VISN 7……………………………………………………………………. Ralph H. Johnson VA Medical Center (Charleston, SC) Wm. Jennings Bryan Dorn VA Medical Center (Columbia, SC) Augusta VA Medical Center Birmingham VA Medical Center

Charleston Veterans Affairs Medical Center (Ralph H. Johnson VA Medical Center) The American Legion visit to Charleston VAMC on January 23, 2006 Task Force Member: Don Lanthorn Field Service Representatives: Daryl H. Puryear Located in the historic part of the city of Charleston, the Ralph H. Johnson VA Medical Center is an authorized 145 bed primary, secondary and tertiary care medical center that provides acute medical, surgical and psychiatric inpatient care, and both primary and specialized outpatient services in southeastern South Carolina and Chatham County, Georgia. The medical center supports the Vet Centers in North Charleston, South Carolina and Savannah, Georgia, and operates the outpatient clinics in Savannah, Georgia and Myrtle Beach, South Carolina. Fiscal The Charleston VAMC FY 2005 budget was $175.2 million and in FY 2006, it was increased to $185.6 million. This increase of some $10.4 million represents just under a 6 percent increase. Charleston’s MCCF collections goal for FY 2005 was $15.5 million; actual collections totaled $15.8 million. For FY 2006, the MCCF goal is $17.8 million and they are on track to meet this goal. Charleston reported that they maintain high production standards and that their coders, billers and MCCF staff are all an integrated, collaborative unit. No capital investment dollars have had to be used to supplement the medical care budget. Charleston lists as its’ budgetary challenge is the dispersion of non-recurring maintenance dollars by the VISN. Currently, the VISN uses a figured derived by looking at 50 percent of the square footage of the facility and 50 percent of the patient workload. Within the VISN, Charleston is not as physically big as many other facilities, yet it has a very high patient workload and consequently, requires more maintenance than usual. However, due to Charleston’s small size and that formula for access to Non-recurring Maintenance dollars, it misses a lot of money it would get if it were larger. Another monetary issue Charleston mentioned was getting 1st party payers to pay what they owe. Charleston suggests they have bills for 1st party payers totaling about $2 million. Enrollment and Access Veterans with urgent needs are seen immediately. Veterans with service connection are seen in less than 30 days. Non-service connected veterans may have to wait longer. With regards to referral from Primary care to specialty care clinics, of fourteen specialty care clinics only four had wait times in excess of 30 days, with two of those four under 40 days: Audiology at 34 days, Orthopedics at 65 days, Combined Eye Care at 37 days, and Combined Mental Health Care at 51 days. 85-90 percent of enrolled veterans are enrolled in Primary Care. Approximately 630 combat veterans have registered for care at the Charleston VAMC. Approximately 8,342 “Priority Group 8” veterans have filed since the January 17, 2003 deadline. Charleston reports that last year they saw 375,000 veterans in outpatient visits; 37,451 uniques and had 4,232 hospital admissions.

CBOCs Charleston currently maintains four Community Based Outpatient Clinics (CBOCs). Charleston’s CBOCs are located in Goose Creek-just opened in August 2005; Savannah, GA, Beaufort Naval Hospital and Myrtle Beach. There was mention in the CARES Decision of another CBOC to be built in Hinesville. All four CBOCs are currently operating at almost full capacity. Each CBOC provides Mental Health services to patrons. Staffing and Affiliations The medical center is closely affiliated with the MUSC and supports 88 medical residents in medical and dental specialties, as well as students from nursing, pharmacy, social work and allied health disciplines. The Research Service has 57 research investigators conducting basic research in cardiology, endocrinology, diabetes mellitus, hematology/oncology, rheumatology, nephrology and alcohol-related disorders and clinical and health service research in mental health, PTSD, hypertension and aging, and rehabilitation research program: hip arthroplasty. There are three J-1 Visa Physicians at the Charleston facility and they are all fulfilling their contractual obligations. Areas of difficulty in recruiting are Anesthesiology, Physical Therapist, Skilled Technologists, Medical Technicians, pharmacists, LPNs, and Contracting personnel in Human Resources. Fee/Contract physicians are being used in Anesthesiology, Cardiology, Cardiothoracic Surgery, Gastroenterology, Infectious Disease, Internal Medicine, Neurosurgery, Orthopedic Surgery, Perfusion Therapy, Pulmonary Care, Vascular Surgery, Radiation Therapy, CAT Scan, Dermatological Surgery, Sleep Studies, Eyes Exams and Short Term Fee-Basing for Physical Therapy. Hiring Incentives include relocation and retention bonuses, moving expenses, educational debt reduction program and Scholarship Programs. Currently six of Charleston’s employees have been activated to active duty service in OIF/OEF. Temporaries and contract staff absorb the remaining workload. Physical Plant Located in the historic part of the city of Charleston, the Ralph H. Johnson VA Medical Center is an authorized 145-bed primary, secondary and tertiary care medical center that provides acute medical, surgical and psychiatric inpatient care, and both primary and specialized outpatient services in southeastern South Carolina and Chatham County, Georgia. The Medical Center is in relatively good physical shape for a building that is 40 years old. Major physical plant issues include: the original piping, the HVAC model is rusting through on active floors, there are projects underway to replace these; some older electrical equipment needs to be replaced (approximately $750,000 in equipment is needed to modify the areas where the equipment is located); parking lot does not have enough spaces for patients; employee parking lot is on marsh land that is consistently settling and needs repaving approximately every 5 years and portions of the medical center need updating (2nd floor Clinical Addition, 5-A North Rehab Medicine and Prosthetics, some of the 3rd floor area etc. Albeit, Charleston has been very successful in obtaining Minor projects in the past three years, mainly due to the CARES initiatives and higher patient workloads resulting from that. This makes Charleston very competitive with the other VA medical centers for Minor monies. Charleston has not specifically applied for a Major in the past few years, though they plan to try to bid for a Major project to improve/increase the amount of parking by building a parking garage over their existing surface lost. They recognize that this may project might not receive

