by making health care services available at any location of the Veteran. My HealtheVet will provide health care record data to the Veteran for their download anywhere. Telehealth services will make the home into the preferred place of care for the Veteran. Telehealth store and forward capabilities will allow data transmission to providers for timely assessment outside of clinic hours. Web and Mobile Solutions will continue to make mobile devices and webbased applications available for use by the Veteran and their health care providers on-thego. Veterans Point of Service will continue to provide information on VA prescriptions and business/benefits management at kiosks. The Innovations program will provide opportunities to pilot new approaches Deliverables: Veterans Point of Service: Deployment of the Veterans Point of Service capability representing 5400 kiosks deployed to 161 medical centers and 691 community based outpatient centers. 8 million successful kiosks interactions My HealtheVet: The redesign (to improve navigation, ease of use, and device agnostic) of the My HealtheVet Website providing services to almost 2.9 million registered Veteran participants. Maintain, enhance and add additional functionality to the My HealtheVet services such as the on-line Rx refill program which will complete an estimated 10 million requests in FY 2015, and the Secure Messaging capability which over 1 million patients have selected as an optional communication channel to their care providers. Access to Care (Medical Core and Medical Legacy) - $31.8 million Access to care helps to transform VHA and to ensure a more holistic, Veteran-centered system. The aim of improved access to care is to create a culture of continuous process improvement that effectuates improved operational efficiencies and improved Veteran and employee satisfaction. The program is critical to VHA s goals and initiatives to improve: access to health care; patient flow; cost reductions; decrease in wait times; patient safety; and the quality of care delivery for patients across VHA. Surgery Quality Workflow Management (SQWM), Emergency Department Information System (EDIS) and Clinical Flow Management (CFM) are part of a suite of patient flow applications that also includes Bed Management System (BMS). These applications enhance patient flow by improving Operating Room (OR) scheduling, decreasing elective surgery wait times, improving emergency department patient tracking and throughput, integrating all flow applications, providing real time bed status and improved data quality Request: The 2016 request of $31.8 million consists of $17.97 million in development and $13.78 million in sustainment. These funds will be used to achieve the following outcomes: 2016 Congressional Submission IT-342

345 Decrease wait times for elective surgery; Improved OR scheduling; Improved quality of care (EDIS will provide clinical pathways for care e.g. stroke); Improved patient flow resulting in improved access to care; Integration of flow applications; Decrease in VA purchased care; Improved patient safety by decreasing medical errors; and Ensure Less wait time for elective surgery Deliverables: 2015 deliverables include: Complete initial testing of SQWM capability at 11 sites and system sustainment activities. Capabilities include Operating Room Scheduling, Nurse Intraoperative Reporting, Surgeon Pre-operative and Post-Operative Clinical Documentation and automated collection of Surgery Quality Data. Health Administrative Systems - $29.0 million The Health Administrative Systems program supports several critical VHA business functions that ultimately expand Veterans access to care and reduce the cost of that care. It partners with key VHA and VBA stakeholders to develop health information technology solutions for transformational healthcare delivery with strategies including efforts to fully transition from a partially manual claims processing system to a completely automated system; eliminate multiple billing for Veterans; create a web-based package that tracks volunteers, their assignments, schedules, hours and affiliated organizations; annual enhancements to information systems supporting the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), which is a vital health benefits program that allows cost sharing of certain health care services and supplies with eligible beneficiaries). Additionally, the Health Administrative Services program is designed to help expand capabilities and tools that allows for efficient and secure data sharing of valuable administrative and demographic information. The Health Administrative System will significantly improve health care delivery for Veterans by enhancing patient satisfaction stemming from Veterans no longer burdened to pay multiple administrative delinquency fees to VA each billing cycle 2016 Request: The 2016 request of $29.0 million consists of $27.8 million in development and $1.2 million in sustainment. Funding for the Health Administrative System will allow VA to: Develop a consolidated patient statement that includes Veterans co-payment charges from all VA facilities, eliminating redundant patient statements going to Veterans. Implement multiple enhancements to VHA billing systems to improve the efficiency of generating first and third party billing processes; this will result in increased collections Congressional Submission IT-343

346 Address errors through automation in Veteran family member health care benefit programs, such as Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) and Spina Bifida, by eliminating manual eligibility decisions; increased decision accuracy will result in fewer resources needed to recover and recapture medical service dollars. Provide critical upgrades to the VA Voluntary Service System (VSS) which has not been enhanced since 2006, which will significantly increase the ability to meet mandatory security requirements, safety, fiscal accountability, reporting, tracking and communications. VA will also benefit by reducing current lengthy processes, which will allow VA Voluntary Service to place volunteers into service more quickly, with increased donations and volunteer hours that help support VA field stations, and efficiencies that will save much money for VA over the long-term. Continue deployment of a web-based, integrated, enterprise-level asset and service management system for both administrative and clinical support lines of business, allowing VHA to address deficiencies and replace existing legacy systems 2015 Deliverables: In 2015, OIT will: Develop a consolidated patient statement that includes Veterans co-payment charges from all VA facilities, eliminating redundant patient statements going to Veterans; and implement multiple enhancements to VHA billing systems to improve the efficiency of generating first and third party billing processes. Address errors through automation in Veteran family member health care benefit programs, such as CHAMPVA and Spina Bifida, by eliminating manual eligibility decisions; and continue deployment of a web-based, integrated, enterprise-level asset and service management system for all clinical support lines of business, allowing VHA to address deficiencies in and replace existing legacy systems. Expand Administrative Data Repository (ADR) capabilities to additional end user applications and include additional administrative related data in the database; and provide critical enhancements to the Voluntary Service System, which will allow VA to place volunteers into service more quickly and further support the efficient delivery of health care. New Models of Care (NMOC) - $25.7 million The New Models of Care program provides critical support for VHA s efforts to: improve access to and coordination of care; enhance patient flow and quality of care; increase provision and effectiveness of localized care and transform its healthcare to a more holistic, Veteran-centered system. The program supports: the expansion and enhancement of Patient Aligned Care Teams (PACT) which focuses on partnerships with Veterans, access to care using diverse methods, team-based, Veteran centered care; enhanced ability to care for Veterans in remote areas and in their homes; enhanced patient centered care of women Veterans; increased overall health-related quality of Veterans life and well-being by reducing Veteran morbidity and premature mortality; improved patient flow and operating efficiencies, enhanced patient access to care and maximized Veteranprovider-family collaboration; providing Veterans with patient-centered alternatives to long-term institutional care Congressional Submission IT-344

347 2016 Request: The 2016 request of $25.7 million consists of $25.4 million in development and $250 thousand in marginal sustainment. Funding in 2016 will: Ensure patient engagement in self-care, preventive services, primary care, and mental health services; Ensure that all women Veterans experience equitable, high quality, timely, and comprehensive health care in a sensitive and safe environment at all points of care; Enhance the ability to provide care for Veterans in remote areas and in their homes; Enhance patient access to care and continued maximization of Veteran-providerfamily collaboration; Improve access to and quality in the delivery of Veteran services; and Identify and resolve patient flow bottlenecks between and among departments and VA Medical Centers (VAMCs) Deliverables: Release of three separate mobile applications: Move! Coach, Safe Prescribing and Caring4Women Veteran s. Linkage of Veteran s Health Library (VHL) to the Compensation Pension Records System (CPRS) Tools Menu. Release of Health Risk Assessment / HealtheLiving Assessment (HLA/HRA) capabilities which will include addition of treatment location and enhanced clinical reporting capabilities. Complete development on VA Moms, the Maternity Care Coordinator, Preconception care mobile applications. Complete development and deploy the Breast Care Registry Completion Project. Complete the pilot for the Maternity Tracking - Women s Health VAI2 Innovation Project. Complete integration of Tracking Abnormal Test Results and Notification of Teratogenic Drugs into CPRS V31. Deploy Tele Intensive Care Unit (ICU) Capability to 8 additional sites. Home Telehealth Records Enhancement (HTRE): Enhancements to web tools and Vendor data streams and enhancements to web portal. Enrollment System Modernization - $18.9 million The Enrollment System Modernization Program supports a shared enterprise business solution for the future modernizations of Core Registration, Eligibility and Enrollment information, Health Benefits information and integration with other VA and Federal Government agencies. This solution will improve Veterans, Family Members and Beneficiaries access to VA s Heath Care System and services. Additionally, this business solution supports an enterprise approach and distributes health benefits decision making and management across VA s systems such as Purchased Care, Caregivers, State Homes, etc. This shared enterprise business solution will improve the cost, quality, and performance of many business processes and systems. The implementation of this business solution will allow Chief Business Office (CBO) staff to focus on continued business process improvements and standardized solutions that can be implemented, maintained and managed by experienced staff. This will allow other departments within the VA and other Federal Government agencies to focus on their core mission Congressional Submission IT-345

348 2016 Request: The 2016 request of $18.9 million consists of $13.9 million in development and $5.0 million in marginal sustainment funds. Funding for Specialty Care and PACT will ensure that specialists and the PACT concept have the necessary support staff to optimize their outpatient clinic(s) and staffing for Teamlet (Provider, RN, LPN, & clerk) and Expanded PACT staff (Clinical Pharmacists, Social Workers & Dieticians). Additional High Level Requirements for the Enrollment System Modernization Program are: Providing one Health Benefits System (HBS) that distributes health benefits decision-making and management across VA s system. Providing greater transparency into the Core Registration, Eligibility and Enrollment and Health Benefits information. Improvement in: the enrollment pre-termination process; handling of Core Registration, Eligibility and Enrollment and Health Benefits data inconsistencies; Core Registration, Eligibility and Enrollment and Health Benefits data quality; Address Management; and business processes across the agency and the mechanism for one HBS. All new registrations to be performed in the Enrollment System (ES), in lieu of VistA. Improving Core Registration, Eligibility and Enrollment and Health Benefits Auditing and Access Control. Providing one source for Core Registration, Eligibility and Enrollment and Health Benefits auditable reporting that support varies levels throughout the VA. Mobile Development Health Apps - $12.7 million The goal of the Mobile Applications Program (MAP) is to provide VA with a mobile applications development and production environment that leverages mobile devices for expanding the number and quality of services provided to Veterans. The MAP effort will reduce application development time, improve code quality, reduce risk to source systems, reduce application cost, and provide objective metrics regarding code quality Request: The 2016 request of $12.7 million consists of $11 million in development and $1.7 million in marginal sustainment funds. The program s objective is to develop and release mobile device enabled software. Funds in 2016 will improve Veteran access to VA benefits and healthcare services through self-service technology-enabled interactions. The technology promotes faster access to care as well as access to Patient Generated Data that promotes quality care. Self-service technology-enabled interactions provide access to information and the ability to execute transactions at the place and time convenient to the Veterans; allowing Veterans the opportunity to access VA information and services anytime through enhanced quality, accuracy, efficiency, and timeliness of information and data exchanges conducted over the web Deliverables: In 2015, OIT will provide an agile support team to facilitate requirements gathering and software development resulting in new web and mobile applications in support of virtual health care delivery Congressional Submission IT-346

349 For the Mobile Application Environment, OIT will provide maintenance, related monitoring and capacity planning. Also, provide the tools for software quality assurance, performance and integration testing. Provide an overarching enterprise mobile application software that defines objective workflows and outcomes, reuses software, facilitates communication, prevents duplication, and links resources in order to achieve successful governance and facilitate development processes. Memorials Development - $11.5 million The objective of the Memorials Development Program is to support the transformation of the National Cemetery Administrative (NCA) business in order to improve the efficiency of Veterans' access to memorial benefits, improve end-user functionality, improve data quality, enhance chain of custody tracking of Veteran case status, enable remains tracking capability and increase NCA customer satisfaction Request: The 2016 request of $11.5 million consists of $10.0 million in development and $1.5 million in marginal sustainment funds. In 2016, the Memorials Development Program will continue to enhance or deliver new capabilities within the Memorial Benefits Management System (MBMS) suite of IT Products. MBMS leverages modern technology with web-based, on-line application systems designed for data flow interchange with VA s standardized modern platforms. When completely implemented, MBMS will provide interoperability with external systems, allowing Veterans, their next of kin and other users to save time with faster eligibility and forms processing capabilities. MBMS will also improve end-user functionality, end to end decedent chain of custody tracking, real time Veteran case status and will also enable state of the art remains tracking, digital real time Geographic Information System (GIS)/Global Positioning System (GPS) based mapping and geographic information, as well as mobile and web based under users enabling tools. These new capabilities will enable the VA strategic Goals of more effective delivery of services and improved NCA customer satisfaction in support of Veterans and their families. Specific 2016 goals of the Memorials Development Program include the following: Improving Veterans awareness of and access to burial and memorial benefits; Expanding the use of innovative methods for outreach and self-service to Veterans, their families, and the public; and Developing and implementing an automated, pre-need eligibility certification system and VA system interfaces to eliminate multiple inquiries from VA over the lifecycle of benefits delivery. The NCA continually strives to improve the Burial Operations Support System (BOSS) Enterprise solution through the investment of resources to automate manual business processes. In 2016, MBMS will continue to support the transformation of the NCA by enhancing and improving the delivery of Memorial Benefits IT capabilities. MBMS will improve end-user functionality, data quality, and chain of custody tracking of Veteran case status and will also enable remains tracking capability and increase NCA customer satisfaction in support of Veterans and their families Congressional Submission IT-347

350 2015 Deliverables: Deliverables will include: Web based application for Medallion Requests: Create a web based application for the customer to submit VA Form M, Claim for Government Medallion for Placement in a Private Cemetery, which is expected to increase customer self-service Web based Presidential Memorial Certificates (PMC) applications: Create a web based application for the customer to submit requests for PMC, which is expected to increase customer self-service PreNeed ebenefits Burial Planning: Provide changes to the PreNeed design and processing to allow for an interface with the ebenefits web portal, which is expected to increase customer self-service. Disability Exam and Assessment Program (DEAP) - $6.4 million DEAP delivers a clinical disability exam and assessment workflow system that universally assists healthcare professionals in conducting quality, timely and complete medical evaluations while simultaneously tracking performance and workload, and generating and delivering the medical evidence needed to the disability claims adjudicator and DoD, as needed Request: The 2016 request of $6.4 million consist of $6.1million in development and $250 thousand in marginal sustainment. The DEAP program will provide a secure, integrated, centralized location where Compensation Pension Fiduciary (CPF) evaluators (i.e.,vha, contract, DoD, and authorized private providers) and VBA end users can access and complete Disability Benefits Questionnaires (DBQs); whereby, improving the user experience of clinicians and raters by aligning DBQs with individual rating and clinical workflows; and providing computable data to facilitate a paperless claim process. This information is directly used in rating Veteran s percentile of disability, for quickly processing disability claims, and for rewarding earned service-connected benefits. It includes examination requests, assigning a provider, amassing information regarding the exam and tracks through adjudication and award status. Health Provider Systems (Medical Core) - $6.0 million This program area consists of critical major enhancements for the Computerized Patient Record System (CPRS) and important maintenance for a variety of related systems. CPRS, a Veterans Health Information Systems and Technology Architecture (VistA) computer application, provides an electronic medical record used throughout the VA in all care settings (Inpatient, Outpatient, Long-term care) in the delivery of patient care. CPRS integrates many clinical packages (e.g., laboratory, pharmacy, radiology) into a patient centric view and provides an environment where clinical care can be reviewed, documented, and preserved Request: The accessibility to patients online clinical information is a significant factor in the delivery of timely, safe, and quality care to the Veteran population. The CPRS development project addresses 10 requested enhancements, patient safety issues, and reported issues. Examples of these include Nurse Order Verification, Drug-Allergy Order Checks, Averse Reaction Reporting, and Medication Reconciliation. The ability to 2016 Congressional Submission IT-348

351 access a patient s clinical information across the VHA is a key driver for the continued delivery of high quality, safe clinical care. CPRS version 32 modifications are necessary to support dependent projects to keep pace with ongoing improvements in the delivery of health care services to Veterans Deliverables: Release CPRS v31 GUI will include: Tracking Abnormal Test Results. Notification of Teratogenic Drugs. Primary Care Management Module Re-host/Reengineering (PCMMR). Patient Safety /Remedy ticket updates and changes. Enhancements required by the Health Risk Assessment (HRA), VistA Imaging, and Camp Lejeune projects. Mental Health - $4.3 million VA is placing emphasis on the integration of Mental Health Services within Primary Care Services to ensure important coordination occurs in the delivery of comprehensive care to the Veteran. This integration activity supported by IT investments ensures the availability of a range of health care services, from treatment of a variety of common mental health conditions in primary care to more intensive interventions in specialty mental health programs for more severe and persisting mental health conditions. Specialty services such as evidence-based psychotherapies, intensive outpatient programs, residential rehabilitation treatment, and inpatient care are available to meet the range of Veterans' needs. Close coordination and collaboration of Mental Health Services with the VA Homelessness program is expected to result in reduction of substance abuse of homeless Veterans. Investment in IT for the Mental Health Services program area is essential for the success of the Homelessness program, improvement in comprehensive health care, and the reduction in Veteran suicides Request: Funding for the Mental Health Program will allow VA to: Develop the Compensated Work Therapy Payroll system which is an application supporting vocational rehabilitation that matches and supports work ready Veterans, mental health patients, in competitive jobs, through consultation with business and industry regarding their specific employment needs. This will help Veterans achieve a high level of vocational functioning by helping to place them in work assignments within the VA facility or the local community. Provide for Enhancements to the Veteran Crisis Line Software Application which will standardize nomenclature on the web-based application form in a way that allows the Suicide Prevention Center of Excellence (SPCE) to extract the information as actionable and reportable data, and develop a tool that can be used to pull reports on this data. Develop the National Clozapine Coordination Application needed for automation of ordering clozapine and reporting data for inpatients including all patient safety features currently provided to outpatients. This will create mechanisms to safely dispense a limited supply of clozapine under emergency conditions when Food and Drug Administration (FDA) and supporting agencies are not available Congressional Submission IT-349

352 Develop the Methadone Dispensing Tracking System needed to eliminate multiple drugs interaction risks. Develop an Evidence Based Psychotherapy (EBP) Training Tracking System needed to implement tracking and reporting enhancements to EBP training database in response to the addition of new EBP protocols. EBPs are used for treatment of Post-Traumatic Stress Disorder (PTSD), depression, serious mental illness, insomnia, and other conditions. Funding for the Mental Program will help significantly improve health care delivery for Veteran s by offering opportunities for improved access to new and innovative methods of treating mental health illnesses, as well as preventing the worsening of mental health conditions. Quality of care will be enhanced by reducing medication errors. Improvements in training opportunities with lead to better patient treatment outcomes. Mental health of Veterans will improve and suicides will be reduced. Overall health of Veterans will be improved and the public will have greater trust that VA is taking great care of Veterans Deliverables: Release of enhancements to the existing National Clozapine Coordination Application which improve the tracking of usage of Clozapine for patients with certain mental illness diagnosis. These improvements include that automation of ordering of Clozapine, a reduction in transaction times, increased data security, and elimination of manual paper handling, recording and storing of patient information. Increase the reliability and accuracy of data reported to the National Clozapine Coordination Center (NCCC) via automatic data rollup, reducing the amount of time currently required to manually retrieve missing information and correct erroneous information before transmission to the Food and Drug Administration (FDA). Addition of Clozapine to the Inpatient Medications package, allowing for Clozapine to be prescribed in an inpatient setting. Release of a version of the Posttraumatic Stress Disorder Symptom Checklist (PCL). PCL-5 is based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for PTSD. This tool will enable VA to begin to access PTSD symptoms in a manner reflected by the current science. Stabilize currently deployed Mental Health Assistant (MHA) in order to address known patient safety issues Congressional Submission IT-350

353 Information and Technology Eliminate the Disability Claims Backlog Eliminate the Disability Claims Backlog (Dollars in Thousands) / Actuals Carryover Budget Estimate Current Estimate Budget Request Increase / Decrease DME OM DME DME OM DME OM DME OM DME OM Veterans Benefits Management Systems $ 40,293 $ 67,938 $ 466 $ 44,500 $ 92,500 $ 44,500 $ 92,500 $ 76,000 $ 177,000 $ 31,500 $ 84,500 Veterans Service Network (VETSNET) $ 1,950 $ 3,582 $ 125 $ 19,000 $ 8,000 $ 19,000 $ 8,000 $ 10,000 $ 13,000 $ (9,000) $ 5,000 Appeals Modernization $ - $ - $ - $ - $ - $ - $ - $ 19,100 $ - $ 19,100 $ - Total $ 42,243 $ 71,520 $ 591 $ 63,500 $ 100,500 $ 63,500 $ 100,500 $ 105,100 $ 190,000 $ 41,600 $ 89,500 TOTAL DME and OM $ 113,763 $ 591 $ 164,000 $ 164,000 $ 295,100 $ 131,100 Eliminate the Disability Claims Backlog - $295.1 million The 2016 request of $295.1 million supports VA s initiative to eliminate the disability claims backlog. Improving quality and reducing the length of time it takes to process disability claims are integral to VA's mission of providing benefits to eligible Veterans in a timely, accurate, and compassionate manner. In 2013, VBA began measuring the accuracy of individual issues for each claim ( issue-based accuracy ), as it provides a more detailed measure of workload proficiency. However, VBA will continue to monitor and report out on claim-based accuracy as a key indicator for this Agency Priority Goal (APG). To improve benefits delivery, VA began transitioning to an electronic claims process that will reduce processing time and increase accuracy. Information technology solutions, such as VBMS, VETSNET and Appeals Modernization will drive automation, improve the quality of work, reduce variance, and speed efforts to complete claims electronically. These innovative technologies will also integrate business processes to take into account electronic filing of claims, national workload distribution, as well as the receipt of complete and certified medical, dental, and personnel records from the military services. A more detailed discussion on these innovative technologies is below. Veterans Benefits Management System (VBMS) - $253 million Each month, VBA processes approximately $3 billion in service-connected disability compensation benefits for over three million beneficiaries. The disability benefits claims process consists of five core process areas that require the execution of a series of key activities: claims establishment; claims development; rating management; award management; and appeals management. The full VBMS capability will support four of these key activities. VBMS impacts Veterans through automation opportunities and process improvements. Only through full funding for VBMS will VA be able to reduce reliance on legacy systems as well as continue to these improvements and capitalize on 2016 Congressional Submission IT-351

354 opportunities. VBMS has made significant strides and it is important to continue to evolve the systems and processes to transform not only our organizations, but the Veteran experience. Through the automated workflow, automated workload, and centralized distribution methods provided by the VBMS, VBA can target and prioritize specific claims, reducing the amount of time Veterans and beneficiaries are waiting for a decision. Additionally, automating business-rules for straightforward awards and decisions requiring few, if any, calculations will provide Veterans and beneficiaries with quicker notification and benefits delivery. Continued integration of benefits-related technology initiatives, will solidify VA s ability to provide 21st century benefits delivery to Veterans and beneficiaries. VBMS functionality gives VBA in 2016 the potential to complete over 3,000 more Veterans claims per month than now Request: The 2016 request of $253 million consists of $76 million in development and $177 million in sustainment funds. VBMS will enable VBA to go beyond eliminating the existing claims backlog by providing the integrated claims processing solutions that support the strategic goals to Empower Veterans to Improve Their Well-being and Enhance and Develop Trusted Partnerships. For example, the Integrated Disability Evaluation System (IDES) initiative, targeted for 2016, will enable the IDES process to be completely paperless, resulting in improved claims processing times ultimately leading to benefits being paid to qualified discharging Servicemember immediately upon discharge. This will enhance VA s Partnership with the Department of Defense (DoD) and develop solutions to seamlessly interface with IDES to ensure a smooth transition for some of our more seriously injured Veterans. By the end of fiscal year 2015, VBMS will have delivered the 80 percent" solution to claims processing automation and electronic folder capabilities. VBA requires full 2016 funding for VBMS development, modernization, and enhancement (DME), to development and implement the remaining 20% automation capability Deliverables: Expansion of the Digits-to-Digits (D2D) direct data exchange, further allowing the claims processing systems of the Veteran Service Organizations (VSOs) and state processing agencies to push data directly into VBMS and the Corporate Database. This includes processing of all VA forms and secures bi-directional messaging. This will expand Veterans access to services and expedite claims processing. Expansion of new mobile application solutions, and increase access to self-service tools and benefits/services information in the ebenefits and Stakeholder Enterprise Portal (SEP) environments providing Veterans the ability to edit personal contact information; file compensation claims to include the upload of claims-related supporting documents by taking a picture via the mobile device; and access detailed information about their compensation claim and VA home loan. Provide Veterans a personalized list of potential benefits based on their ebenefits profile Congressional Submission IT-352

355 Allow Servicemember, Veterans, and VSOs to request and retrieve their Service Treatment Records (STR) via an integrated process. Establish direct Social Security Numbers verification with the Social Security Administration system of record in order to provide enhanced security of Veterans confidential information and PersonalIdentifiable Information (PII). VETSNET / Finance and Accounting System (FAS) - $23 million The Veterans Service Network (VETSNET) Finance and Accounting System is the payment engine for both VETSNET and VBMS. VETSNET is a streamlined information system that establishes, develops, and rates a claim, prepares award, generates payment information and notifies the Veteran. The 2016 initiative is primarily concerned with 3 areas: Support of Veteran and Beneficiary payments through VBA s Finance and Accounting System (FAS). Support of Veteran and Beneficiary payments through maintenance and new development of interfaces between FAS and external agencies and departments, i.e. Treasury, Debt Management Center (DMC), and others. Cost savings by transferring dependence on legacy Benefits Delivery Network (BDN) system to FAS so that legacy systems can be retired. This will require significant new development within FAS. FAS has significant impact to the Veteran, as it is VA s payment engine, paying all the Department s Veterans and Beneficiaries each month; roughly 4.5 million Veterans and beneficiaries receive an estimated $5 billion dollars monthly. Additional opportunities may exist to leverage FAS as VHA s success with the Caregivers Enhancement project expands to other initiatives. Keeping the payment system current, as laws change and as external dependencies change (Treasury, Debt Management Center, Congressional activity, etc.) is a necessity for VBA to continue to fundamentally continue its mission. As BDN support knowledge is reduced through attrition, VA loses the ability to react to increased risk of older system maintenance needs, and any new requirements realized by external agencies, changes in law, interfaces to internal and external systems, etc. With an ever-decreasing support base for BDN systems, and an ongoing incentive for BDN retirement, the impact to the Veteran is experienced in the added risks of continued dependency on these systems Request: The 2016 request of $23 million consists of $10.0 million in development and $13.0 million in sustainment funds. In 2016, plans are to complete as much work as possible on retiring the legacy BDN system that is very expensive to maintain and very risky to rely upon. Funding in 2016 will provide support for the delivery of the following FAS functionality: Conversion of Chapter 30 - Montgomery GI Bill benefit payments Conversion of Restored Entitlement Program for Survivors (REPS) benefit payments 2016 Congressional Submission IT-353

356 Development of interfaces and supporting functionality for the Debt Management Center Centralized Accounts Receivable System (CARS) update that they have in process Deliverables: OIT will provide the following payment functionality through FAS and continue the retirement of BDN, along with record conversion from the legacy system to the VBA CORPORATE database: Chapter 18 Benefits for Children of Vietnam Veterans benefit payments Chapter 31- Vocational Rehabilitation Burials benefit payments Provide functionality to support OMB initiative to identify current year funds separately from prior year funds. Appeals Modernization - $19.1 million The Board of Veterans Appeals (BVA or the Board) plans to establish VA Appeals Modernization as an enterprise-wide initiative to manage end-to-end appeals modernization, providing improved appeals processing at every stage of the multi-step appeals process throughout the Department in order to better serve Veterans and their families. The VA appeals process spans across all VA Administrations, to include VBA, VHA, and NCA, as well as the Office of General Counsel (OGC) and BVA. Veterans, dependents, and survivors have a right to appeal any aspect of a benefits decision. The VA appeals process is unique from other standard appeals processes across Federal and judicial systems. While the vast majority (approximately 96 percent) of appeals to the Board come from VBA Compensation Service, it is important to note that the Board receives appeals from all other business lines within VBA (to include Fiduciary, Pension, Vocational Rehabilitation, Home Loan Guaranty, Education), as well as appeals from VHA, NCA, and OGC. Modernization has occurred on the front end (i.e., claims) and the back end (i.e., Federal courts) of the VA benefits process, yet VA appeals processing at VBA (and other appeals business lines) and the Board remain largely paper bound with heavy reliance on manual data processing by utilizing antiquated, uncoordinated systems. Appeals across the Department are currently processed in a hybrid environment with reliance on paper, and multiple unsynchronized, outdated legacy systems. Manual data entry and lack of appeals-specific paperless functionality creates risk for the Department in workload management as well as processing delays, and there is minimal appeals-specific VBMS functionality, which creates inefficiencies in end-to-end appeals processing. VA has seen the benefits of people, process and technology transformation at the claims level with increased claims decisions being issued and more Veterans being served 1.17 million in 2013 and record-breaking projections for claims decided in 2014; the same rigorous, multi-pronged efforts to modernize must be applied to the appeals process. The Board will lead this initiative, which includes robust IT and FTE components, in order to mitigate risks and to provide timely service to Veterans and their families. Notably, with appeals-specific functionality enhancements, Veterans and their families will directly 2016 Congressional Submission IT-354

357 benefit through issuance of more appeals decisions and reduced wait times for these decisions. In addition, the Department will gain future cost savings by being able to retire or sunset outdated and unsynchronized legacy systems exclusively used for appeals processing, such as the Veterans Appeals Control and Locator System (VACOLS), which was created in the 1990s Request: The 2016 request of $19.1 million in development funding will allow the Department to contain and ultimately reduce the VA appeals inventory, which currently stands at over 350,000 appeals, and efficiently process future appeals workload. On average, 11-12% of VA claims decisions are appealed a rate that has held steady over the past 20 years. As more claims have been completed over the past 5 years, more appeals have emerged at a steady proportional rate. In 2016, the Department will be able to begin a multi-phase process of enhancing appeals functionality in the paperless environment. These enhancements are necessary to keep pace with the transformation of benefits processing that has occurred on the front end (i.e., claims) of the VA benefits system. Initial key appeals-specific functionalities in the paperless environment, which do not currently exist in VBMS or other systems, would include: Creating work queues to move paperless appeals between jurisdictions and within the Board; Ability to push/pull data between systems so as to avoid the requirement of logging on to multiple, unsynchronized systems; Programming a new station coding to properly identify that appeals have been transferred to or from the Board; Automating docket management features; Building ad-hoc report capabilities for appeals-related data, personnel performance data, and other information; Programming a correspondence/decision builder capability to streamline written work product; Building indicators/alerts; Programming a mass export capability, and other features Congressional Submission IT-355

358 Information and Technology Eliminate Veteran Homelessness Eliminate Veteran Homelessness - $1.5 million The Eliminate Veteran Homelessness (EVH) initiative originated in 2010 as a major initiative (MI) and it s intended to prevent Veterans and their families from entering homelessness and to assist those who are homeless in exiting as safely and quickly as possible. VA s no wrong door philosophy will ensure that homeless and at risk for homeless Veterans have timely access to appropriate housing and services. Any door a Veteran comes to - at a medical center, a regional office, or a community organization - will lead to the tools to offer Veteran assistance. Eliminating homelessness among Veterans will advance the mission of VA by ensuring that all Veterans and their families achieve housing stability. Homelessness (Registries) $1.5 million Systems such as, Health Management Information System (HMIS) and Veteran Re-entry Identification System (VRIS), support the EVH program s efforts by automating processes to gather data needed to provide services to Veterans that are in need of homelessness services. Homelessness Registries will provide a tremendous benefit to Veterans by: Identifying incarcerated Veterans (Incarceration is the most powerful predictor of homelessness) Ensuring faster implementation of services to incarcerated Veterans by local Healthcare for Re-entry Veterans (HCRV) and Veterans Justice Outreach (VJO) Specialists. Results generated by VRIS are used by VJO staff daily to conduct outreach to Veterans in prison, jail and court facilities Congressional Submission IT-356

359 Allowing local communities to identify Veterans currently accessing non-va community homeless programs Helping local providers connect homeless Veterans to VA services Request: The 2016 request of $1.5 million consists of $1.2 million in development and $300 thousand in marginal sustainment will provide support for the following: Enhancement and sustainment of VRIS to provide an automated method to identify incarcerated Veterans in custody in U.S. correctional facilities (promoted by the Secretary in his December 2, 2013 keynote address) Enhancement and sustainment of HMIS which is the integral to meeting reporting requirements by Supportive Services for Veteran Families (SSVF) grantees (VA s SSVF program currently provides $300 million in grants each year to community non-profits grantees) 2016 Congressional Submission IT-357

360 Information and Technology Information Security Information Security** (Dollars in Thousands) / Obligations Carryover Budget Estimate Current Estimate Budget Request Increase / Decrease Cyber Security Program $ 52,338 $ - $ 45,400 $ 45,400 $ 53,060 $ 7,660 Network Operations Center (NOC) $ - $ - $ 45,000 $ 45,000 $ 45,630 $ 630 CRISP Support $ - $ - $ - $ - $ 30,160 $ 30,160 Security Operations Center (SOC) $ - $ - $ 22,200 $ 22,200 $ 24,000 $ 1,800 Network and Security Operations Center (NSOC)* $ 87,894 $ - $ - $ - $ - $ - Mobile Applications and Wireless Security $ - $ - $ 25,000 $ 25,000 $ - $ (25,000) Privacy & Records Management $ 4,402 $ - $ 5,300 $ 5,300 $ 10,340 $ 5,040 Risk Management Incidence Response $ - $ - $ 4,900 $ 4,900 $ - $ (4,900) Business Continuity Support $ - $ - $ 4,200 $ 4,200 $ 6,850 $ 2,650 Field Security Services $ - $ - $ 4,000 $ 4,000 $ 5,180 $ 1,180 Information /Data Security $ - $ - $ - $ - $ 3,900 $ 3,900 ICAM development $ - $ - $ - $ - $ 800 $ 800 Identity, Credential and Access Management (ICAM) $ - $ - $ - $ - $ 380 $ 380 Total $ 144,635 $ - $ 156,000 $ 156,000 $ 180,300 $ 24,300 * For 2015 and 2016 funding for NSOC is split into NOC and SOC ** Information Security funding is categorized as mandatory sustainment with the exception of ICAM development, shown in the table. Information Security - $180.3 million Cyber Security Program - $53.1 million The Office of Cyber Security (OCS) is responsible for advancing the overall cyber security posture of VA through enhanced visibility in VA IT systems and networks, and with leading edge guidance, support and tools, while ensuring the VA and its mission partners information systems, practices, policies, processes and procedures comply with federal mandates. OCS works to proactively mitigate risks resulting from the increase in the number and sophistication of cyber threats. In addition, OCS develops and evaluates Department-level information security policies, supports Certification and Accreditation (C&A) activities, assists in remediation of Plan of Action and Milestones (POA&M), and ensures that VA IT systems security is managed in a manner that is compliant with all federal laws, regulations, and guidelines governing IT security. Lastly, OCS is responsible for managing the Enterprise Visibility and Vulnerability Management (EVVM) function that continually assesses the VA s environment consistent with Federal Continuous Monitoring mandates Request: The 2016 request of $53.1 million in mandatory sustainment will support the operations and maintenance of the Cyber Security Program. Implementation of cyber 2016 Congressional Submission IT-358

361 security requirements evolves the VA cyber posture improving service delivery and collaboration and risk awareness, while improving the security and resiliency of the underlying VA infrastructure facilitating enhanced visibility, access and functionality across the spectrum of VA services for the Veteran. Funds in 2016 will: Develop and implement policy and program activities that provide Cyber Security services and products to support the mission of the OCS; Promote the Cyber Security program in terms of its business value by knowing and representing the program, consistent with VA and OIT objectives and goals; Expand capabilities to improve Continuous Monitoring capabilities across the Department; Develop cyber security architecture capabilities to improve the Department s ability to address evolving threats; Expand visibility to everything efforts to enforce security; Improve VA threat intelligence by developing partnerships with trusted sharing communities, mission partners, and other government entities; and Share information and collaborate more closely with federal partners to build a more comprehensive understanding of advanced cyber threats Deliverables: In 2015, OIT will: Review system posture, identify any IT related deficiencies, and implement corrective actions or develop compensating controls; Development of corrective actions list, strategic, operational and tactical guidance and plans; Enhance VA s Continuous Monitoring (CM) capability by expanding functionality, accessibility as well as pursing enhancements to meet the policy mandates associated with CM; Foster cyber security collaboration and information sharing with VA and its mission partners; Remediate the malware and threats; Provide vulnerability and platform updates including bug fixes, technical support for the platform, as well as Enterprise Visibility, Internal/external (e.g. IG, DHS, OMB, GAO) reporting; Revise, review, and interpret the operational, technical, and management controls required by VA s information security program; Maintain information protection directives and handbooks so that VA is compliant with all applicable federal requirements and standards; and Develop a Risk Management capability to a disciplined and structured process that integrates information security and risk management activities into the system development life cycle. Network Operations Center $45.6 million The reorganization of the Network Security Operations Center (NSOC) separated the Network Operations Center (NOC) communications costs from Security Operations Center (SOC) security functions in order to better understand costs and performance, 2016 Congressional Submission IT-359

362 provide better oversight, increase responsiveness, and provide a better understanding of long-haul transport costs. The NOC is also responsible for protecting VA information on a 24x7 basis by monitoring, responding to, and reporting cyber threats and vulnerabilities; managing Internet gateways; conducting Enterprise-network monitoring; and providing value-added network and security management services as requested Request: The 2016 request of $45.6 million in mandatory sustainment will support the operations and maintenance of the NOC Trusted Internet Connection (TIC) Initiative, which is a Department of Homeland Security (DHS) requirement and is mandated in Office of Management and Budget (OMB) Memorandum M Deliverables: In 2015, there will be increased technical and operational control capabilities required to detect malicious activity and mitigate vulnerabilities that potentially expose system or personally identifiable information. Continuous Readiness in Information Security Program (CRISP) Support - $30.2 million The CRISP Program is designed to ensure VA s information security infrastructure is continuously secure and VA is protecting the sensitive information of approximately 22 million Veterans. CRISP ensures the proper technology and policies are in place nationwide so that Veteran information at VA offices, clinics, and hospitals is constantly secure and Veterans identities are never put at risk. The primary objectives of CRISP are to: identify, prioritize, and remediate vulnerabilities on VA information systems; ensure baseline configurations and security standards are updated as new vulnerabilities are discovered and remediated; ensure software standards are continually reviewed and updated and that installed software versions comply with these standards; identify, collect, analyze, and report performance metrics to measure the effectiveness of the patch and vulnerability management, baseline configuration maintenance, and software standards maintenance processes; and propose changes to improve these processes Request: Funds in 2016 will create a program management office to oversee information security controls within VA and ensure continuous readiness in VA s information security structure. Oversight will include all phases (e.g., development, prioritization, implementation, monitoring, etc.). The program will assist VA in eliminating the information security material weakness, and it will ensure that VA continues to meet the highest standard of information security Deliverables: OIT will: Assist VA Senior Management to understand the efficacy of the Information Security controls implementation consistent with FISCAM audit requirements. Develop and support the implementation of a prioritized set of corrective actions to enhance the effectiveness of these controls in time to meet the planned audit cycle Congressional Submission IT-360

363 Provide suggestions for improvement associated with the mitigation and/or remediation of the recurring Material Weakness finding. Security Operations Center - $24 million The Security Operations Center (SOC) provides continuous, around-the-clock monitoring of VA s network and Trusted Internet Connection Gateways protecting, responding to, and reporting threats. Security services include the identification and full complement of incident response capabilities to deter, detect, and defeat potential threats that may adversely affect VA networks and systems Request: VA-SOC maintains two operations sites and four Trusted Internet Connection Gateways on a 24x7x365 basis. As such, funding is required to operate, manage and maintain security systems that protect VA information systems and defend against malicious actions. The services provided by VA SOC facilitate a secure network environment that enables VA Business lines to protect Veteran information and deliver safe, secure and timely world class services to our Nation s Veterans Deliverables: 2015 deliverables include the following activities: Current technologies that provide electronic mail filtering, content validation and inspection and forensic analysis will be refreshed and upgraded to deliver service consistent with the increased use of electronic media. Firewalls and intrusion prevention devices at the Trusted Internet Gateways will be refreshed and upgraded Privacy and Records Management - $10.3 million The Office of Privacy and Records Management (OPRM) works across the Department to integrate privacy considerations, requests for information, manage official records, and ensure that the confidentiality, integrity, and availability of VA sensitive information and information systems are protected. OPRM is made up of three services: the Privacy Service, Enterprise Records Service, and the FOIA Service Request: The objective of Privacy and Records Management is ensure provisions are in place to protect all personally identifiable information, protected health information and sensitive personal information (SPI) of the Veteran and the employee. The protection of Veteran information ensures that all available benefits and entitlements are processed and provided in a timely manner. Assurances are made during the Privacy Impact Assessment process to ensure Veteran data is protected and used in accordance with applicable laws and statutes. This process allows current and proposed systems to accurately process claims and provide Veteran services within the law and as allowed by policy. Funds in 2016 will work to protect VA against data breaches Deliverables: Provide mandatory compliance support for various matters related to information protection including privacy, risk management, records management, Freedom of Information Act (FOIA), incident response and identity theft prevention Congressional Submission IT-361