priority scoring because it is not related to CARES or a medical necessity. Nevertheless, insufficient parking spaces for the veterans mean that they are constantly spending non-recurring dollars on the employee parking lot. Charleston does not have a hoptel, but if a family member needs to stay overnight will put them up in one of the local area hotels. Long Term Care, Mental Health, Homelessness Long Term Care at Charleston does provide a Nursing Home Care Unit (NHCU). The NHCU is currently in the midst of a reorganization of the care they provide. Currently the bed level is 15 with a capacity is 28. They are working to get their facilities up to the Central Office required standard of having a 50-person Nursing Home Care Unit. Long Term Care at Charleston also offers Home Based Primary Care to patrons. Charleston has approximately 25 contracted nursing home beds in the community. Although the NHCU does not have designated beds set aside for Hospice Care patients, close attention is made to staffing levels because of the care needs of hospice patients. Charleston estimated that they had approximately 14 patients a month in Hospice Care and suggested that hospice care is one of the fastest growing segments in the demand for Long Term Care. Charleston felt that the NHCU, though providing for the needs of a number of needing veterans, did not provide the kind of access that NH care patients really need. There was not any direct access to the outdoors from the unit or access to smoking areas, the NHCU was rather shut off and away. Overall, the feeling was that although they provided a good service, the NHCU grounds were not conducive for growth and expansion of the NHCU. Charleston also mentioned that as they formulate their Long Term Care contingent, they are working closely with Dr. Amos Bailey in his research of Nursing Home Care Units. The Mental Health Strategic Plan sought to streamline mental health care within all CBOCs and Charleston has long provided this care before many facilities across the country. Charleston is now looking at moving more specialized mental health programs into the CBOC as well. Charleston worked to obtain additional funding for a substance abuse treatment. These monies were set-aside in VA for special initiatives in the comprehensive Mental Health care provision and Charleston was able to secure the additional monies. Charleston is still working on the Mental Health Intensive Case Management (MHICM) system wherein they provide comprehensive coverage and care to veterans with chronic mental illness to ensure their follow up care is facilitated. They are slowly increasing the number of veterans with chronic mental illness in the MHICM program to 50. Another mental health care point unique to Charleston is the “hot phone.” As an alternative to advanced clinical access which did not seem to work well there, Charleston developed a “hot phone” concept in which a “walk in” into primary care who is exhibiting behavior suggesting needs of a mental health professional, a call is made to MH and the mental health professional manning the hot phone for that day addresses the need expressed in PC. Additionally, the mental health professional that meets with the veteran initially will follow him throughout his course of treatment and care at Charleston. The PTSD Clinic has been open since 1991 and over time there have been slight increases in the number of veterans using the service. Recently Charleston submitted a proposal for funding to take the information about the various MH services available to returning veterans out to where they are.