364 Develop, implement and oversee the policies, procedures, training, communication and operations related to improving how VA and its partners safeguard the personally identifiable information (PII) of Veterans, dependents and VA employees while assuring confidentiality, integrity and availability of information and information systems. Comply with specific Health Insurance Portability and Accountability Act (HIPAA), Health Information Technology for Economic and Clinical Health Act (HITECH), the Privacy Act, the E-Government Act, the Federal Information Security Management Act (FISMA), the National Institute of Standards & Technology (NIST) and other policy-related and administrative requirements. Comply with egov Act, OPEN Government Act and current FOIA regulations and open government timeframes established by Presidential Memorandum and Attorney General's guidance. Review and track Privacy Impact Assessments (PIA) in accordance with the Federal Information Security Management Act (FISMA) and Section 208, E- Government Act of Provide tools required to successfully track and investigate privacy/security incidents across the VA. Business Continuity Support (COOP) $6.9 million Business Continuity (BC) acts as a liaison between the VA Office of Operations, Security, and Preparedness (OSP) and OIT on matters concerning Continuity of Operations and operational situational awareness. BC maintains the OIT Continuity of Operations Plan in accordance with Departmental Federal Continuity guidance and policies, and is responsible for ensuring that OIT Emergency Relocation Group (ERG) members, Reconstitution Emergency Relocation Group (RERG) members, and Devolution Emergency Response Group (DERG) are properly trained to assume their positions on designated teams. Members of the BC OIT Liaison Watch Officer team provide coordination across VA's administrations and staff offices within the Integrated Operations Center, providing situational awareness to OIT leadership and support OIT emergency management activities. Watch officers are a critical link during crisis events, from initial notification to termination, providing OIT leadership and staff members with vital and potentially lifesaving information. During continuity events, watch officers become part of the OIT Emergency Relocation Group and provide leadership with decision making information to ensure mission essential functions continue. BC also develops tests and exercises, aimed at testing OIT s ability to respond to events and continue operations Request: BC Continuity Support (COOP) provides OIT a higher state of readiness by providing trained staff members ready to respond during crisis events. Whether it is an ERG, RERG, or DERG member responding to an activation of the departments Continuity of Operations plan, or an OIT Liaison Watch Officer providing critical situational awareness information to OI&T leadership, OIT stands ready to act on its responsibilities to ensure that primary mission and mission essential functions continue and we provide uninterrupted services to customers Deliverables: 2016 Congressional Submission IT-362

365 Refine Contingency Plans/Disaster Recovery Plans and Incident Response Plans through improved automation efforts. Participate in National Level Exercises and support to VA exercise efforts with emphasis on external communications between other federal, state, and local agencies responsible for Cyber security. Continue development of OIT exercises to test the coordination of incident response efforts across VA OIT. Field Security Services (FSS) - $5.2 million The OIT Enterprise is the backbone of the Department s ability to provide continual, quality service to its customers. Highly trained team members provide leadership with timely, accurate information that enables them to make decisions affecting systems and applications in a seamless manner, minimizing adverse impact to customers during an event or crisis. FSS has a major role in participating in many national committees, projects, and initiatives. FSS managers provide leadership in committees such as the Security Improvement Program (SIP), Field Operations Council, VHA Business Relationship Management (BRM), and VHA/The Office of Information Security (OIS) Joint Security Call, etc. FSS staff provides ISO support and guidance to system owners, information owners, programs, projects, etc Request: Funds in 2016 will expand capabilities to improve Continuous Monitoring across the Department and expand visibility to everything efforts to enforce security. FSS will manage the Information Security Programs and servers as the Principle Security Advisor for VA Medical Centers, Clinics, VBA Regional Offices, Field Program Offices, NCA and VHA/VBA Central Offices. FSS will also act as the principle advisor for security on all contracts and review new and existing contracts and statements of work (SOW), Complete the Contactor Security Controls Assessments (CSCAs) Deliverables: In 2015, OIT will provide: Improved field communications to the geographically dispersed information security officers; Continued and improved communications to all of VA regarding information security practices, policies, procedures and how to locate an ISO; Continued support of the CRISP initiative which ensures that Federal laws and mandates and VA information security policies are implemented and audited for the security of VA s information systems and the data contained within; and Maintainance the FSS web page on the OIS Portal as: o Acritical vehicle for communicating program information to stakeholders across VA; o A collaborative workspace for special projects; o A vehicle for program announcements; o A document repository for templates, brochures, bulletins, directives, and guidance; and 2016 Congressional Submission IT-363

366 o An important customer service tool, enabling OIS, OIT, and VA stakeholders, as well as end-users, to access FSS information 24 hours a day. Information/Data Security - $3.9 million OIS is undertaking numerous initiatives to improve systems and data security throughout the Department of Veterans Affairs. In 2016 $3.9 million in mandatory sustainment funds will assist OIS in developing and augmenting systems to safeguard Veterans, employee personnel, and medical information. In addition, the OIS Business Office will oversee a set of capabilities that ensure VA users authenticate to information technology resources and have access to only those resources that are required for their job function. The increase in complex initiatives necessitates additional contracting actions and technical contract management support. Expert acquisition planning and effective management of extremely complex systems and products are required for information security contracts to ensure sound business decisions are made and comply with laws and regulations requiring agencies to measure and achieve concrete mission results. In a cyber security environment that is continuously changing, VA must continue to evolve to keep up with the change. To help support the change and Veterans, the OIS Business Office provides VA with a smoothly functioning information security office. With over 530 employees nation-wide, OIS safeguards the sensitive information of our Veterans and their beneficiaries are safe and secure. OIS also assists with ensuring that the right individuals have access to the right information at the right time to guarantee excellent patient care while still keeping Veteran information secure. Identity, Credential and Access Management (ICAM) - $1.2 million The ICAM Onboarding Solution will create a uniform, effective, efficient, and robust process that will ensure all VA employees, contractors, and affiliates who require access to VA facilities and systems are identity-proofed and credentialed at the appropriate level upon assumption of duties. It will also ensure all users are continuously monitored during their tenure with appropriate provisioning and de-provisioning of access and adjustment of levels of trust required as duties, functions, and/or conditions of service change. Finally, it will ensure access is terminated, deactivated, or suspended when access is no longer needed. The current processes erode support to Veterans by creating unacceptable delays in onboarding individuals who are needed to provide required services and by creating unnecessary risk to sensitive information due to lack of effective monitoring and offboarding procedures Request: The 2016 request of $1.2 million consists of $800 thousand in development and $380 thousand in mandatory sustainment funds. Funding will enable the program to; Improve accessibility of healthcare, benefits and memorial services to Veterans while optimizing value; Increase customer satisfaction through improvements in benefits and services delivery procedures; Evolve VA information technology capabilities that meet emerging customer service of both VA customers and employees; Reduce resources required for onboarding personnel and provide opportunities for repurposing resources for other human capital investments; Ensure preparedness to provide services 2016 Congressional Submission IT-364

367 and protect people and assets continuously and in time of crisis; Ensure HSPD-12 controls are met; Ensure compliance with VA Directive 0710 and Congressional Submission IT-365

368 Information and Technology Veterans Choice Act Section 801 Veterans Access Choice, and Accountability Act (Dollars in Thousands) Current Estimate Current Estimate Increase / Decrease IT Development $ 107,500 $ 43,900 $ (63,600) MASS Scheduling $ 76,000 $ - $ (76,000) Mobile Apps & Video Visits $ 6,500 $ 13,600 $ 7,100 Veterans Relationship Management $ 25,000 $ 30,300 $ 5,300 IT Infrastructure Sustainment $ 82,700 $ 103,500 $ 20,800 VHA Facility/Construction Activations $ 46,300 $ 33,600 $ (12,700) Equipment for IT Staff $ 36,400 $ 69,900 $ 33,500 Pay and Admin $ 13,000 $ 26,000 $ 13,000 Total Section 801 $ 203,200 $ 173,400 $ (29,800) Section 802 Veterans Access Choice, and Accountability Act Veterans Choice Card (Dollars in Thousands) Current Estimate Current Estimate Increase / Decrease Veterans Choice Card/Fund $ 63,998 $ - $ (63,998) IT Systems Costs $ 63,744 $ - $ (63,744) IT Staff $ 254 $ - $ (254) Total Section 802 $ 63,998 $ - $ (63,998) On August 7, 2014, President Obama signed into law the Veterans Access, Choice, and Accountability Act of 2014, Public Law , (the Veterans Choice Act). Section 801 of the Choice Act provides $5 billion to increase Veterans access to health care and to improve the physical infrastructure of the Department. The funds are available for obligation or expenditure without fiscal year limitation. Of the $5 billion total, $2.34 billion (46.8 percent) will support Veterans' Medical Care; $2.28 billion (45.7 percent) will support capital infrastructure; and $376.6 million (7.5 percent) will support information technology (IT) infrastructure and development. This chapter describes how the Office of Information Technology plans to obligate VACAA funding for years 2015 and Section 802 of the Choice Act provides $10 billion to support the Veterans 2016 Congressional Submission IT-366

369 Choice Program, of which VA has identified $64 million in IT requirements so far and that may increase as more requirements become known. Section 801 Information Technology: Development $151.4 million VA plans to obligate $151.4 million in Veterans Choice Act funding to support IT development activities $107.5 million in 2015 and $43.9 million in These activities include: Medical Appointment Scheduling System, Mobile Applications, and Veterans Relationship Management/Veterans Customer Experience (enhanced medical access and customer service). Medical Appointment Scheduling System: VA is planning to purchase a highly capable, tested, private-sector system to meet its medical scheduling needs. This approach will yield the best results in the most efficient, timely, and effective manner. VA expects to award a contract to procure the system in early calendar year Mobile Applications: VA has identified two mobile applications that will significantly improve Veterans' ability to interact with the VA healthcare system and improve their health outcomes. The first application is a Mobile Scheduling application, which will allow Veterans to check on an existing appointment, or schedule a new one, with a smartphone, ipad, or other tablet device. The second application is Mobile Video Visits, which will allow a Veteran to have a secure video medical visit with a VA provider. The application will initially be pilot-tested at five sites; this technology will be especially helpful with the treatment of rural Veterans. Veteran Customer Experience (Previously Veterans Relationship Management): Funding will accelerate and expand Veterans' access and improve customer service. The funds will provide one VA site that will allow a Veteran to access health care information and services; support agent-assisted call centers; and provide increased and expanded selfservice capabilities for new health care initiatives. In addition, this funding will be used to accelerate integrated online support for Veterans to ensure a positive resolution to questions or requests for services. This effort also will help reduce the number of different logon screens that Veterans must navigate. Section 801 Information Technology: Infrastructure Sustainment $225.2 million VA plans to obligate $225.2 million in Veterans Choice Act funding $95.7 million in 2015 and $129.5 million in 2016 to support new medical facility activations, provide IT equipment for new medical care staff, and hire additional IT staff to provide support for the new facilities. When VA opens a new medical clinic, it must provide IT support for the clinicians and other staff, including computers, printers, cell phones, software licenses, help desk support, and cyber security protection. New clinics require desk phones, shared workstation computers, and dedicated network connections to VA medical network, routers, local wiring, or secure Wi-Fi. VA cost estimates associated with new activations include $28 per square foot for leases and new construction, and $6,600 per new employee. These estimates cover all related IT costs, including network connections, 2016 Congressional Submission IT-367

370 equipment, licenses, expansion servers, and cyber protection of the VA's electronic healthcare information system. Section 802 Information Technology: VA Choice Card/Fund $64.0 million The Veterans Choice Act funds will enable modification of VA s software applications in support of expanded Veteran eligibility to and increase funding of fee-basis care authorized by the Veterans Choice Program. The changes include identification of eligible Veterans, interfacing with third-parties (non-va care) who will be providing the fee-basis care, processing increased volume of fee-basis claims, as well as mandated reporting. This includes changes to the following systems, among other downstream systems: Enrollment, Eligibility, Fee Basis Claims, Veterans Health Information Systems and Technology Architecture (VistA) Imaging, VistA Integrated Billing / Accounts Receivable, Choice Fund Third Party Insurance Reimbursement, and Pharmacy Congressional Submission IT-368

371 Information and Technology Maintain the IT Infrastructure Maintain the IT Infrastructure (Dollars in Thousands) / Actuals Carryover Budget Estimate Current Estimate Budget Request Increase / Decrease Mandatory Sustainment $ 1,418,663 $ 745 $ 1,548,660 $ 1,531,452 $ 1,629,731 $ 98,279 Enterprise Operations $ 405,054 $ - $ 323,000 $ 305,792 $ 369,900 $ 64,108 IT Support Contracts $ 436,899 $ 745 $ 269,833 $ 269,833 $ 376,170 $ 106,337 Telecommunication $ 243,794 $ - $ 275,000 $ 275,000 $ 297,161 $ 22,161 Software License Maintenance $ 141,751 $ - $ 284,384 $ 284,384 $ 132,500 $ (151,884) Hardware Maintenance $ 65,580 $ - $ 104,688 $ 104,688 $ 100,000 $ (4,688) Activations $ 68,126 $ - $ 84,000 $ 84,000 $ 90,000 $ 6,000 Acquisition Fees $ 15,000 $ - $ 73,227 $ 73,227 $ 80,000 $ 6,773 National Service Desk $ - $ - $ 40,000 $ 40,000 $ 59,000 $ 19,000 Support for Major Initiatives $ - $ - $ 16,528 $ 16,528 $ - $ (16,528) CRISP Removal of the Material Weakness $ - $ - $ - $ - $ 39,000 $ 39,000 Mobile Application Security (Mobile Technologies) $ - $ - $ 5,000 $ 5,000 $ 25,000 $ 20,000 Guardian Edge and Anti Virus Maintenance $ - $ - $ - $ - $ 22,000 $ 22,000 Server Virtualization $ - $ - $ 5,000 $ 5,000 $ - $ (5,000) Telephony Emergency Replacement (PBX) $ - $ - $ 20,000 $ 20,000 $ 20,000 $ - RTLS Hosting $ - $ - $ - $ - $ 12,000 $ 12,000 PD Tools, E-Gov, (CDW in FY16) $ - $ - $ 3,000 $ 3,000 $ 5,000 $ 2,000 Divesture of Systems/Application $ - $ - $ - $ - $ 2,000 $ 2,000 FY 2014 Deployed Capabilities $ - $ - $ 45,000 $ 45,000 $ - $ (45,000) VBA & NCA IT Infrastructure Platform Upgrades $ 16,859 $ - $ - $ - $ - $ - Enterprise Architecture (EA Tools and Support) $ 10,808 $ - $ - $ - $ - $ - Warrior support $ 2,300 $ - $ - $ - $ - $ - Human Capital $ 12,492 $ - $ - $ - $ - $ - Discretionary Sustainment $ 269,958 $ - $ 240,000 $ 240,000 $ 180,000 $ (60,000) Telephony (Unified Communications Strategy - VaaS) $ 64,319 $ - $ 92,000 $ 92,000 $ 60,000 $ (32,000) Enterprise IT Lifecycle Management (Desktops/Laptops) $ 129,571 $ - $ 40,000 $ 40,000 $ 50,000 $ 10,000 Network Lifecycle HW Refresh (Servers/Routers/Storage) $ - $ - $ 40,000 $ 40,000 $ 50,000 $ 10,000 Section 508 Compliance - Legacy Sys/Apps $ - $ - $ - $ - $ 15,000 $ 15,000 WAN Acceleration (Wireless) $ - $ - $ 15,000 $ 15,000 $ - $ (15,000) Disaster Recovery $ - $ - $ 15,000 $ 15,000 $ - $ (15,000) RTLS Hosting Expansion $ - $ - $ - $ - $ 5,000 $ 5,000 VOW/VEI $ - $ - $ 15,000 $ 15,000 $ - $ (15,000) Enterprise Data Warehouse (EDW) $ - $ - $ 1,000 $ 1,000 $ - $ (1,000) IP Video to Home Expansion $ - $ - $ 7,000 $ 7,000 $ - $ (7,000) VistA Imaging (Gateways and RAID Upgrade) $ - $ - $ 15,000 $ 15,000 $ - $ (15,000) VBA & NCA IT Infrastructure & Platform Upgrades $ 30,336 $ - $ - $ - $ - $ - Enterprise IT Support Contracts $ 2,143 $ - $ - $ - $ - $ - Enterprise License Expense $ 30,145 $ - $ - $ - $ - $ - VHA IT Infrastructure & Platform Upgrades $ 1,763 $ - $ - $ - $ - $ - VHA IT Support Contracts $ 11,681 $ - $ - $ - $ - $ - Marginal Sustainment $ 4,151 $ - $ - $ - $ - $ - Enterprise IT Support Contract $ 4,151 $ - $ - $ - $ - $ - Infrastructure Development $ - $ - $ - $ - $ 18,000 $ 18,000 Divesture of Systems/Application $ - $ - $ - $ - $ 18,000 $ 18,000 Total to Maintain the IT Infrastructure $ 1,692,771 $ 745 $ 1,788,660 $ 1,771,452 $ 1,827,731 $ 56,279 Total to Maintain and Enhance the IT Infrastructure - $1.828 billion 2016 Congressional Submission IT-369

372 The table above represents the Operations and Maintenance (sustainment) funding necessary to maintain the IT Infrastructure. Total Operations and Maintenance can be found in the IT Budget Appendix. The IT Infrastructure provides the backbone necessary to meet the day-to-day operational needs of VA Medical Centers, Veteran facing systems, benefits delivery systems, memorial services, and all other IT systems supporting the Departments mission. To ensure the IT infrastructure platform is fully capable of providing for VA s data storage, transmission, and communications requirements funding is critical to sustain essential IT requirements which have grown steadily since 2010 and are expected to continue growing into and beyond A robust, healthy IT infrastructure is necessary to ensure delivery of reliable, available, and responsive IT services to all VA staff offices and administration customers as well as Veteran clients. A viable and reliable infrastructure supports VA s 21 st century transformation as well as underlying missions and strategic plans, and service level requirements for all customers. The infrastructure investment considers the health and capacity of the IT enterprise to be a shared resource that has far reaching, complex, and interconnected consequences across the organization. It also mitigates a risk of increased frequency and severity of system outages and major incidents that may potentially result in serious harm to Veterans (patient safety) or data loss. Without consistent annual investment in lifecycle replacement, platform modernization, and infrastructure expansion, VA runs the risk of increasingly unreliable systems and services. The cost of replacing IT equipment that is beyond useful lifecycle is considerable. Annual investments are required as part of a constant lifecycle replacement program, otherwise the accumulated cost of replacing obsolete equipment expands as a sizable IT Debt to be paid in the future or face increasing risk of degradation. Key business drivers include: (1) growth in number of users; (2) new facility activations; (3) new systems and platforms released into production; (4) increases in mobile computing and communications; (5) increase in the number and complexity of IT tools; and(6) increased security complexity and requirements. The 2016 IT Infrastructure budget request will support the following: Hardware/Software refresh: Replacement of the oldest hardware that has fallen beyond its useful lifespan. Server/Storage Virtualization: Rehost legacy systems on modern platforms. Application Virtualization and Standardization: Transition to virtualized server farms and shared storage arrays to control costs and improve speed of applications. Desktop Support: PC refresh vehicle, Microsoft Enterprise Licensing Agreement. Hardware Maintenance: Regional pool/procurement of hardware commodity maintenance contracts. Software Licensing: Extend number of national license agreements and Enterprise Licensing Agreements. Centralize software license procurement to regional pools. IT Support Contracts: Regional Service Lines bring needed skill sets in line to replace contracts Congressional Submission IT-370

373 Infrastructure Upgrades: Platform upgrades of major systems. Technical Solutions to implement the Agency Priority Goals: Provides resources to improve access to Veteran services, eliminate the claims backlog and support the development of registries to track homeless Veterans Mandatory Sustainment Enterprise Operations/Legacy Systems - $369.9 million Enterprise Operations (EO) manages VA s national datacenters. As a full-service IT provider, EO manages over 4,000 servers for the VA and delivers secure, highlyavailable, and cost-effective IT services to medical, benefits, and memorial initiatives in support of the VA Administrations Request: Funds in 2016 will administer approximately 300 complex IT applications that support VA medical care, financial payments, benefits, record-keeping, and research programs, legacy systems for the Enterprise, VHA /VBA, and other Federal government agencies (OGA). The increase from prior years is a direct result of VA delivering more IT capability to the business users. IT Support Contracts - $376.2 million In 2016 IT Support contract costs include recurring payments for existing contracts for services and support for implemented IT solutions. OIT s internal and external customers expect skilled and prompt service in a variety of areas. For example, in the area of Help Desk Support, OIT has instituted a National Service Desk that is supported by contracted staff. This allows OIT to meet and exceed customer expectation for help. However, as VA adds more users, more systems and more facilities, the calls to help desks increase. The increase from prior years is a direct result of VA delivering more IT capability to the business users. Telecommunications $297.2 million Telecommunication provides means for voice communications between VA and Veterans, healthcare partners, business partners, employees, local government entities; telephone answering systems; paging system interfaces in large facilities for locating medical staff and others (paging systems are separately funded but are dependent on the voice infrastructure); and direct management of emergency Code calls for medical life safety and security as well as support of telehealth capabilities Request: The 2016 $297.2 million request will be used for recurring payments to support voice, data, and video circuits paid to telecommunication vendors; this includes local voice dialing, long distance voice dialing, toll free dialing, calling cards, and mobile wireless communication charges; i.e., the monthly bills for voice telecommunications. Data includes the core Wide Area Network (WAN) and Gateways that connect the VA to the internet and the distribution WAN that connects the core to the VA s main facilities. Enterprise Software License and Maintenance - $132.5 million Enterprise Software License and Maintenance is comprised of recurring payments for existing software and an existing numbers of licenses. Costs are driven by the number of 2016 Congressional Submission IT-371

374 users and number of new applications and systems supporting these users. OIT s internal customers must have the ability to use their devices and applications with a standard set of performance expectations. The 2016 budget request will allow for the continuing maintenance of IT software licenses. Hardware Maintenance - $100 million Hardware maintenance is comprised of recurring payments for extended warranty and support for critical hardware components in support of customer service level agreements. OIT s internal customers expect that failure of a device, system, or application with the concomitant downtime or degradation in performance will be followed by prompt return to normal service. The 2016 budget request will allow for the continuing maintenance of hardware components. Activations - $90 million IT Activations is the program which funds the purchase, installation, and issuance of IT equipment in order to stand up new VA Medical Centers (VAMCs), Veterans Benefits offices, and National Cemeteries or other facilities. Activations also funds any IT expenses occurring from the renovation of any existing facility, and IT equipment required for new employees being added due to a growth in the VA s mission. Funding of Activations at a sufficient level is required for the timely opening of Medical Centers, Community Based Outpatient Clinics (CBOCs), and other offices that work towards assisting Veterans and improving their access to care and services Request: VA is continuously expanding the services and capabilities to meet the Veteran needs for access to care, services and benefits. IT Activations funding is a critical component in the delivery of quality healthcare and benefits which includes everything from the Veteran s Health Care Records, to the services that VA frontline providers and Veterans utilize to interact in the delivery and recording of Veteran services. The funding request of $90 million in mandatory sustainment will provide for the acquisition of the required IT equipment identified to meet the VA expansion of facilities and services as represented by the following planned activations: Up to 12 major construction and lease projects are currently identified to activate in FY 2016 in order to meet the expansion of access to service for Veterans. These construction and lease projects are projected to add more than 2.8 million square feet to the overall VA footprint, 76 planned Minor construction projects representing over 2 million square feet of new space and 9 million square feet of renovated space, Planned on-boarding of the required new programmatic (non-oit) personnel additions to meet the continued increase in demand for Veteran access to services and expansion of VA s mission enhancements across all Administrations Deliverables: Continued work with the Orlando VA Medical Center (VAMC) leadership to provide any needed IT equipment in order to fully open their facility as required 2016 Congressional Submission IT-372

375 Prepare the required IT infrastructure for the 16 new CBOCs, 3 new VAMC additions, and 1 new VAMC (Denver) to activate as required Ensure that the 82 Minor construction projects representing over 2.5M new square feet and 9.5M renovated square feet are able to complete on schedule as it pertains to IT requirements. Acquisition Fees - $80 million The 2016 request will pay for acquisition fees, which are required for services rendered by acquisition organizations as they provide warranted contracting officers, related staff, and related functions to execute and administer contracts received by OIT. Fees from internal and external acquisition organizations vary up to approximately 5 percent of contract value. Acquisition organizations include VA s Technology Acquisition Center (TAC), General Services Administration (GSA) and Navy s Space and Naval Warfare Systems Command (SPAWAR). National Service Desk - $59.0 million The VA National Service Desk (NSD) serves as the single point of contact for all VA IT support requests with a focus on Tier 1 First Contact Resolution for improved VA customer satisfaction. It also provides coordination of IT incident management to assure service disruptions are expediently resolved for improved availability Request: In 2016 NSD is implementing a standardized set of processes for IT Service Management (ITSM) activities across the Department for improved service delivery. To streamline ITSM processes, OIT is realigning all field Help and Service Desks under the umbrella of the NSD. Funds will also lead to lower wait times for customers. CRISP Sustain Removal of Material Weakness (Patch Management) - $39.0 million Implementation of the CRISP program objectives improves the security state of the VA and its overall security posture improving service delivery and collaboration and risk awareness, while improving the security and resiliency of the underlying VA infrastructure facilitating enhanced visibility, access and functionality across the spectrum of VA services for the Veteran Request: In 2016, CRISP will maintain and enhance its existing integrated framework for governing and managing IT and cyber securityfunding will allow CRISP to identify and remediate security weaknesses in operations or systems that severely impair or threaten the organization s ability to accomplish its mission, or prepare timely, accurate financial statements or reports. Mobile Applications (Includes Applications Security) - $25.0 million VA is increasing the use of mobile technologies to enable better service delivery to Veterans in clinical and non-clinical settings, and VA is deeply concerned for the protection of the Veteran information we store and use. The Mobile Applications program ensures that mobile devices are used securely and do not put Veteran information at risk Congressional Submission IT-373

376 2016 Request: VA s goal is to use mobile devices effectively to serve Veterans, principally in healthcare, but mobile devices have also been used in non-clinical settings such as the homeless Veteran survey in OIT manages a mobile device management solution (MDM) to securely manage VA s mobile devices. Current number of devices on the network is over 22,000. Guardian Edge and Anti-Virus Maintenance - $22.0 million The 2016 budget request supports the Anti-Virus maintenance contract which provides antivirus, malware protection, host intrusion protection (HIPS), whitelisting/blacklisting of apps, and malware detection for a segment of our mobile devices. The contract provides clients for 450,000 workstations, 1,500 androids, and approximately 22,000 servers. In addition to physical device protection, it also covers virtual clients. The contract also covers operations and maintenance (O&M) of the solution. The vendor provided hardware is in data centers located on the east and west coast, along with distributed hardware for traffic loads across the VA. This solution addresses security standards, material weaknesses, as well as data protection Request: This funding, for license and support contract only, will support full disk encryption for VA s 415,000 workstations. It also protects all data located on the workstations, and laptops, used in the organization. This solution addresses security standards as well as data protection for Protected Health Information (PHI) and PII. Telephony Emergency Replacements/Private Branch Exchange (PBX) - $20.0 million As VA moves toward a Government-Owned/Contractor Operated (Go/Co) model of providing enterprise telephony services, continued investment to maintain existing telephony systems, during this transition, is critical. Aging systems must be able to continue to function to provide Veterans and their families with confidence in the capability of reaching our VA facilities through the telephone Request: 2016 funding provides means for voice communications between VA and veterans, healthcare partners, business partners, employees, local government entities; provides telephone answering systems; provides paging system interface in large facilities for locating medical staff and others (paging systems are separately funded but are dependent on the voice infrastructure); direct management of emergency Code calls for medical life safety and security. Aging telephony systems continue to reach end of life/end of manufacturer support. The 2016 funding request will provide maintenance support for the continued operation of these systems, as well as address infrastructure requirements to support movement to the Unified Communications strategic direction of an enterprise voice system. Existing telephony systems in critical need must continue to be maintained until they have been replaced. Real Time Locator System (RTLS) Hosting Expansion - $17.0 million VHA has a requirement to locate medical equipment, instruments and supplies in their facilities. The ability to locate equipment, supplies, staff, and patients in real time, down 2016 Congressional Submission IT-374

377 to the bedside, will enable medical and facility staffs to better manage their clinical and administrative healthcare delivery processes, thereby improving patient and staff satisfaction and improving access to care Request: The 2016 $17.0 million request (including $5 million for discretionary sustainment) is needed to evaluate, test, secure, accredit and sustain new RTLS installations across all 153 VAMCs and over 800 CBOCs. Continued deployment at medical centers and also at the Austin Information Technology Center (AITC) for hosting RTLS servers will be the Department s funding priority Deliverables: RTLS National Data Repository (NDR) System Storage NDR Database Server to support Corporate Data Warehouse Domain Design & Development of the NDR Initial System Initial Operating Capability Entry & Testing Continued deployment of RTLS data interfaces Sustainment of existing RTLS data interfaces and equipment Sustainment and Development for National RTLS Servers Corporate Data Warehouse (CDW) - $5.0 million The Corporate Data Warehouse (CDW) is a central collection of standardized databases integrating key enterprise wide clinical, administrative, and financial data to provide a unified view of VA. The CDW strategy is a result of three primary factors: (1) VA needs to have ready access to data to support management decision making; (2) there is a recognized value in standard business intelligence and analytics architecture and platform; and (3) the need to have modern, proven, robust access tools for reporting and analyzing data at the enterprise level Request: The CDW is Business Driven in that the information contained in the CDW will be strategic and actionable; it will be aligned with enterprise strategic objectives; it will include a common integration framework; it will be feedback centric; it will maximize reuse, interoperability, and collaboration, and leverage enterprise best practices. CDW captures and consolidates information that will result in improved quality of care, improved patient outcomes, improved patient safety, more efficient operations, and provide a significant cost savings to the Enterprise. Divestiture of Systems/Applications $2.0 million This initiative will enable the development of a mature, repeatable and timely System Divestiture Planning process to assess IT systems and make determinations about how future investments should be applied to maximize business value and in alignment with Architecture Strategy and Design overall guidance. Immediate deliverables include System Inventory criteria to identify System Divestiture Candidates and the analysis to help management decide how to divest the Benefits Delivery Network (BDN) and Beneficiary Identification Record Locator Service (BIRLS) Congressional Submission IT-375

378 The improved Divestiture Planning capability must leverage current efforts to assess the constraints to legacy system retirements. System costs, data management, and technology roadmap synchronizations must be considered as part of the Divestiture Plan to fully retire legacy systems. Business Case Analysis must be completed that defines cost estimations and associated criteria, such as mission requirements and business value to support a system s selection of capabilities to be retired. Discretionary Sustainment Telephony (Unified Communications Strategy VaaS) $60.0 million The Voice as a Service (VaaS) program is VA s proposed solution for creating a standardized, consolidated and centrally managed voice infrastructure that maximizes equipment value and enhances infrastructure oversight and control. VaaS services include calling in, out and across VA, Automatic Call Distribution/Interactive Voice Response services for local call center requirements, voic , agent services such as call reporting and monitoring, training, security, and call recording. Additional services include local operation and maintenance at the facility level and optional training Request: This effort will allow VA to transition away from traditional PBXs and provide telephony services with the least cost, least technical risk and least operational risk. VaaS will allow for a centrally-managed, standardized, and interoperable solution that can be used as a foundation for future capabilities including video, unified communications, chat, on-line support and contact centers. Enterprise IT Lifecycle Management (Desktops/Laptops/Mobile Devices) - $50.0 million The 2016 request will support Field Operations lifecycle desktop, laptop and mobile device refresh. Emphasis is on ensuring replaced equipment is done on the basis of functionality required to support VA operations. We replace this IT equipment based on a lifecycle management structure that in general is a 5 year useful life. Network Lifecycle Hardware Refresh - $50.0 million Lifecycle replacement for VA-wide end-of-life/end-of-service networking equipment. Equipment provides continued functional availability of networking infrastructure including support for wireless, RTLS and Voice Over Internet Protocol (VOIP) initiatives. Existing LAN and WAN hardware is at or near end of life and requires refresh replacement. Additional non end-of-life hardware does not include Power over Ethernet and other functionality for dependent VA initiatives. Improved support of Power-Over- Ethernet related projects such as National Wireless, Voice over Internet Protocol and Real Time Location Services. Program is to the benefit of interconnected clinical and administrative services provided to veterans. Section 508 Compliance (Legacy Systems/Applications) - $15.0 million Giving access to accessible Electronic Information Technology (EIT) increased the employment of the disabled and integrates them into an effective work force. Section 508 strives to ensure comparable access to EIT to members of the public. This will empower Veterans by giving them electronic access to goods and services. Currently, the Section 2016 Congressional Submission IT-376

379 508 program is reactive to issues and concerns. The Program Office has little ability to plan or forecast upcoming conformance issues for the Agency. VA has received six Congressional Inquiries and two Accessibility complaints since The Federal law mandated under Section 508 of the Rehabilitation Act of 1973 (29 U.S.C. 794d), as amended by the Workforce Investment Act of 1998 (Public Law ) requires VA s electronic information technology to be accessible to Veterans, VA employees, and members of the general public with disabilities. VA s Section 508 office provides VA-wide policy to ensures Veterans, VA employees, and members of the general public with disabilities have access to and use of VA s EIT at levels comparable to that provided to non-disabled persons Congressional Submission IT-377

380 Information and Technology Other Development Programs Other Development Programs (Dollars in Thousands) / Actuals Carryover Budget Estimate Current Estimate Budget Request Increase / Decrease DME OM DME DME OM DME OM DME OM DME OM MCCF-Electronic Data Exchange (EDI) - Provider $ - $ - $ - $ 29,987 $ - $ 29,987 $ - $ 17,000 $ - $ (12,987) $ - Interoperability (Dependency with VE/VLER Health)** $ 18,176 $ 6,190 $ 1,620 $ - $ - $ 17,208 $ - $ 15,000 $ 15,000 $ (2,208) $ 15,000 VHA Research $ - $ 4,493 $ - $ 3,771 $ 2,394 $ 3,771 $ 2,394 $ 12,250 $ 7,340 $ 8,479 $ 4,946 Registries $ 4,965 $ 2,783 $ 566 $ 3,954 $ 2,923 $ 3,954 $ 2,923 $ 11,500 $ 3,200 $ 7,546 $ 277 Electronic Data Exchange (EDI) - Payer $ - $ - $ - $ 11,140 $ 2,228 $ 11,140 $ 2,228 $ 10,000 $ - $ (1,140) $ (2,228) VLER Health (Dependency w/ve/interoperability) ** $ 9,503 $ 2,659 $ 3,583 $ - $ - $ - $ - $ 10,000 $ 10,000 $ 10,000 $ 10,000 Repository $ - $ 3,646 $ - $ - $ - $ - $ - $ 7,920 $ 1,020 $ 7,920 $ 1,020 VA Center for Innovation (VACI) $ - $ - $ - $ 12,000 $ 4,000 $ 12,000 $ 4,000 $ 6,000 $ 1,500 $ (6,000) $ (2,500) Standards and Terminology Services (STS) $ - $ 4,620 $ - $ - $ - $ - $ - $ 2,000 $ 5,320 $ 2,000 $ 5,320 Healthcare Efficiency $ - $ 1,063 $ - $ 10,723 $ 7,862 $ 10,723 $ 7,862 $ 6,660 $ 500 $ (4,063) $ (7,362) Caregiver's Enhancements $ - $ - $ - $ 7,004 $ 1,750 $ 7,004 $ 1,750 $ 5,000 $ 1,750 $ (2,004) $ - Compensation and Pension Records Interface (CAPRI) $ 876 $ 502 $ 224 $ 1,100 $ 500 $ 1,100 $ 500 $ 2,200 $ 500 $ 1,100 $ - Centralized Administrative Accounting Transaction System (CAATS) $ - $ - $ - $ 750 $ - $ 750 $ - $ 640 $ - $ (110) $ - Memorial Development $ 4,399 $ 886 $ 3,953 $ 8,600 $ 2,000 $ 8,600 $ 2,000 $ - $ - $ (8,600) $ (2,000) Data Access Services (DAS) $ 3,326 $ 4,368 $ - $ 10,000 $ - $ 10,000 $ - $ - $ - $ (10,000) $ - Mental Health (Medical Legacy) $ - $ 220 $ - $ 2,700 $ 995 $ 2,700 $ 995 $ - $ - $ (2,700) $ (995) Health Administrative Systems $ - $ - $ - $ - $ - $ - $ - $ - $ - Health Provider Systems (Medical Legacy) $ - $ 14,972 $ - $ 2,616 $ 8,739 $ 2,616 $ 8,739 $ - $ - $ (2,616) $ (8,739) Systems To Drive Performance Dashboards $ - $ - $ - $ 1,000 $ 1,520 $ 1,000 $ 1,520 $ - $ - $ (1,000) $ (1,520) Safety & Security Initiative (HSPD-12) $ 429 $ - $ 971 $ 2,300 $ 4,598 $ 2,300 $ 4,598 $ - $ - $ (2,300) $ (4,598) ediscovery Platform (General Council) $ - $ 184 $ - $ 3,000 $ 250 $ 3,000 $ 250 $ - $ - $ (3,000) $ (250) General Counsel LAWS $ - $ - $ - $ 200 $ - $ 200 $ - $ - $ - $ (200) $ - EDI Transactions- Mandated Compliance $ 12,011 $ - $ 5,721 $ - $ - $ - $ - $ - $ - $ - $ - Health Management Platform (Health Informatics) $ 4,177 $ 278 $ 2,397 $ 5,746 $ 2,920 $ 5,746 $ 2,920 $ - $ - $ (5,746) $ (2,920) Integrated Operating Model (IOM) $ - $ 26,886 $ - $ - $ - $ - $ - $ - $ - $ - $ - Human Resource Information System (HRIS) $ 2,106 $ - $ 94 $ - $ 16,700 $ - $ 16,700 $ - $ - $ - $ (16,700) VA Times and Attendance System (VATAS) $ 520 $ - $ 320 $ - $ - $ - $ - $ - $ - $ - $ - Clinical Flowsheet Observation (CLIOv2) $ - $ - $ 1,000 $ - $ - $ - $ - $ - $ - $ - $ - Total $ 60,488 $ 73,750 $ 20,449 $ 116,591 $ 59,379 $ 133,799 $ 59,379 $ 106,170 $ 46,130 $ (27,629) $ (13,249) TOTAL DME and OM $ 134,238 $ 20,449 $ 175,970 $ 193,178 $ 152,300 $ (40,878) Total Other Development Programs - $152.3 million In 2016, other development funds not previously described in this chapter will support the programs list below. Medical Care Collections Fund (MCCF-Provider) and Electronic Data Exchange (EDI- Payer) - $27 million The MCCF EDI provider program implements software solutions to meet evolving industry changes to electronic health care operations and to carry out VA s MCCF mandate to bill private insurers, collect payment, and supplement VA s medical care appropriations by allowing VA to retain all third-party collections and some other copayments. The work delivered under this program meets requirements set forth by the original Health Information Portability & Accountability Act (HIPAA) legislation and subsequent amendments to HIPAA, such as Affordable Care Act (ACA). Software solutions delivered under the MCCF EDI program impacts roughly 3,800 revenue staff, 2016 Congressional Submission IT-378

381 approximately 2,500 pharmacists, and potentially 9.3 million enrolled Veterans. Failure to execute federally mandated work under this program puts VHA s ~$3B in annual revenue at risk. The healthcare Electronic Data Exchange (EDI) payer program is the automated transfer of health eligibility, claims, authorization and remittance data in specific formats, following data content standards between healthcare providers and payers. This body of work will accelerate first party (Veteran) copayment determination. For the nearly 5 million Veterans served by VA s health care system who seek assistance for non-service connected conditions and have third party insurance, VA is able to expedite their out of pocket expenses through electronic means in a fraction of the time spent to determine copayment costs manually, avoiding improper invoicing to Veterans Request: 2016 funding includes $17 million for MCCF-Provider and $10 million for EDI- Payer. This budget request will allow the program to implement health care industry requirements for electronic claims attachments (EDI Transaction Set [TS] 275), the Health Plan Identifier, Coordination of Benefits, Claims Enrollment, Referrals, and Authorizations (TS 278), the epharmacy National Council for Prescription Drug Programs (NCPDP) communication standards, Health Care Claim Status and Response (TS 276/277), and Medical epayments Compliance (TS 835) Deliverables: The Purchased Care EDI program in 2015 builds upon completed compliance work to implement the most urgent process improvements and program deficiencies that will advance the effectiveness of automated transactions and provide a quantifiable return on investment. Funding will allow for: Improved efficiency of Health Administration Center voucher examiners by improving the display of EDI claims that require intervention and provide tracking of split claims, and support a larger volume of claims. Reduced calls to VAMCs by allowing self-service capability for non-va providers to obtain eligibility or claim status. Improved prescription processing. Automated checks to prevent unwarranted self-referrals by VA providers to facilities they have a business relationship with. VHA Research - $19.6 million The Office of Research and Development (ORD) discovers knowledge, develops VA researchers and health care leaders, and creates innovations that advance health care for our Veterans and the nation. ORD oversees a number of world renowned research centers nationwide. Clinical research programs and participation bring benefits to patients and to society as a whole providing knowledge for superior interventions to improve healthcare outcomes. In order to continue to meet the critical fundamental VA Research mission for advancing the healthcare of Veterans, IT funding is required for new projects, existing projects, and infrastructure refresh Congressional Submission IT-379

382 2016 Request: Funding for the VHA Research Program will allow VA to: Enhance and further develop existing projects The Genomic Information System for Integrated Science (GenISIS) supports the MVP (Million Veteran Program) genomics medicine study and requires capability and capacity expansion. The Veterans Informatics and Computing Infrastructure (VINCI) requires enhancements to enable more researchers/investigators to utilize the secure computing environment and tools to perform studies, analyze results and publish outcomes The Research Administrative Management System (RAMS) requires more modules to support field and VACO administrative and business functions for research. Point of Care Research (POC-R) embeds research in clinical care to facilitate an evidence based clinical treatment and improve clinical care. Implement new projects These would improve research data capture and management, provide interconnections work and comply with government mandates. These include Enterprise Data Architecture Services (EDAS), Patient Centered Outcomes Research Institute (PCORI), Enhanced DMZ (platform supporting exchange of files and data) at the Austin Information Technology Center (AITC) for Cooperative Studies Program (CSP), Tiered storage, Public Access to Research Data, CSP clinical trials data capture, and Research Electronic Data Capture (REDCap). Refresh existing infrastructure This is needed for field hardware, GenISIS hardware, and VINCI hardware. Provide mandatory sustainment of projects - This includes VINCI, Portfolio Classification Reporting Tool (PCRT), new Field grant activation, existing IT infrastructure renewals in the field, central CSP support, Baltimore Research and Development Computing Center (RDCC) campus support, and VACO ORD IT campus support. Proposed new projects would improve research data capture and management and provide system interconnections work. Research data comprises very large data sets and the capture and management of this data is a critical component of a successful VA research program. Additionally, new projects would allow compliance with an OIG mandate (Tiered storage), and an Office of Science and Technology (OSTP) mandate (Public Access to Research Data). GenISIS needs involve both more capability and capacity expansion as more veterans are enrolled (more petabytes of data) but more importantly GenISIS will need to begin to utilize Internet 2 to move genomic data around the country, incorporate the newer big data tools (like Hadoop) that are better able to manipulate the very large data sets during the FY16-20 time frame. VINCI-GenISIS integration/convergence is also required to maximize the large data sets for research studies and analysis. The goal of all this needed work is to advance healthcare of Veterans. Health Registry Program - $14.7 million The Health Registry Program identifies Veterans in different classification such as infectious and non- infectious disease and provides information used in: Estimating magnitude of the problem, determining the incidence of disease, examining the trends of disease over time, assessing service delivery and 2016 Congressional Submission IT-380

383 identifying groups at high risk, documenting the types of patients served by a health provider. Monitors and tracks diagnostic testing and treatments and facilitates coordination of care to improve management and timeliness of treatment for all veterans and their beneficiaries. Enhancing business processes and procedures (automation of business process to eliminate or reduce some manual processes) Integrating all registries with the converged registry solution (CRS) Exchanging secure data between DoD and VA Improving reporting systems to increase effectiveness and efficiency. Repositories - $8.9 million The Repositories Program, which is made up of the Health Data Repository and Administrative Data Repository, supports a number of projects, to include major initiatives, by storing discrete administrative and clinical data for use by clinicians and other personnel in support of veteran-centric care and doing so at a national level. The data is structured, standardized and used by clinicians and in analytic applications. Administrative Data Repository (ADR), the centralized repository for all VHA registration, enrollment and eligibility information and VHA s System of Record needs to provide or support: New Start of the Enrollment Modernization effort Business Informatics the ability to create temporary tables in the Reporting Database; Enrollment (~8.6M records) Identity Management (~21M records) Business groups to perform data reviews, audits, and validations Health Data Repository (HDR II) is a national database of Veterans clinical and health data that is used by clinicians and other personnel. It is needed to: Support Veteran-centric care For integration of clinical patient data across VHA and external healthcare systems, including DoD. The ADR project enables several dependent projects to improve access and quality of benefits and services delivered to the Veteran. Examples of this include: Enrollment System: Provides clear communication to Veterans on their Health Benefit Eligibilities. Additionally, the project provides faster and more accurate benefits enrollment and eligibility determination for Veterans, Servicemember, and their dependents and beneficiaries. Identity and Access Management: Provides processes and systems to seamlessly share unique digital identities for all Clients. Veterans Online Application: Provides self service capabilities to Veterans. Military Service Data Sharing (MSDS): Provides centralized enterprise capabilities to enhance and improve Veteran focused services delivery. The HDR project: 2016 Congressional Submission IT-381

384 Encourages and facilitates increased patient and family engagement in care and decision making (through patient-entered data, ready for review & integration into clinical documentation). Supports population and evidence-based care that is focused on preventive and chronic disease management. Assists with enabling patients with chronic diseases to be monitored at home, reducing hospital admissions, clinic visits, emergency room visits, as well as enabling independent living. Innovations (VACI) - $7.5 million The VA Center for Innovations (VACI) represents the Department s commitment to continuous innovation and the development of evidence that can be used to improve existing programs or to inform decisions about new ways to achieve greater outcomes in service to Veterans. To do this, VACI uses low-cost methods to select, test, and evaluate promising solutions in order to generate insights about potential VA-wide investments to reduce costs, increase quality, improve access, and exceed Veterans expectations. Examples include pay for success initiatives, pay for performance contracting, incentive prizes, and no-cost demonstration efforts. All VACI projects are measured by their ability to ensure that both taxpayers and Veterans benefit from VA using and even creating- the latest developments in healthcare technology, increase employment and economic impact and improved operational capabilities within VA Request: The 2016 request will fund 10 to 12 innovations focused on achieving two of VA s APGs in 2015: (1) ending chronic homelessness among Veterans; and (2) eliminating the compensation claims backlog. A significant focus for VACI in 2016 is on mental health innovations that find new, evidence-based methods for expanding access to mental health care at the lowest cost and the greatest positive impact on Veterans quality of life. In 2016, the VACI program will test and evaluate promising new ways to provide suicide prevention as a critical addition to the current clinical state-of-the-art that focuses on treatment of those already under care. The 2016 request will support the transition of four or five of the most successful innovations that meet stringent standards of evidence to justify transition into production level deployment across VA. The funding will support transition of innovations in such areas as mobile ebenefits, maternity continuity of care, tele-audiology applications, and tele-mental health applications Deliverables: VACI is planning to transition seven major projects from the innovation portfolio into broad adoption in VHA and VBA. Sample projects include the following: Traumatic Brain Injury (TBI) Toolbox: This innovation enables the patient/clinician interface with unprecedented data capture tools, outcomes measurement, and an evidence base for assessing and improving TBI treatment protocols Congressional Submission IT-382

385 Mental Health escreening Assessment: VA will be able to improve access to mental health services by using a new tablet-based application that Veterans can fill out regardless of where they live and automates the paper-bound mental health assessment allowing quicker identification of those Veterans at risk for PTSD and other critical challenges. Radiology Protocol Tool Recorder: Honored as one of the Top 5 Medical Imaging IT projects in 2012, this application will transition the predominantly paper driven protocol assignment process to a data driven electronic environment resulting in increased productivity of radiology staff, reduction of preventable complications from contrast administration adverse events, and lower IT life cycle costs through the use of open source application development practices. Standards and Terminology Services (STS) - $7.3 million Standards and Terminology Services (STS) develop, deploy, and maintains standard clinical terminology for VistA and HealtheVet (HeV) applications. It manages VA s efforts to shift from institution-centric to patient-centric data allowing data interchange and support for analytical computing and clinical decision support. Health Information Portability & Accountability Act (HIPAA) mandated code sets, domains such as lab, drugs, drug allergies, allergy reactants, immunization and many others updates are satisfied as well as recurring terminology mappings between Veterans Administration (VA) and Department of Defense (DoD), and other external partners. STS bridges clinical and technical domains in order to address both the Congressional and Executive concerns and mandates for interoperability, standardization, computability and meaningful use Request: The 2016 request of $7.32 million consists of $2 million in development and $5.32 million in marginal sustainment. Key elements of the projects within this program are: Ensure continued maintenance and updates to data management elements that support critical clinical and business functions including the VA Enterprise Terminology Services (VETS) repository of standard code sets such as International Classification of Diseases and Related Health Problems (ICD9/10), Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT), Pharmacy, Logical Observation Identifiers Names and Codes (LOINC), Allergies, Vitals and Reactants. Maintain and update the standard code set repository in support of the CPRS Problem List, VISTA legacy applications, National Drug File and CHDR data repository. Incorporate additional standardization requirements identified by other future development projects Deliverables: Perform monthly updates to the National Drug File with the National Library of Medicine, monthly updates to CHDR map sets within the Health Data Repository (HDR), and quarterly updates to mapping of lab test names to LOINC codes. Maintain accurate SNOMED CT code mapping to ICD codes used for patient billing and analytics Congressional Submission IT-383

386 Manage the CPRS Problem List and Veteran s Health Administration Terminology (VHAT), including adding new terms, and retiring terms from the source terminology and from VistA data reference sets (essentially pick lists within VistA applications). Maintain the Web Services for Nationwide Health Information Network (NwHIN). Healthcare Efficiency - $7.2 million Health Care Efficiency (HCE) focuses on the identification, reduction, or elimination of organizational variation in business and clinical areas. The elimination of unwanted variation throughout the organization will reduce health care operational costs and create a more streamlined deployment of targeted programs. This standardization will enhance program efficiency throughout the VHA. All aspects of the program are designed to create organizational value by reducing costs while maintaining quality. Enhanced care to the veteran is provided through the standardization of clinical and business practices, evaluation of specially funded programs, analysis of expenses associated with various organizational oversight programs, and the acceleration of cost-savings initiatives Request: The 2016 request of $7.2 million will support the following: Non-VA Care Claims Processing: Authorized when VA services or facilities are not available. The new Health Claims Processing System (HCP) provides centralized processing for Eligibility and Enrollment, Non-VA medical care referrals and authorizations, and claims payment processing. Vet Traveler/Beneficiary Travel: Provide functionality currently found in thirdparty expense management applications for reimbursement of beneficiary travel Deliverables: Non-VA Care Claims Processing Enterprise deployment of the Referral Authorization System (RAS) and Claims Payment Processing System (CPPS). Deployment of the Health Claims Processing (HCP) system, which replaces the current Fee Basis Claims System. Caregiver s - $6.8 million The Caregiver Support Program needs have evolved and grown since implementation in May The Program of Comprehensive Assistance for Family Caregivers has experienced tremendous population growth at nearly 400 percent and continues to grow at a steady rate. Current participation far exceeds original program estimates and has placed strain on the short term manual processes initially used to get the program launched. The current manual Caregiver stipend payment process is extremely vulnerable and continues to pose a significant risk for the Veteran s Primary Caregiver and the VA. To meet the legislative mandate described in Title I, P.L , this project will utilize automated IT capabilities, to reduce manual processes, and increase accuracy and timeliness of stipend payments, improve efficiency in providing benefits and services to program approved caregivers. IT needs include producing interfaces to the 2016 Congressional Submission IT-384

387 Administrative Data Repository (ADR), VistA Registration, Eligibility, and Enrollment packages, and providing the ability to submit applications on line. Family Caregivers allow Veterans to receive care in the least restrictive environment possible, in their homes/communities, surrounded by family and friends. The VA Caregiver Support Program offers services and benefits to support Family Caregivers and allow them to successfully remain in the Caregiver role long-term; supporting their own well-being as well as the well-being of the Veteran they care for. The availability of a Family Caregiver is often the deciding factor in determining whether a Veteran can remain safely at home or must turn to more costly institutional care settings. Compensation and Pension Record Interchange (CAPRI) - $2.7 million The CAPRI project improves service to disabled veterans by promoting efficient communication between the Veterans Health Administration (VHA) and Veterans Benefits Administration (VBA). The software acts as a bridge between the VBA and VHA information systems. It offers VBA Rating Veteran Service Representatives and Decision Review Officers help in building the rating decision documentation through online access to Electronic Health Record (EHR) data found in the Computerized Patient Record System (CPRS). It also offers VHA Compensation and Pension (C&P) staff an easy, standardized way of recording C&P Examination reports. The CAPRI interface is currently the only Compensation & Pension (C&P) exam management system available for use for VHA/VBA C&P staff to support and track VBA exam requests and exam fulfillment by VHA clinicians. It is also the primary access to information by VBA and main tool used by VHA clinicians to provide medical evidence necessary to complete Disability Benefits Questionnaires (DBQ) templates Request: The 2016 budget request of $2.7 million will be used to modify the CAPRI application. Modifications are needed to allow VHA (in-house and contracted) DBQ data to be utilized by Veterans Benefits Management System (VBMS), which would also support eliminating the claims backlog Congressional Submission IT-385

388 Information and Technology Staffing and Administration Subaccount Payroll & Administrative Support Highlights (dollars in thousands) Actuals Budget Estimate Current Estimate Budget Request Increase / Decrease Obligations: Personal Services & Benefits 852, , , ,152 34,699 Travel 5,863 14,760 8,884 8, Comm., Utilities & Rent 17,234 15,352 18,109 18, Printing & Reproduction Other Services 1/ 137, , , ,677 45,157 Supplies & Materials Equipment 1,579 3,500 6,949 2,652-4,297 Lands & Structures Other 20, Subtotal $1,036,593 $1,042,823 $1,087,737 $1,164,192 $76,455 Funding Sources: Appropriation 1,026,400 1,039,000 1,039,000 1,115,757 76,757 Rescission -1,066 1,066 Transfers 2/ -3,853-3,952-3,952-4, Pay Reimbursements (+) 16,470 7,775 25,599 26, Available Balance SOY (+) 3/ 13,157 15,156 26,000 10,844 Available Balance EOY (-) -15,156-26,000 26,000 Adjustments (Expiring) Lapse -425 PL Veterans Choice Act 39,000-39,000 Total Obligations $1,036,593 $1,042,823 $1,087,737 $1,164,192 $76,455 Total Full Time Equivalents (FTE) 7,291 7,427 7,515 7, Direct 7,208 7,325 7,325 7,325 Direct (PL Veterans Choice Act) Reimbursement / Other Services include administrative contracts such as for workforce development, architecture, engineering standards, shared cost from other organizations, etc. 2/ Reflects transfers from OIT to the North Chicago Facility in pay funding. 3/ In 2016, this line represents anticipated carryover for the Veterans Choice Act. The majority of the staffing and administration budget is devoted to salaries and benefits. The remaining funding is for travel, training, administrative support contracts, leases (including those supporting data centers), as well as office equipment and 2016 Congressional Submission IT-386

389 supplies. Also included in this budget is funding for the mass transit benefits program and worker s compensation related to OIT employees. OIT is the steward of VA s IT assets and resources, and is responsible for ensuring the efficient and effective operation of VA s IT Management System to meet mission requirements of the Secretary, Under Secretaries, Assistant Secretaries, and other key officials. With the requested funding, OIT will continue to provide strategy and technical direction, guidance, and policy to ensure that IT resources are acquired and managed for the VA in a manner that adheres to various federal laws and regulations. OIT is composed of eight major organizational components; the table below displays FTE for each component: 2014 Actuals Note: This table includes reimbursement FTE 2015 Budget Estimate 2015 Current Estimate 2016 Budget Request Increase / Decrease Service Delivery and Engineering 5,386 5,400 5,391 5,391 0 Veterans Choice Act Product Development Information Security Quality, Performance and Oversight IT Resource Management Architecture Strategy Design Interagency Program Office Customer Advocacy Total FTE 7,291 7,427 7,515 7, Staffing Request The 2016 staffing and administration budget request reflects funding for the following Office of Information Technology staff offices. Service Delivery and Engineering (SDE) The Service Delivery and Engineering component provides all operational and maintenance activities associated with VA's IT environment. This includes the following activities: (1) overseeing and managing VA regional data centers, the IT network, and telecommunications; (2) conducting production monitoring for all information systems, production services, managing the delivery of operations services to all VA geographic locations; and (3) conducting all PBX management and maintenance. Product Development (PD) The Product Development component manages all enterprise application development activities. Development consists of planning, developing (or acquiring), and testing applications that meet business requirements. It provides day-to-day direction over all solutions developed by OIT for VA business units. The 2015 and 2016 budget includes funding for PD to hire Digital Services staff (25 in 2015 and 50 more in 2016) that will directly perform critical and more complex IT software development projects. These are not IT program managers, but rather IT technical expert individuals in their field to provide VA with more effective IT solutions Congressional Submission IT-387

390 The success rate of government digital services is improved when agencies have digital service experts on staff with modern design, software engineering, and product management skills. To ensure the agency can effectively build and deliver important digital services, the 2016 budget includes funding for staffing costs to build a Digital Service team that will focus on transforming the agency s digital services with the greatest impact to citizens and businesses so they are easier to use and more cost-effective to build and maintain. These digital service experts will bring private sector best practices in the disciplines of design, software engineering, and product management to bear on the agency s most important services. The positions will be term-limited, to encourage a continuous influx of up-to-date design and technology skills into the agency. The digital service experts will be recruited from among America s leading technology enterprises and startups, and will join with the agency s top technical and policy leaders to deliver meaningful and lasting improvements to the services the agency provides to citizens and businesses. This digital service team will build on the success of the United States Digital Service team inside of OMB, created in Since standing up, this small OMB team of has worked in collaboration with Federal agencies to implement cutting edge digital and technology practices on the nation s highest impact programs, including the successful relaunch of HealthCare.gov in its second year, which led to millions of Americans receiving health coverage; the Veterans Benefits Management System; online visa applications, green card replacements and renewals; among others. In addition to their work on these high priority projects, this small team of technical experts has worked to establish best practices (as published in the U.S. Digital Services Playbook at playbook.cio.gov) and to recruit even more highly skilled digital service experts and engineers into government. Information Security (OIS) Information Security deals with matters related to information protection including privacy, cyber security, risk management, records management, FOIA, incident response, critical infrastructure protection and business continuity. The office develops, implements and oversees the policies, procedures, training, communication and operations related to improving how VA and its partners safeguard the PII of Veterans and VA employees. Its objective is to assure the confidentiality, integrity and availability of information and information systems. Quality, Performance and Oversight (QPO) Quality, Performance & Oversight facilitates the establishment of performance measures and metrics related to the full range of IT program responsibilities and strategic objectives and manages associated measurement efforts. The office has an integrated enterprise-wide risk management framework to identify and manage risk. This framework is designed to anticipate, identify, prioritize, and monitor OIT enterprise risks, ensures information technology investments are managed efficiently and effectively, and provides assurance in the achievement of OIT objectives. IT Resource Management (ITRM) ITRM directs the financial management, multi-year programming, budget formulation and execution, workforce development, IT facility management; as well as acquisition strategy 2016 Congressional Submission IT-388

391 and vendor management within OIT. As such, it has the primary responsibility of linking the budgeting process with IT programs. ITRM must accomplish resource requirements validation and correlation during the annual Planning, Programming, Budgeting and Execution (PPBE) multi-year intake programming process. Architecture Strategy Design (ASD) ASD advises and assists the DeputyAssistant Secretary of IT in overseeing and directing the areas of IT strategy, plans, and programs for the Department. The office develops the Enterprise Architecture and IT Strategic Plan, which addresses short and long-term IT goals, objectives and performance measures necessary to support VA business lines. Interagency Program Office (IPO) The IPO supports the VA s efforts to implement national health data standards for interoperability with DoD - a key component to updating VistA - and will be responsible for establishing, monitoring, and approving terminology and technical standards profiles and processes to ensure seamless integration of health data between the two departments and private health care providers. Responsibility for development of requirements and execution of IT solutions remain with the respective DoD and VA organizations. Office of Customer Advocacy (OCA) The Office of Customer Advocacy (OCA) is a new office created in 2014 to ensure that OIT works with its customers more effectively to provide them with the best IT services possible. The OCA is still crystallizing its vision and mission while it brings together three existing program areas with years of experience in customer advocacy, collecting and analyzing customer satisfaction metrics, and responding to IT support requests. OCA consists of the Customer Advocates for Benefits, Corporate, and Health; the Service Coordination (SC) Office; and IT Customer Relationship Management (CRM). These groups each specialize in different areas of customer service, and their combined expertise will enable the OCA to see a holistic view of the customer experience. The Customer Advocates are primarily responsible for liaising with VA s different business lines to ensure that OI&T provides the services they need. They broker with the business side to see how business challenges can be resolved in order to meet desired outcomes in an effective, efficient manner. Additionally, they advocate as advisors providing insight into the business line and OI&T, as well as presenting external factors that may come into play. The SC office has historically been an intermediary between the VA business community and OI&T, serving as technical IT operations advocates in such areas as IT activations resource planning, enterprise project rollout coordination, service agreement formulation, and translating technical bulletins into digestible customer communications. The IT Customer Relationship Management program area is responsible for measuring OI&T s success in serving its internal VA customers with industry-proven tools such as the American Customer Satisfaction Index (ACSI). CRM was responsible for assessing ACSI scores, National Service Desk data, and Key Performance Indicators from across the business lines to assess the consistency of the OI&T customer experience Congressional Submission IT-389

392 OCA is committed to ensuring that OI&T provides top-notch customer service and works strategically with the various business lines to improve and develop VA IT solutions. Funding for this program area will enhance OIT s ability to focus on delivering personal productivity to the end user not technical functionality Congressional Submission IT-390

393 Information and Technology VistA Evolution/Interoperability and VLER Health VistA Evolution/Interoperability and VLER Health (Dollars in Thousands) / Actuals Carryover Budget Estimate Current Estimate Budget Request Increase / Decrease DME OM DME DME OM DME OM DME OM DME OM VistA Evolution $ 113,869 $ 25,497 $ 105,131 $ 179,922 $ 89,484 $ 179,922 $ 89,484 $ 81,900 $ 100,700 $ (98,022) $ 11,216 Interoperability $ 18,176 $ 11,382 $ 1,620 $ - $ - $ 36,123 $ 21,850 $ 15,000 $ 15,000 $ (21,123) $ (6,850) VLER Health $ 9,503 $ 2,659 $ 3,583 $ - $ - $ 13,085 $ 3,150 $ 10,000 $ 10,000 $ (3,085) $ 6,850 iehr & VLER Health $ - $ - $ - $ 32,000 $ 25,000 $ - $ - $ - $ - $ - $ - Total $ 141,548 $ 39,538 $ 110,334 $ 211,922 $ 114,484 $ 229,130 $ 114,484 $ 106,900 $ 125,700 $ (122,230) $ 11,216 TOTAL DME and OM $ 181,086 $ 110,334 $ 326,406 $ 343,614 $ 232,600 $ (111,014) Total VistA Evolution/Interoperability and VLER Health - $232.6 million VistA Evolution - $182.6 million Veterans health Information Systems and Technology Architecture (VistA) Evolution is a joint program of the VA OIT and VHA and will provide interoperability with Electronic Health Record (EHR) systems of the Department of Defense (DoD) and other healthcare partners to promote improved outcomes in quality, safety, efficiency, and satisfaction in healthcare for Veterans, Servicemember, and their dependents. Interoperable EHR systems will ensure that authorized beneficiary and medical data are accessible, usable, shared, and secure to meet the needs of VA patients, healthcare providers, and other stakeholders. VistA Evolution will modernize the VA EHR and ancillary health information technology (IT) systems to facilitate their use by clinicians inside and outside VA. The modernized VA system will be interoperable with the EHR systems of the DoD and other healthcare partners to enhance patient-centered, team- and evidence-based care by giving healthcare providers a complete picture of a patient s care and treatment history. VA established the VistA Evolution Program to focus on delivering an evolved VistA (VistA 4) that is based on open architected and non-proprietary in design. The VistA 4 Product Roadmap leverages open standards endorsed by the Office of the National Coordinator and adheres to key open architecture tenets such as open transport formats (e.g., HL7 messaging), open interface specifications, and design patterns that enable an open and scalable solution. VistA 4 will promote the delivery of an interoperable, effective, safe, and efficient healthcare that improves the lives of Veterans, Servicemember, and their dependents Congressional Submission IT-391

394 The VistA 4 Product Roadmap, a planning document contingent upon receiving requested funding for FY 2016 and beyond, has targeted delivery objectives by year as shown in the figure below. The VistA Evolution (VE) program will provide health information management capabilities that support patient-centric, team-based, quality-driven healthcare, which will improve outcomes in quality, safety, efficiency, and satisfaction in healthcare. Patientcentric capabilities include tailoring care plans to realize explicit patient goals and preferences related to function, comfort, and dignity. Team-based features include a single plan of care traced to clinical and patient goals and greatly enhanced communication tools. Quality-driving features focus on activity management with includes granular capture and management of workload through care-plan tasks and granular capture of demand through patient status in relation to goals. In conjunction with analytical systems, this information can drive lean-style management of healthcare processes to improve access and realize goals that matter to patients. In addition, achieving of health equity requires a population health view into health information data. This will be met through the enhancements provided by VE Congressional Submission IT-392

395 The program supports all three of VA s strategic goals of empowering Veterans to improve their well-being; enhancing and develop trusted partnerships; and managing and improving VA operations to deliver seamless and integrated support. The Vista Evolution Program will use the following governance organization structure to manage the program and ensure that the goals and objectives of the program are met. Vista Evolution Governance Organization Structure In the chart above, IPT stands for Intergrated Project Team, and CMIO stands for Chief Medical Information Officer. The Systems Life Cycle (SLC) Moves Left to Right from Requirements to Operations & Maintenance 2016 Request: The requested $182.6 million for Vista Evolution includes $81.9 million in development, $15.7 million in marginal sustainment, and $85 million in mandatory sustainment. Funding in 2016 will contribute to: 2016 Congressional Submission IT-393

396 Delivering prioritized high value aspects of seamless electronic sharing of interoperable healthcare data with DoD and community partners through implementation of interoperability standards. Improving quality, safety, efficiency, equity, and satisfaction in healthcare for Veterans through addition of new EHR features that provide patient-centric, teambased, quality-driven healthcare. Making incremental improvements in systems supporting ancillary services. Reducing risk and cost and increase quality and speed of HIT acquisitions through growing a standards-based market for VistA 4 components with community healthcare systems and vendors Deliverables VistA accomplishments in 2015 will include: Deploying the Initial Operating Capability (IOC) standardized software at an additional 30 sites; Enhancing military and demographic information available to clinicians in support of treatment plans and decision-making; Configuring the existing VistA pharmacy system to accommodate outside healthcare providers to send electronic prescriptions to VA, thereby increasing the speed of filling prescriptions for Veterans and potentially reducing the cost to Veterans of medications through improved access to VA pharmacy benefits; Adding decision support that will help radiologists complete work for their patients; and Providing VLER Health with the ability to perform additional clinical functionality and the ability to filter data provided to external partners. Interoperability - $30.0 million Interoperability supports the electronic exchange of health information among caregivers and other authorized parties, allowing clinicians to access and view multi-sourced patient data. Improving cross-departmental interoperability and interoperability with industry will provide improved access to a more comprehensive and integrated patient health history from multiple sources where care originally occurred. Additionally, improved interoperability of inter-departmental health benefit information should expedite administrative and financial decision-making processes; helping to ensure services are made available to Veterans and family members quickly Request: The 2016 request of $30 million consists of $15 million in development and $15 million in mandatory sustainment funds funding will: Ensure that the electronic health record systems of the DoD and VA are interoperable with an integrated display of data; Transition the current data exchanges between the Departments and private sector health care providers where practical to modern, open-architecture frameworks that use computable data mapped to national standards allowing data availability for determining medical trends and other enhanced clinician decision support efforts; 2016 Congressional Submission IT-394

397 Provide DoD and VA patients the ability to view and download their Department medical records as well as upload other healthcare records insuring an integrated, longitudinal record for all medical personnel use in the course of the patient s care; and Provide the ability to support interoperability requirements with DoD in areas such as contact information, demographics, and others as required. The VA and DoD will continue efforts to share information about the Veteran, find common representations of Veteran information that can be understood, and make this information available on demand (under appropriate security controls). DoD and VA s joint efforts is represented in the following Operating Model. Virtual Lifetime Electronic Record (VLER) Health - $20.0 million 2016 Congressional Submission IT-395

398 VLER Health will enable clinicians, providers, and their administrative staffs to streamline their workflows and increase the breadth of health information available, coordinate care, and streamline transitions of care for their Veteran patients. VLER Health also enables Veteran access to care by enabling integration between a Veteran s VA health record and his/her private health records; this means that Veterans should have better options to see private health care providers, at their convenience, and be assured that their health information should be available to their VA providers. As VLER Health expands, by adding new partners and capabilities, it will continue to improve the opportunity for enhanced access to care for even larger numbers of Veterans in locations across the Unites States, including those in rural and underserved areas Request: The 2016 request of $20.0 million consists of $10 million in development and $10 million in mandatory sustainment funds. The 2016 funding is critical to the continued expansion of VLER Health and its corresponding benefits to Veterans. This includes onboarding nationwide partners with the ability to reach diverse Veteran populations (i.e., rural Veterans) as well as continuing to define and execute use cases unique to regions or specific VA medical centers. With 2016 funds, the program will also be able to: Expand partnerships with nationwide providers and other Health Information Exchange (HIE) programs to support purchased care; Stand up Health Information Handlers (HIHs) for providers without access to Direct Secure Messaging; Partner with community exchanges and address unique needs; Strive to change laws allowing VLER Health to transition to an opt-out model; Extend current authorization language and the Data Use and Reciprocal Support Agreement (DURSA); Promote campaigns for all Veterans; improve the speed, performance, and availability of data; and Generate new or modify existing policies for external data retention; Ensure communications are delivered to appropriate target audiences Congressional Submission IT-396

399 Information and Technology Improve Access to Benefits and Services Veteran Customer Experience (VCE) 2014 Accomplishments Deployed CRM utilizing standard platform and add additional lines of business to improve one view of the veteran in both Call Center and Case Management Quarterly Releases (10 Lines of Business (LOB) and over 3,000 users) Expanded Knowledge Management (KM) to new VA business lines currently several LOBs within VBA and VHA use the solution (over 2,700 users) Deployed IAM release enhancing single sign-on (SSO) authentication for internal and external users, expanding the use of Master Veteran Index (MVI) to VBA systems Deployed Self Service release completing Fully Developed Claims (FDC) implementation Quarterly releases including Attorney Claim Submission (over 55 features on ebenefits) Deployed Digits-to-Digits and Customer Gateway Services in support of VHA, VBA and the Customer Data Integration Enterprise effort Access to Care (Medical Core and Medical Legacy) Three Initial Operating Capability (IOC) sites are live and using Surgical Quality Workflow Manager (SQWM) EDIS version 2.2 nationally deployed CFM requirements and business use cases completed Connected Health/Telehealth Expansion In FY 2014, My HealtheVet registered over one million patients in the Secure Messaging program and has processed over 55 million prescription refills since Web and Mobile Solutions developed and put into production the Open Burn Pit registry web application. Veterans Point of Service devices have been used by Veterans for appointment check and to update their contact information over 1.2 million times and there have been over 10 million Veteran interactions. Over 200,000 Veterans are using clinical video teleconferencing capabilities to receive health care. Over 3,600 mobile devices have been deployed to providers and health care teams at eight VA facilities across the country Congressional Submission IT-397

400 Health Provider Systems (Medical Core) In 2014, Computerized Patient Record System (CPRS) version 29 completed deployment. Accomplishments include testing and national release of version 30A ICD-10 enhancements, testing of version 30B enhancements for Lab display, clinic orders, supply orders, 508 changes, patient safety items, and Windows 7 modernization. Completed development of version 31 includes enhancements for Abnormal Test Results (ATR), Primary Care Management Module (PCMM), Teratogenic Drugs, Health Risk Assessment (HRA), VistA Imaging, and Camp Lejeune projects. Testing for the RAI MDS replacement application began as well. Disability Exam and Assessment Program (DEAP) DEAP BRD updated and provided to IPT for review June Development Activities: Sprint 11 ended June 24, 2014, and Sprint 12 began June 25, Sprint 11 User Stories (Completed/Accepted): Development Coordination; System and User Support; System security role and persona definition; Exam request data field capture; Technical documentation review; Exam and Exam Request status update; and System to VBMS BSD091 gap analysis. Mental Health VA provided specialized mental health treatment to more than 1.4 million Veterans. Released the Mental Health Suite Treatment Planning Software for treatment planning in all specialty care MH settings. The product was substantially modified to meet VHA standards for Veteran-centric, recovery-oriented care and is integrated within the electronic health record system. Added the identification of the Principal Mental Health Provider to the Primary Care Management Module (PCMM) application. This enhancement facilitates making the identification of a mental health provider readily available to all care providers and improves coordination of mental health care. This includes the designation of the Mental Health Treatment Coordinator (MHTC) in the Computerized Patient Record System (CPRS) v29. My Recovery Plan (MRP) was released that includes an interactive set of webbased tools accessible via My HealtheVet (MHV) that follows a recovery model for mental health care. The goal of MRP is to provide the veteran with hope of improved health and quality of life through collaborative involvement in his or her own mental health care. Deployed the High Risk Mental Health Patient National Reminder and Flag in CPRS to notify clinicians of a patient s risk of suicide. The Category I Flag is universal within the VHA electronic health record system and expands across all Veterans Health Information Systems and Technology Architecture (VistA) systems. This created a series of reports that facilitates quickly identifying patients that are on a high risk for suicide list who have missed a mental health appointment, a significant risk factor for completed suicide Congressional Submission IT-398

401 Behavioral Health Laboratory (BHL) Software was successfully developed and the integration between the BHL software and the current VA electronic health record, CPRS was nationally released. This allows export of defined data elements from CPRS to BHL, pass progress notes from BHL to CPRS and import BHL assessment data into the MHA files of VistA. Eliminate the Disability Claims Backlog VBMS In FY2014, VBMS had over 29,000 unique end-user accounts and nearly 90% of VBA s inventory was electronic. A total of 17 software releases (3 major, 14 minor) were delivered since October 2013 and VBMS was deployed to 16 new stakeholders so far this year. In addition, VBMS conducted 13 requirements rotations and 10 design sessions that resulted in over 200 requirements artifacts, conducted 12 weeks of User Acceptance Testing, and delivered training to end users for each of these releases. VETSNET/Financial and Accounting System (FAS) This program provided ongoing support for COLA changes enacted by Congress, support for the Treasury s ongoing initiative for paper reduction through the COMERICA debit card program, and fundamental changes in payment processing through Treasury due to their mandatory Payment Application Modification (PAM) program, which required VBA to make significant changes to our database tables, application entry and display screens, and to backend services that store, retrieve and display data to the applications. These accomplishments exemplify the critical need for ongoing development funding to support Veteran payments while reacting to dynamic dependencies on other Federal agencies and as changes in law are enacted. Maintain the Infrastructure Activations IT Activations has funded over 600 separate requests through 3 rd quarter for IT equipment required for new facilities opening in 2014 and 2015 and associated renovations for existing facilities. These requests are broken down as follows: o Major Construction & New CBOC Leases: $6.3M o Minor Construction & CBOC Expansion: $2.57M o Other Leases: $2.92M o Non-Recurring Maintenance (NRM) and Clinical Specific Improvements (CSI): $883K o Station Level Projects: $6.3M Provided IT equipment for the phased opening of the Orlando VAMC s Community Living Center, and provided the Orlando VAMC s Inpatient Hospital with required IT equipment and installation. RTLS Hosting Enterprise Data Architecture completed National Data Repository (NDR) Project entered planning state 2016 Congressional Submission IT-399

402 Completion of NDR milestone I briefing Initial documentation completed which included Use Cases, Requirements Specification Document, System Design Document, Requirements Traceability Matrix and Enterprise Data Architecture Other Development Programs VHA Research As of June 2014, 374,268 Veterans have been recruited into MVP with 47 sites actively recruiting. RAMS IT contract recently awarded and has entered PMAS active stage for development (first of seven modules needed). POC-R conducted a small clinical pilot study at several VAMCs and gained approval for a national rollout study. VINCI capacity now supports 300 researchers/investigators. VA Center of Innovations (VACI) 2014 VA Innovation Investment Projects includes: Remote Veteran Apnea Management Portal (REVAMP) used wireless data transmission to offer diagnostic studies to Veterans in their home environment Retail Immunization Care Coordination- allowed enrolled Veteran patients the option of getting a flu shot at any of Walgreen s 8,000 locations and their VA electronic health record is automatically and securely updated via the VA s ehealth Exchange project. VistA Evolution/Interoperability/VLER Health VistA Evolution Initial VistA 4 core capabilities were made available to a group of users at the Hampton VA Medical Center (VAMC), in Hampton, VA and the Audie L. Murphy VA Hospital, South Texas Veterans Health Care System (STVHCS), in San Antonio, TX and some of their associated CBOCs. These capabilities include: o Interoperability: VA/DoD information sharing via the Joint Legacy Viewer (JLV). o Graphical User Interface (GUI) Tools: Delivery of new tools to support Google-like searches within patient records, context-aware InfoButtons that link to clinical monographs on the web, and tools to facilitate medication reviews. These tools can be considered initial tests of functionality envisioned in the ehmp which is the target VA clinical interface. Vista Site Standardization achieved at 44 sites. Implementation of Immunization and structured data capture at IOC sites Radiology protocols were deployed in production environment Congressional Submission IT-400

403 Interoperability improvements with the transition of all traffic to the new VA/DoD Gateway. Acquisition strategy planning and data reporting capability achieved for ONC certified development. Vista Evolution Full Operating Capability (FOC) plan delivered. Interoperability Provided Data Standardization Analysis Reports for 21 additional data domains (28 total). Expanded the features and distribution of Joint Legacy Viewer (JLV) to include additional VA and DoD data domains to an additional 3,500 users. VLER Health VLER Health Exchange successfully: On-boarded 14 of 12 partner health care organizations (2014 goal of one partner per month surpassed); Activated non-va health summaries in all 130 VistA instances; Enrolled over 81,000 authorized Veterans, with over 12,000 records received by VA and over 50,000 records sent by VA; Used VLER Health technologies to successfully partner with a retail pharmacy in Florida for the purpose of Veteran access to flu vaccines (flu vaccine information made available to clinicians using VLER Health Exchange); and Implemented Direct Secure Messaging with non-va partners in two states (Utah and Alaska). Other Notable 2014 Accomplishments Customer Satisfaction VA OIT continuously strives to improve IT customer satisfaction, which in turn positively impacts the service VA employees provide to Veterans and their families. The IT Customer Service Improvement Program collects data on IT end-user customer satisfaction through enterprise-wide surveys which started in 2010, targeted surveys which started in 2012, and focus group interviews which started in The 2016 Data collection consists of an annual survey, multiple targeted surveys, and other new measurement systems. Data from these surveys is used to calculate customer satisfaction with various IT products and services using the American Customer Satisfaction Index (ACSI), which is a widely used measurement method that allows an organization to compare its customer service delivery to similar organizations. A number of quantitative analysis techniques were used including mathematical and statistical analysis to identify technical areas that have the highest impact on customer satisfaction. In VA s overall ACSI score was 70 which putsva slightly above average for the affinity group that VA is a part of. To establish a continuous IT service improvement, VA instituted the program to apply a holistic approach to collecting customer feedback data through site visits and structured 2016 Congressional Submission IT-401

404 interviews at various VA sites. These sites are selected based on the survey results and their data is analyzed to identify issues, opportunities, and best practices, and develop recommendations. VA recommendations are based on objective, transparent, and standard methods of data analysis using structured and group interviews with customer leadership and general staff. VA uses both the qualitative research methodologies using interview data and quantitative research methodologies using survey data to identify and implement the most pervasive, impactful, and feasible IT service improvement solutions. This program has already collected feedback directly from hundreds of customers on IT products and services. Site visits and interviews include VHA medical center leadership, clinical managers, and hospital staff; VBA regional office leadership, service line department managers, and staff; and NCA cemetery directors and staff. These meetings and interviews provide a hands-on mechanism to measure customer satisfaction, identify customer needs, assess customer expectations, and discover best practices. VA identified several customer issues, and has started solving them either directly or by involving the assistance of other subject matter experts within VA. In addition, several best practices were identified and they are being standardized and disseminated throughout VA through the channels available to the Communication Program. IT Governance and Financial Management Oversight VA IT governance and financial management oversight ensures the alignment of IT strategy, systems and processes to VA s business strategy. The governance and financial management processes in place provides a framework by which the overall impact of IT investments upon VA, Veterans, Servicemember, employees and other stakeholders must be taken into consideration before scarce resources are assigned to IT projects. A primary driver of this framework has been aligning business and IT processes across VA in meeting the primary objective exceptional services for Veterans, their dependents and their survivors. The two IT governance boards are the Information Technology Leadership Board and the Planning, Programing, Budgeting and Execution Board. These boards provide VA IT direction, oversight, prioritization, enforcement and issue resolution. Each board meets monthly or as needed. All VA Administrations and staff offices are represented to ensure their input to critical business requirements. Effective coordination and information flow between the boards is critical to a synchronized IT governance effort. Specific focus areas have been assigned to each board to effectively address and manage both near term and long term IT requirements and resources. VA IT governance and financial management oversight services provide a full accounting and reporting of all financial activity and supports an effective program of internal controls implementation and compliance across all resource activities throughout the IT enterprise. IT governance and financial management oversight serves as OIT s accounting, financial policy, and reporting interface to VA; with the responsibility for developing and implementing OIT travel policy, and serving as the OIT lead for assessing and reporting internal controls that enhance financial and operational accountability within OI&T in accordance with the requirements of the Federal Managers Financial Integrity Act/OMB Circular A Congressional Submission IT-402

405 The objective of VA IT governance is to evaluate OIT risks and provide a level of assurance that OIT achieves effectiveness and efficiency of operations, reliability of financial reporting and compliance with applicable laws and regulations. Effective and efficient IT resource stewardship and OIT systems delivery also touches every aspect of meeting VA s mission needs in support of more than 1,100 medical facilities supporting more than 8.5 million enrolled Veterans. OIT prepares a detailed financial plan every year, known as the Prioritized Budget Operating Plan. This plan had two main purposes: To have a vehicle for OIT to agree with its customers on what the high priority IT services and project are, and allocate resources to ensure success on the most important items. It also allows OIT to communicate clearly and objectively which projects and services will not be accomplished. To allow OIT to track spending from the planning phase to expenditures and know the business purpose for each dollar spent. The Plan then tracks the outcomes expected from the expenditure Congressional Submission IT-403

406 Information and Technology 2016 Budget Appendices 2016 Congressional Submission IT-404

407 Information and Technology Development, Modernization, and Enhancement Subaccount 1/ Numbers do not include reimbursements 2/ In 2016, this line represents anticipated carryover for the Choice Act Information Technology Development Activities Highlights (Dollars in Thousands) / Actuals Carryover Budget Estimate Current Estimate Budget Request Increase / Decrease Activities Access to Healthcare 4,128 2,156 9,686 9,686 28,970 19,284 Surgical Quality and Workflow Management Healthcare Efficiency IT Development ,723 10,723 6,660-4,063 Electronic Health Record Interoperability & VLER Health 27,679 5,203 32,000 49,208 25,000-24,208 VistA Evolution 113, , , ,922 81,900-98,022 New Models of Care 27,617 6,186 30,551 30,551 25,430-5,121 Veterans Benefits Management System (VBMS) 42, ,500 63,500 86,000 22,500 Virtual Lifetime Electronic Record (VLER) 4,399 3,953 18,600 18,600 10,000-8,600 Veterans Relationship Management (VRM) 126,637 9,916 76,600 76,600 73,333-3,267 Health Management Platform 4,177 2,397 5,746 5, ,746 International Classification of Diseases (ICD-10) 2,522 2, VHA Research IT Support Development ,250 12,250 Integrated Operating Model 2, Other IT Systems Development 31,625 12, , , ,200 51,401 Total Development 1/ $ 388,137 $ 150,432 $ 531,127 $ 548,335 $ 504,743 -$43,592 Funding Sources Appropriation 388, , , ,743-43,592 Recission Emergency Supplemental Transfers Reimbursements (+) ,000-4,445 4,445 Available Balance SOY (+) 2/ 124, ,432 43, ,532 Available Balance EOY (-) -150, ,900-43,900 PL Veterans Choice Act , ,400 Total Obligations $ 362,374 $ - $ 600,127 $ 806,267 $ 553,088 -$253, Congressional Submission IT-405

408 Congressional Report Detail Development Information and Technology Total Budget Authority Development (Dollars in Thousands) / Actuals Carryover Budget Estimate Current Estimate Budget Request Increase / Decrease Access to Healthcare $ 4,128 $ 2,156 $ 9,686 $ 9,686 $ 28,970 $ 19,284 Surgical Quality and Workflow Management $ 617 $ - $ - $ - $ - $ - Healthcare Efficiency IT Development $ - $ - $ 10,723 $ 10,723 $ 6,660 $ (4,063) Electronic Health Record Interoperability & VLER Health $ 27,679 $ 5,203 $ 32,000 $ 49,208 $ 25,000 $ (24,208) VistA Evolution $ 113,869 $ 105,131 $ 179,922 $ 179,922 $ 81,900 $ (98,022) New Models of Care $ 27,617 $ 6,186 $ 30,551 $ 30,551 $ 25,430 $ (5,121) Veterans Benefits Management System (VBMS) $ 42,243 $ 591 $ 63,500 $ 63,500 $ 86,000 $ 22,500 Virtual Lifetime Electronic Record (VLER) $ 4,399 $ 3,953 $ 18,600 $ 18,600 $ 10,000 $ (8,600) Veterans Relationship Management (VRM) $ 126,637 $ 9,916 $ 76,600 $ 76,600 $ 73,333 $ (3,267) Health Management Platform $ 4,177 $ 2,397 $ 5,746 $ 5,746 $ - $ (5,746) International Classification of Diseases (ICD-10) $ 2,522 $ 2,078 $ - $ - $ - $ - VHA Research IT Support Development $ - $ - $ - $ - $ 12,250 $ 12,250 Integrated Operating Model $ 2,625 $ 415 $ - $ - $ - $ - Other IT Systems Development $ 31,625 $ 12,406 $ 103,799 $ 103,799 $ 155,200 $ 51,401 Subtotal $ 388,137 $ 150,432 $ 531,127 $ 548,335 $ 504,743 $ (43,592) Sustainment/O&M Medical Operations and Maintenance $ 720,733 $ 745 $ 917,751 $ 917,751 $ 952,763 $ 35,012 Benefits Operations and Maintenance $ 234,613 $ - $ 280,516 $ 280,516 $ 278,710 $ (1,806) Enterprise Operations and Maintenance $ 1,073,460 $ - $ 1,038,185 $ 1,020,977 $ 1,143,920 $ 122,943 Interagency Operations and Maintenance $ 105,307 $ - $ 96,765 $ 96,765 $ 137,470 $ 40,705 Subtotal $ 2,134,114 $ 745 $ 2,333,217 $ 2,316,009 $ 2,512,863 $ 196,854 Development $ 388,137 $ 150,432 $ 531,127 $ 548,335 $ 504,743 $ (43,592) Sustainment/O&M $ 2,134,114 $ 745 $ 2,333,217 $ 2,316,009 $ 2,512,863 $ 196,854 Staffing and Administration $ 1,006,966 $ 15,156 $ 1,039,000 $ 1,039,000 $ 1,115,757 $ 76,757 H1N1 Supplemental (P.L ) $ - $ 2 $ - $ - $ - $ - OEF/OIF Supplemental (P.L ) $ 473 $ 2,055 $ - $ - $ - $ - Rescission $ - $ - $ - $ (1,066) $ - $ 1,066 Total $ 3,529,690 $ 168,390 $ 3,903,344 $ 3,902,278 $ 4,133,363 $ 231, Congressional Submission IT-406

409 Information and Technology Development Detail (Dollars in Thousands) / Actuals Carryover Budget Estimate Current Estimate Budget Request Increase / Decrease Access to Healthcare $ 4,128 $ 2,156 $ 9,686 $ 9,686 $ 28,970 $ 19,284 Emergency Department Information System $ 414 $ 1,225 $ 2,780 $ 2,780 $ - $ (2,780) Mobile Development - Health Apps $ - $ - $ - $ - $ 11,000 $ 11,000 Bed Management Solution Development $ - $ - $ 4,309 $ 4,309 $ (4,309) Veterans Point of Service (VPS) Kiosk $ 3,124 $ 521 $ 2,597 $ 2,597 $ - $ (2,597) Veterans Implant Tracking Alert System (VITAS) $ 590 $ 410 $ - $ - $ - $ - Access to Care $ - $ - $ - $ - $ 17,970 $ 17,970 Surgical Quality and Workflow Management $ 617 $ - $ - $ - $ - $ - Surgical Quality and Workflow Manager $ 617 $ - $ - $ - $ - $ - Healthcare Efficiency IT Development $ - $ - $ 10,723 $ 10,723 $ 6,660 $ (4,063) Healthcare Efficiency IT Development $ - $ - $ - $ - $ 6,660 $ 6,660 Real Time Location System (RTLS) National Middleware Data Repository $ - $ - $ 5,723 $ 5,723 $ - $ (5,723) HCE Non-VA Care - Claims Processing $ - $ - $ 2,500 $ 2,500 $ - $ (2,500) Non-VA Care Claims Processing Enhancements $ - $ - $ 2,500 $ 2,500 $ - $ (2,500) Interoperability & VLER Health $ 27,679 $ 5,203 $ 32,000 $ 49,208 $ 25,000 $ (24,208) VLER Health $ 9,503 $ 3,583 $ - $ 13,085 $ 10,000 $ (3,085) Data Management Services $ 18,176 $ 1,620 $ - $ - $ - $ - Interoperability $ - $ - $ - $ 36,123 $ 15,000 $ (21,123) iehr and VHLER Health $ - $ - $ 32,000 $ - $ - $ - VistA Evolution $ 113,869 $ 105,131 $ 179,922 $ 179,922 $ 81,900 $ (98,022) User Experience, Data Standards, Clinical Decision Support $ 50,837 $ 4,302 $ - $ - $ - $ - VistA - API $ 7,909 $ 11,050 $ - $ - $ - $ - VistA Module Enhancements $ 10,024 $ 9,453 $ - $ - $ - $ - Identity Management Services $ 2,009 $ 880 $ - $ - $ - $ - Access Control Services $ - $ - $ - $ - $ - $ - Immunization Specific Services $ 2,348 $ 4,025 $ - $ - $ - $ - Laboratory Specific Services $ 4,946 $ 25,043 $ - $ - $ - $ - Medical Scheduling $ 6,389 $ 13,021 $ - $ - $ - $ - Pharmacy Specific Services $ 9,636 $ 21,369 $ - $ - $ - $ - Meaningful Use $ 4,430 $ 14,505 $ - $ - $ - $ - Enterprise Service Bus/Services Oriented Architecture (ESB/S0A) $ 15,340 $ 1,482 $ - $ - $ - $ - New Models of Care $ 27,617 $ 6,186 $ 30,551 $ 30,551 $ 25,430 $ (5,121) TeleHealth $ - $ - $ 7,143 $ 7,143 $ - $ (7,143) New Models of Care $ - $ - $ - $ - $ 25,430 $ 25,430 MyHealtheVet $ - $ - $ - $ - $ - $ - Patient Health Record (PHR) On-Line Viewing $ - $ - $ - $ - $ - $ - Secure Messaging Development $ - $ - $ - $ - $ - $ - PACT Primary Care Management Module Re-engineering $ - $ - $ 573 $ 573 $ - $ (573) Health Risk Assessment $ - $ - $ - $ - $ - $ - TeleMedicine (Store & Forward) $ 1,931 $ 31 $ - $ - $ - $ - e-move (Mobile Development) $ - $ - $ - $ - $ - $ - Care Coordination - Patient Aligned Care Team (PACT) and Women's Health $ - $ - $ - $ - $ - $ - Enterprise Mobile Applications Store $ - $ - $ 12,061 $ 12,061 $ - $ (12,061) My HealtheVet Suite $ - $ - $ - $ - $ - $ - Telehealth Modalities $ - $ - $ - $ - $ - $ - VistA Imaging Storage Infrastructure $ 4,194 $ 588 $ - $ - $ - $ - My HealtheVet Integrations $ 17,578 $ 2,850 $ 10,774 $ 10,774 $ - $ (10,774) Integrated Veterans Health Library $ - $ - $ - $ - $ - $ - Home TeleHealth (HT) Capabilities Enhancements $ 3,914 $ 2,717 $ - $ - $ - $ - Veterans Benefits Management System (VBMS) $ 42,243 $ 591 $ 63,500 $ 63,500 $ 86,000 $ 22,500 VBMS $ 40,293 $ 466 $ 39,500 $ 39,500 $ 76,000 $ 36,500 VETSNET $ 1,950 $ 125 $ 19,000 $ 19,000 $ 10,000 $ (9,000) Virtual VA Migration $ - $ - $ - $ - $ - $ - Benefits Gateway Services (BGS) $ - $ - $ 5,000 $ 5,000 $ - $ (5,000) Data Architecture Management Services (DMAS) $ - $ - $ - $ - $ - $ Congressional Submission IT-407

410 (Dollars in Thousands) Virtual Lifetime Electronic Record (VLER) $ 4,399 $ 3,953 $ 18,600 $ 18,600 $ 10,000 $ (8,600) Memorial/Cemetarial Legacy Development $ - $ - $ 8,600 $ 8,600 $ 10,000 $ 1,400 VLER Benefits $ - $ - $ - $ - $ - $ - VLER Core $ - $ - $ 10,000 $ 10,000 $ - $ (10,000) VLER Memorials $ 4,399 $ 3,953 $ - $ - $ - $ - Veterans Relationship Management Development $ 126,637 $ 9,916 $ 76,600 $ 76,600 $ 73,333 $ (3,267) Veterans Relationship Management $ - $ - $ - $ - $ 67,233 $ 67,233 Enterprise Veterans Self Service $ 38,653 $ 222 $ - $ - $ - $ - Customer Relationship Management $ 16,474 $ 122 $ - $ - $ - $ - Voice Access Modernization $ 3,264 $ 42 $ - $ - $ - $ - Identity and Access Management $ 38,875 $ 5,922 $ - $ - $ - $ - Military Service Data Sharing $ 5,657 $ 153 $ - $ - $ - $ - Enterprise Health Benefits Determinations $ 19,123 $ 670 $ - $ - $ - $ - Disability Exam and Assessment Program (DEAP) $ 4,590 $ 2,786 $ - $ - $ 6,100 $ 6,100 Enabling Infrastructure (IAM, CGS) $ - $ - $ 36,500 $ 36,500 $ - $ (36,500) Web Self Service (VetSuccess, EVSS) $ - $ - $ 21,500 $ 21,500 $ - $ (21,500) Agent Assisted (CRM, FBSR, VAM) $ - $ - $ 18,600 $ 18,600 $ - $ (18,600) Health Management Platform $ 4,177 $ 2,397 $ 5,746 $ 5,746 $ - $ (5,746) VHA Research IT Support Development $ - $ - $ - $ - $ 12,250 $ 12,250 Genomic Information System for Integrative Service (GenISIS) $ - $ - $ - $ - $ 4,084 $ 4,084 Research Administrative Mgmt. System (RAMS) $ - $ - $ - $ - $ 4,083 $ 4,083 Veteran Informatics & Computing Infrastructure $ - $ - $ - $ - $ 4,083 $ 4,083 International Classification of Diseases-10 $ 2,522 $ 2,078 $ - $ - $ - $ - Integrated Operating Model $ 2,625 $ 415 $ - $ - $ - $ - PMAS Dashboard $ - $ - $ - $ - $ - $ - VA Time and Attendance System (VATAS) $ 520 $ 320 $ - $ - $ - $ - Human Resource Information System (HRIS) $ 2,106 $ 94 $ - $ - $ - Other $ 31,625 $ 12,406 $ 103,799 $ 103,799 $ 155,200 $ 51,401 Homelessness Handheld Devices $ - $ - $ - $ - $ 1,220 $ 1,220 Homeless Management Information System (HIMS) $ 757 $ 148 $ - $ - $ - $ - Mental Health Systems Enhancements $ - $ - $ - $ - $ - $ - Identity, Credential and Access Management (ICAM) $ - $ - $ - $ - $ 800 $ 800 IVMH National Clozapine Coordination $ - $ - $ 2,700 $ 2,700 $ - $ (2,700) Chapter 33 $ - $ - $ - $ - $ - $ - Safety and Security Initiative (HSPD-12) $ - $ - $ 2,300 $ 2,300 $ - $ (2,300) STDP/EWCA (Corporate Core) $ - $ - $ 1,000 $ 1,000 $ - $ (1,000) VA for VETS $ - $ - $ - $ - $ - $ - Strategic Capital Investment Planning Database $ - $ - $ - $ - Veterans Informatics and Computing Infrastructure (VINCI)/Consortium Healthcare Informatics Research (CHIR) Information and Technology Development Detail Continued $ - $ - $ 3,771 $ 3,771 $ - $ (3,771) Enterprise Systems Integration $ - $ - $ - $ - $ - $ - Enterprise Architecture Support $ - $ - $ - $ - $ - $ - Certification of VistA for Meaningful Use $ - $ - $ - $ - $ - $ - Connected Health/ TeleHealth Expansion (SPI) $ - $ - $ - $ - $ 4,070 $ 4,070 Mental Health (SPI) $ - $ - $ - $ - $ 2,050 $ 2,050 Appeals Modernization - BVA (SPI) $ - $ - $ - $ - $ 19,100 $ 19,100 Divestiture of Systems/ Application $ - $ - $ - $ - $ 18,000 $ 18,000 VHA Registries $ - $ - $ - $ - $ - $ - Prosthetics Enhancements $ - $ - $ - $ - $ - $ - Corporate Performance & Talent Management System (CPTMS) $ - $ - $ - $ - $ - $ - Finance Center Recertification $ - $ - $ - $ - $ - $ - Administrative Data Repository $ - $ - $ 2,588 $ 2,588 $ - $ (2,588) Revenue Reporting Enhancements $ - $ - $ 3,769 $ 3,769 $ - $ (3,769) Health Administrative Systems (ChampVA, VSS, etc.) $ - $ - $ - $ - $ 27,800 $ 27,800 CHAMPVA Family Members Systems $ - $ - $ 2,000 $ 2,000 $ - $ (2,000) Voluntary Service System (VSS) Enhancements $ - $ - $ 2,000 $ 2,000 $ - $ (2,000) Revenue Operations - Development $ - $ - $ 1,827 $ 1,827 $ - $ (1,827) 2016 Congressional Submission IT-408

411 (Dollars in Thousands) Virtual Lifetime Electronic Record (VLER) $ 4,399 $ 3,953 $ 18,600 $ 18,600 $ 10,000 $ (8,600) Memorial/Cemetarial Legacy Development $ - $ - $ 8,600 $ 8,600 $ 10,000 $ 1,400 VLER Benefits $ - $ - $ - $ - $ - $ - VLER Core $ - $ - $ 10,000 $ 10,000 $ - $ (10,000) VLER Memorials $ 4,399 $ 3,953 $ - $ - $ - $ - Veteran Customer Experience (formerly VRM Development) $ 126,637 $ 9,916 $ 76,600 $ 76,600 $ 73,333 $ (3,267) Veteran Customer Experience $ - $ - $ - $ - $ 67,233 $ 67,233 Enterprise Veterans Self Service $ 38,653 $ 222 $ - $ - $ - $ - Customer Relationship Management $ 16,474 $ 122 $ - $ - $ - $ - Voice Access Modernization $ 3,264 $ 42 $ - $ - $ - $ - Identity and Access Management $ 38,875 $ 5,922 $ - $ - $ - $ - Military Service Data Sharing $ 5,657 $ 153 $ - $ - $ - $ - Enterprise Health Benefits Determinations $ 19,123 $ 670 $ - $ - $ - $ - Disability Exam and Assessment Program (DEAP) $ 4,590 $ 2,786 $ - $ - $ 6,100 $ 6,100 Enabling Infrastructure (IAM, CGS) $ - $ - $ 36,500 $ 36,500 $ - $ (36,500) Web Self Service (VetSuccess, EVSS) $ - $ - $ 21,500 $ 21,500 $ - $ (21,500) Agent Assisted (CRM, FBSR, VAM) $ - $ - $ 18,600 $ 18,600 $ - $ (18,600) Health Management Platform $ 4,177 $ 2,397 $ 5,746 $ 5,746 $ - $ (5,746) VHA Research IT Support Development $ - $ - $ - $ - $ 12,250 $ 12,250 Genomic Information System for Integrative Service (GenISIS) $ - $ - $ - $ - $ 4,084 $ 4,084 Research Administrative Mgmt. System (RAMS) $ - $ - $ - $ - $ 4,083 $ 4,083 Veteran Informatics & Computing Infrastructure $ - $ - $ - $ - $ 4,083 $ 4,083 International Classification of Diseases-10 $ 2,522 $ 2,078 $ - $ - $ - $ - Integrated Operating Model $ 2,625 $ 415 $ - $ - $ - $ - PMAS Dashboard $ - $ - $ - $ - $ - $ - VA Time and Attendance System (VATAS) $ 520 $ 320 $ - $ - $ - $ - Human Resource Information System (HRIS) $ 2,106 $ 94 $ - $ - $ - Other $ 31,625 $ 12,406 $ 103,799 $ 103,799 $ 155,200 $ 51,401 Homelessness Handheld Devices $ - $ - $ - $ - $ 1,220 $ 1,220 Homeless Management Information System (HIMS) $ 757 $ 148 $ - $ - $ - $ - Mental Health Systems Enhancements $ - $ - $ - $ - $ - $ - Identity, Credential and Access Management (ICAM) $ - $ - $ - $ - $ 800 $ 800 IVMH National Clozapine Coordination $ - $ - $ 2,700 $ 2,700 $ - $ (2,700) Chapter 33 $ - $ - $ - $ - $ - $ - Safety and Security Initiative (HSPD-12) $ - $ - $ 2,300 $ 2,300 $ - $ (2,300) STDP/EWCA (Corporate Core) $ - $ - $ 1,000 $ 1,000 $ - $ (1,000) VA for VETS $ - $ - $ - $ - $ - $ - Strategic Capital Investment Planning Database $ - $ - $ - $ - Veterans Informatics and Computing Infrastructure (VINCI)/Consortium Healthcare Informatics Research (CHIR) Information and Technology Development Detail Continued $ - $ - $ 3,771 $ 3,771 $ - $ (3,771) Enterprise Systems Integration $ - $ - $ - $ - $ - $ - Enterprise Architecture Support $ - $ - $ - $ - $ - $ - Certification of VistA for Meaningful Use $ - $ - $ - $ - $ - $ - Connected Health/ TeleHealth Expansion (SPI) $ - $ - $ - $ - $ 4,070 $ 4,070 Mental Health (SPI) $ - $ - $ - $ - $ 2,050 $ 2,050 Appeals Modernization - BVA (SPI) $ - $ - $ - $ - $ 19,100 $ 19,100 Divestiture of Systems/ Application $ - $ - $ - $ - $ 18,000 $ 18,000 VHA Registries $ - $ - $ - $ - $ - $ - Prosthetics Enhancements $ - $ - $ - $ - $ - $ - Corporate Performance & Talent Management System (CPTMS) $ - $ - $ - $ - $ - $ - Finance Center Recertification $ - $ - $ - $ - $ - $ - Administrative Data Repository $ - $ - $ 2,588 $ 2,588 $ - $ (2,588) Revenue Reporting Enhancements $ - $ - $ 3,769 $ 3,769 $ - $ (3,769) Health Administrative Systems (ChampVA, VSS, etc.) $ - $ - $ - $ - $ 27,800 $ 27,800 CHAMPVA Family Members Systems $ - $ - $ 2,000 $ 2,000 $ - $ (2,000) Voluntary Service System (VSS) Enhancements $ - $ - $ 2,000 $ 2,000 $ - $ (2,000) Revenue Operations - Development $ - $ - $ 1,827 $ 1,827 $ - $ (1,827) 2016 Congressional Submission IT-409

412 Operations and Maintenance Subaccount Information Technology Operations and Maintenance Highlights (Dollars in Thousands) / Obligations Carryover Budget Estimate Current Estimate Budget Request Increase / Decrease Activities Medical Operations and Maintenance 720, , , ,763 35,012 Benefits Operations and Maintenance 234, , , ,710 (1,806) Enterprise Operations and Maintenance 1,073,460-1,038,185 1,020,977 1,143, ,943 Interagency Operation and Maintenance 105,307-96,765 96, ,470 40,705 H1N1 Supplemental (P.L ) 2 OEF/OIF Supplemental (P.L ) 473 2,055 Total Operations and Maintenance 1/ $ 2,134,587 $ 2,802 $ 2,333,217 $ 2,316,009 $ 2,512,863 $ 196,854 Funding Sources Appropriation 2,134,587-2,333,217 2,316,009 2,512, ,854 Recission H1N1 Supplemental (P.L ) OEF/OIF Supplemental (P.L ) -2, , ,055 Transfers 2/ -2, ,016-3,016-3, Reimbursements (+) 22,852-19,945 29,316 25,897-3,419 Available Balance SOY (+) 3/ 1, , ,755 Available Balance EOY (-) , ,500 PL Veterans Choice Act , ,200 Total Obligations $ 2,153,691 $ - $ 2,350,146 $ 2,427,811 $ 2,639,162 $ 211,352 1/ Numbers do not include reimbursements 2/ This line reflects North Chicago Facility transfers in 2014, 2015 and 2016 from OIT 3/ In 2016, this line represents anticipated carryover for The Choice Act 2016 Congressional Submission IT-410

413 Operations and Maintenance Detail Operations and Maintenance (Sustainment) Detail (Dollars in Thousands) / Obligations Carryover Budget Current Budget Increase / Estimate Estimate Request Decrease Mandatory Sustainment $ 1,581,158 $ 2,802 $ 1,728,227 $ 1,710,749 $ 1,955,431 $ 244,682 Enterprise Operations $ 405,054 $ - $ 323,000 $ 305,792 $ 369,900 $ 64,108 IT Support Contracts $ 436,899 $ 745 $ 269,833 $ 269,833 $ 376,170 $ 106,337 Telecommunication $ 243,794 $ - $ 275,000 $ 275,000 $ 297,161 $ 22,161 Software License Maintenance $ 141,751 $ - $ 284,384 $ 284,384 $ 132,500 $ (151,884) Hardware Maintenance $ 65,580 $ - $ 104,688 $ 104,688 $ 100,000 $ (4,688) Acquisition Fees $ 15,000 $ - $ 73,227 $ 73,227 $ 80,000 $ 6,773 National Service Desk $ - $ - $ 40,000 $ 40,000 $ 59,000 $ 19,000 Mobile Technology and Applications $ - $ - $ 5,000 $ 5,000 $ 25,000 $ 20,000 Server Virtualization $ - $ - $ 5,000 $ 5,000 $ - $ (5,000) TeleHealth $ - $ - $ 32,000 $ 32,000 $ 40,000 $ 8,000 Telephony Emergency Replacement (PBX) $ - $ - $ 20,000 $ 20,000 $ 20,000 $ - VistA Evolution $ 25,497 $ - $ 52,000 $ 52,000 $ 85,000 $ 33,000 Interoperability/VLER Health $ 11,382 $ - $ - $ 21,580 $ 15,000 $ (6,580) iehr and VLER Health $ - $ - $ 25,000 $ - $ - $ - VLER Health $ 2,659 $ - $ - $ 3,150 $ 10,000 $ 6,850 Veteran Customer Experience (aka VRM) $ 46,447 $ - $ 13,016 $ 13,016 $ 98,700 $ 85,684 VBMS/VETSNET $ 68,655 $ - $ 80,000 $ 80,000 $ 157,000 $ 77,000 CRISP Removal of the Material Weekness $ - $ - $ - $ - $ 39,000 $ 39,000 Guardian Edge and Anti Virus Maintenance $ - $ - $ - $ - $ 22,000 $ 22,000 RTLS Hosting $ - $ - $ - $ - $ 12,000 $ 12,000 VHA Access to Care $ 3,741 $ - $ - $ - $ 10,000 $ 10,000 FY 2014 Deployed Capabilities $ - $ - $ 45,000 $ 45,000 $ - $ (45,000) Major Transformation Inititaves (MTI) $ - $ - $ 78,079 $ 78,079 $ - $ (78,079) PD Tools Sustainment/E-Gov/CDW $ - $ - $ 3,000 $ 3,000 $ 5,000 $ 2,000 Divesture of Systems/Application $ - $ - $ - $ - $ 2,000 $ 2,000 Compensation and Pension Records Interface (CAPRI) $ 257 $ - $ - $ - $ - $ - VHA Research (Medical Core) $ 2,695 $ - $ - $ - $ - $ - VHA Research (Medical Legacy) $ 1,798 $ - $ - $ - $ - $ - Data Access Services (DAS) $ 2,213 $ - $ - $ - $ - $ - Mental Health $ 220 $ - $ - $ - $ - $ - Health Provider Systems (Medical Core) $ 4,817 $ 2,057 $ - $ - $ - $ - Health Provider Systems (Medical Legacy) $ 14,972 $ - $ - $ - $ - $ - Standards and Terminology Services $ 4,620 $ - $ - $ - $ - $ - Chapter 33 $ 7,101 $ - $ - $ - $ - $ - Healthcare Efficiency $ 1,063 $ - $ - $ - $ - $ - Health Informatics (Medical Core) $ 278 $ - $ - $ - $ - $ - Registries $ 2,783 $ - $ - $ - $ - $ - Compensation and Pension (C&P) App. Maintenance $ 9,872 $ - $ - $ - $ - $ - Integrated Operating Model (IOM) $ 1,513 $ - $ - $ - $ - $ - Medical Legacy (Class III to I Testing) $ 2,152 $ - $ - $ - $ - $ - Memorials Legacy $ 886 $ - $ - $ - $ - $ - Health Administrative Systems $ 646 $ - $ - $ - $ - $ - Enrollment System Modernization $ 1,365 $ - $ - $ - $ - $ - New Model of Care $ 9,816 $ - $ - $ - $ - $ - VBA & NCA IT Infrastructure Platform Upgrades $ 16,859 $ - $ - $ - $ - $ - Vocational Rehabilitation & Employment (VR&E) $ 2,606 $ - $ - $ - $ - $ - Homelessness (Registries) $ 570 $ - $ - $ - $ - $ - Warrior support $ 2,300 $ - $ - $ - $ - $ - Human Capital $ 12,492 $ - $ - $ - $ - $ - Enterprise Architecture (EA Tools and Support) $ 10,808 $ - $ - $ - $ - $ Congressional Submission IT-411

414 Operations and Maintenance Detail cont. Operations and Maintenance (Sustainment) Detail Cont. (Dollars in Thousands) / Budget Current Budget Increase / Actuals Carryover Estimate Estimate Request Decrease Information Security $ 144,635 $ - $ 156,000 $ 156,000 $ 179,501 $ 23,501 Business Continuity Support (COOP) $ - $ - $ 4,200 $ 4,200 $ 6,850 $ 2,650 CRISP Support $ - $ - $ - $ - $ 30,160 $ 30,160 Cyber Program $ 52,338 $ - $ 45,400 $ 45,400 $ 53,061 $ 7,661 Field Security Services $ - $ - $ 4,000 $ 4,000 $ 5,180 $ 1,180 Network Operations Center (NOC) $ - $ - $ 45,000 $ 45,000 $ 45,630 $ 630 Privacy & Records Management $ 4,402 $ - $ 5,300 $ 5,300 $ 10,340 $ 5,040 Security Operations Center (SOC) $ - $ - $ 22,200 $ 22,200 $ 24,000 $ 1,800 Network Security Operations Center (NSOC) $ 87,894 $ - $ - $ - $ - $ - Information/ Data Security $ - $ - $ - $ - $ 3,900 $ 3,900 Risk Management Incident Response $ - $ - $ 4,900 $ 4,900 $ - $ (4,900) Mobile Applications and Wireless Security $ - $ - $ 25,000 $ 25,000 $ - $ (25,000) Identity, Credential and Access Management (ICAM) $ - $ - $ - $ - $ 380 $ 380 Activations (Equipment and Licenses) $ 68,126 $ - $ 84,000 $ 84,000 $ 90,000 $ 6,000 Discretionary Sustainment $ 273,736 $ - $ 240,000 $ 240,000 $ 180,000 $ (60,000) Telephony (Unified Communications Strategy - VaaS) $ 64,319 $ - $ 92,000 $ 92,000 $ 60,000 $ (32,000) VOW/VEI $ - $ - $ 15,000 $ 15,000 $ - $ (15,000) Enterprise IT Lifecycle Management (Desktops/Laptops) $ 129,571 $ - $ 40,000 $ 40,000 $ 50,000 $ 10,000 Network Lifecycle Hardware Refresh - Includes Servers, Routers & Storage $ - $ - $ 40,000 $ 40,000 $ 50,000 $ 10,000 Enterprise Data Warehouse (EDW) $ - $ - $ 1,000 $ 1,000 $ - $ (1,000) Disaster Recovery $ - $ - $ 15,000 $ 15,000 $ - $ (15,000) Section 508 Compliance - Legacy Sys/Apps $ - $ - $ - $ - $ 15,000 $ 15,000 WAN Acceleration (Wireless) $ - $ - $ 15,000 $ 15,000 $ - $ (15,000) IP Video to Home Expansion $ - $ - $ 7,000 $ 7,000 $ - $ (7,000) RTLS Hosting Expansion $ - $ - $ - $ - $ 5,000 $ 5,000 VistA Imaging (Gateways and RAID Upgrade) $ - $ - $ 15,000 $ 15,000 $ - $ (15,000) VBA & NCA IT Infrastructure & Platform Upgrades $ 30,336 $ - $ - $ - $ - $ - Enterprise License Expense $ 30,145 $ - $ - $ - $ - $ - VHA IT Support Contracts $ 11,681 $ - $ - $ - $ - $ - Enteprise IT Support Contracts $ 2,143 $ - $ - $ - $ - $ - Veterans Relationship Management $ 1,897 $ - $ - $ - $ - $ - VHA IT Infrastructure & Platform Upgrades $ 1,763 $ - $ - $ - $ - $ - Vocational Rehabilitation & Employment (VR&E) $ 1,459 $ - $ - $ - $ - $ - Homelessness $ 422 $ - $ - $ - $ - $ Congressional Submission IT-412

415 Operations and Maintenance Detail cont. Operations and Maintenance (Sustainment) Detail Cont. (Dollars in Thousands) / Budget Current Budget Increase / Obligations Carryover Estimate Estimate Request Decrease Marginal Sustainment $ 60,233 $ - $ 124,990 $ 124,990 $ 107,931 $ (17,059) Access to Care $ - $ - $ 4,018 $ 4,018 $ 3,780 $ (238) Health Administrative System $ 869 $ - $ 6,460 $ 6,460 $ 1,200 $ (5,260) Health Provider System $ - $ - $ 359 $ 359 $ - $ (359) New Models of Care $ 2,293 $ - $ 11,310 $ 11,310 $ 250 $ (11,060) Veterans Customer Experience $ 14,948 $ - $ 10,000 $ 10,000 $ 15,850 $ 5,850 Mobile Development - Health Apps $ - $ - $ - $ - $ 1,725 $ 1,725 Connected Health/TeleHealth Expansion $ - $ - $ - $ - $ 5,980 $ 5,980 Mental Health (SPI - VHA 16-4) $ - $ - $ - $ - $ 2,270 $ 2,270 Disability Exam Assessment Program (DEAP) $ - $ - $ - $ - $ 250 $ 250 Memorial Development $ - $ - $ - $ - $ 1,496 $ 1,496 Enrollment System Modernization $ 400 $ - $ - $ - $ 5,000 $ 5,000 VBMS $ 2,866 $ - $ 12,500 $ 12,500 $ 30,000 $ 17,500 VETSNET $ - $ - $ - $ 3,000 $ 3,000 Homelessness (Registries) $ - $ - $ - $ - $ 300 $ 300 Interoperability $ - $ - $ - $ - $ - $ - VistA Evolution $ 2,150 $ - $ 37,484 $ 37,484 $ 15,700 $ (21,784) VHA Research $ - $ - $ 2,394 $ 2,394 $ 7,340 $ 4,946 Standards and Terminology Services (STS) $ - $ - $ - $ - $ 5,320 $ 5,320 Registries $ - $ - $ 2,923 $ 2,923 $ 3,200 $ 277 Caregiver's Enhancements $ - $ - $ 1,750 $ 1,750 $ 1,750 $ - VA Center for Innovation (VACI) $ - $ - $ 4,000 $ 4,000 $ 1,500 $ (2,500) Repository $ 3,646 $ - $ - $ - $ 1,020 $ 1,020 Compensation and Pension Records Interface (CAPRI) $ 244 $ - $ 500 $ 500 $ 500 $ - Healthcare Efficiency $ - $ - $ 7,862 $ 7,862 $ 500 $ (7,362) Memorial Development $ - $ - $ 2,000 $ 2,000 $ - $ (2,000) Mental Health (Medical Legacy) $ - $ - $ 995 $ 995 $ - $ (995) ediscovery Platform (General Council) $ - $ - $ 250 $ 250 $ - $ (250) Electronic Data Exchange (EDI) - Payer $ - $ - $ 2,228 $ 2,228 $ - $ (2,228) Electronic Data Exchange (EDI) - Provider $ - $ - $ - $ - $ - $ - Health Management Platform (Health Informatics Initiative) $ - $ - $ 1,257 $ 1,257 $ - $ (1,257) Human Resources Information System (HRIS) $ - $ - $ 16,700 $ 16,700 $ - $ (16,700) Data Access Services (DAS) $ 2,155 $ - $ - $ - $ - $ - Intergrated Operating Model (IOM) $ 25,373 $ - $ - $ - $ - $ - Enterprise IT Support Contract $ 4,151 $ - $ - $ - $ - $ - Strategic Capital Investment Planning (SCIP) $ 748 $ - $ - $ - $ - $ - ediscovery (General Council) $ 184 $ - $ - $ - $ - $ - Compensation and Pension $ 206 $ - $ - $ - $ - $ - GRAND TOTAL $ 2,127,888 $ 2,802 $ 2,333,217 $ 2,315,739 $ 2,512,863 $ 197, Congressional Submission IT-413

416 Amounts Available for Obligation Information and Technology Systems Appropriation/Obligations (Dollars in thousands) Description Actuals Budget Estimate Current Estimate Budget Request Increase/ Decrease IT Systems Appropriation: FY 2015 (P.L ) $3,703,344 $3,903,344 $3,903,344 $4,133,363 $230,019 Recission -$1,066 $1,066 Transfers 1/ -$6,789 -$6,968 -$6,968 -$7,158 -$190 Total IT Appropriations $3,696,555 $3,896,376 $3,895,310 $4,126,205 $230,895 Reimbursements IT Non-Pay Reimbursements $22,852 $88,945 $29,316 $30,342 $1,026 IT Pay Reimbursements $16,470 $7,775 $25,599 $26,495 $896 Total Reimbursements $39,322 $96,720 $54,915 $56,837 $1,922 Total Budgetary Resources $3,735,877 $3,993,096 $3,950,225 $4,183,042 $232,817 Adjustments to Obligations Public Law Veterans Choice Act $376,600 -$376,600 Unobligated Balance (SOY): 2/ $139,815 $168,390 $173,400 $5,010 Unobligated Balance (EOY): -$168,390 -$173,400 $173,400 Change in Unobligated Balance (non-add) -$28,575 -$5,010 $173,400 $178,410 Unobligated Balance Expiring (Lapse) -$1,250 Total Obligations $3,706,052 $3,993,096 $4,321,815 $4,356,442 $34,627 Outlays, Gross $3,467,024 $3,926,333 $4,037,476 $4,264,634 $227,158 Less Collections -$34,928 -$96,720 -$54,915 -$56,837 -$1,922 Outlays, Net $3,432,096 $3,829,613 $3,982,561 $4,207,797 $225,236 Direct , Direct (P.L Veterans Choice Act) Reimbursable FTE Total Full Time Equivalents (FTE) / This line reflects transfers to North Chicago in 2014, 2015 and / In 2016, this line represents anticipated carryover for Veterans Choice Act 2016 Congressional Submission IT-414

417 Obligations by Object Class and Funding Sources Office of Information and Technology Obligations by Object Class and Funding Sources (Dollars in Thousands) Actuals Budget Estimate Current Estimate Budget Request Increase / Decrease Personal Services 852, , , ,152 34,699 Travel 5,863 14,760 8,884 8, Rent, Communications and Utilities 741, , , ,643 5,644 Printing and Reproduction Other Services 1,646,443 2,360,933 2,256,070 2,209,051-47,018 Supplies and Materials 5,445 10,085 19,003 17,728-1,276 Equipment 424, , , ,771 42,472 Lands and Structures 8,718 2,366 2,215 2, Other 20, Total Obligations $3,706,052 $3,993,096 $4,321,815 $4,356,442 $34,627 Funding Sources Appropriation 3,703,344 3,903,344 3,902,278 4,133, ,085 Transfers 1/ -6,789-6,968-6,968-7, Non-Pay Reimbursements 22,852 88,945 29,316 30,342 1,026 Pay Reimbursements 16,470 7,775 25,599 26, Unobligated expiring -1,250 Change in uncollected orders Unobligated SOY 2/ 139, , ,400 5,010 Unobligated EOY -168, , ,400 Public Law Veterans Choice Act 376, ,600 Total $3,706,052 $3,993,096 $4,321,815 $4,356,442 $34,627 1/ In 2014, $6.7M was transferred from OIT to the North Chicago facility. This line also reflects North Chicago transfers in 2014, 2015 and / In 2016, this line represents anticipated carryover for Veterans Choice Act 2016 Congressional Submission IT-415

418 Information and Technology Information Technology Systems Appropriations History (Dollars in thousands) Budget Estimate to Congress House Allowance Senate Allowance Appropriations FTE ,442,066 2,492,066 2,471,166 2,539,391 _1/ 6, ,307,000 3,307,000 3,307,000 3,307,000 6, ,307,000 3,222,000 3,147,000 2,993,604_2/ 7, ,161,376 3,025,000 3,161,376 3,111,376 7, ,327,444 3,327,444 3,327,444 3,323,053 7, ,683,344 3,683,344 3,703,344 3,703,344 7, ,903,344 3,874,344 3,913,344 3,902,278 7, ,133,363 7,423 Note: The Information Technology Systems account was established in P.L / Includes $50 million in emergency funding provided in P.L / The 2011 appropriation was $3.141 billion (including ATB rescission) with an additional $147 million in unobligated balances rescinded Congressional Submission IT-416

419 Office of Information Technology Organization Chart Assistant Secretary for Office of Information and Technology Principal Deputy Assistant Secretary for Office of Information and Executive Director Quality, Performance, DCIO Service Delivery and Engineering DCIO Product Development DCIO Architecture, Strategy, and Design DAS IT Resource Management DAS Information Security Interagency Program Office Deputy Director DCIO Customer Advocacy 2016 Congressional Submission IT-417