Charleston has 80 per diem beds in the community for Homeless Veterans. They actively seek out information about other homeless veteran programs out there to stay informed. The homeless program at Charleston manages to place just about every veteran who enters and desires it, into permanent housing. They also seek out employment for veterans through partnerships with private companies. The Homeless Program is submitting a RFP to put addiction therapists at CBOCs in order to try and reach out more to this population because there is often a correlation between homelessness and drug abuse. Patient Surveys There were a total of twelve surveys completed. There were five outpatient surveys completed and seven family surveys completed. Average distance traveled for outpatients was 76 miles. All outpatients expressed above average regards about the quality of care they received at the VA. With family members, the average distance traveled of the seven completed questionnaire was 48.4 miles and with the quality of care at Charleston VA Medical Center, three said their family member’s care was good, two said the care was fair, one suggested the care was poor and one did not answer the question. Columbia Veterans Affairs Medical Center (William Jennings Bryan Dorn VA Medical Center) The American Legion visit to Columbia VAMC January 24, 2006 Task Force Member: Donald Lanthorn Field Service Representative: Daryl H. Puryear The Columbia VA Medical Center (VAMC) is a 216 bed facility encompassing acute medicine, surgery, psychiatry, and long term care. 122 of those beds are divided between general medicine, surgery, and psychiatry. The Nursing Home Care Unit (NHCU) maintains the other 94. The hospital provides primary, secondary, and some tertiary care. Current Community Based and Satellite out patient clinics (CBOCs) are located in Anderson, Greenville, Florence, Orangeburg, Sumter, and Rock Hill, SC. Columbia VAMC provides administrative support to the Florence National Cemetery in Florence, SC; the Vet Centers in Greenville and Columbia, SC; and the VA Regional Office (VARO) also in Columbia. Fiscal The Columbia VAMC FY 2005 budget was $192.3 million. In FY 2006, was increased to $206.7 million, representing an increase of 14.4 million dollars or about a 7% increase from 2005. Columbia’s MCCF collections goal for FY 2005 was $21.6 million, whereas actual collections were $17.07 million--a shortfall of some 4.6 million and a collections rate just below 79%. A 47% increase reflected in the FY 2005 MCCF collections goal from the FY 2004 goal was described as the culprit. The MCCF goal for FY 2006 is $19.3 million and Columbia feels strongly it will achieve this goal. It currently utilizes Quadramed software to identify billable insurances and various potentially billable encounters. No capital investment dollars were used to fund the

medical care budget in direct correlation to the Congressional Supplement provided in August. Major budgeting challenges for Columbia were described as finding the “happy medium” between spending its extra funds to increase staff for direct patient care and subsidizing new programs it would like to implement. Enrollment and Access The average new patient wait time for a primary care appointment after enrollment into the system is 38.9 days and 51% of new patients had a wait time at or above that figure. Approximately 75-80% of veterans enrolled in the Columbia VAMC are enrolled in Primary Care. In 2005, Primary Care saw approximately 22,000 “first time & never seen before” veterans. Columbia has enrolled 1,033 new combat veterans of OIF/OEF, which represents about 1% of its patient care load. Columbia estimates that some 4,680 priority group 8 veterans have applied for enrollment since the January 17, 2003 cutoff date. Columbia is equally uncertain about estimate dollar costs these veterans might represent in lost income for medical treatment and services potentially provided. CBOCs Columbia’s jurisdiction covers approximately two-thirds of the entire state of South Carolina, with six Community Based Outpatient Clinics (CBOCs). Those CBOCs are located in Anderson, Greenville, Florence, Orangeburg, Sumter, and the newest edition Rock Hill. Columbia is hoping for another CBOC in Spartanburg as was touted by the CARES initiative, but is dealing with budget constraints. Five of the six current CBOCs are contracted out, which leaves one VA staffed CBOC in Greenville. Columbia monitors closely its CBOCs that are contracted out and reports that it is actively comparing cost savings on patient care versus logistics issues that actually swallow up any perceived cost savings. Additionally Columbia is excited about the new prospect of CBOCs in Aiken and Athens that will help augment the heavy increases in primary care requests. Columbia expects physician panel sizes of 1,000 to 1,100 veterans/patients at these prospective CBOC sites. The proposals for these facilities have already been submitted to VA Central Office. Staffing and Affiliations Columbia has approximately 37 different affiliates including: University of South Carolina School of Medicine, University of South Carolina, Midlands Technical College, South Carolina State College, Medical University of South Carolina, Benedict College, Palmetto Health, Augusta State University, Barry University, Coastal Carolina Technical College, Clemson University, Eastern Washington University, Florida State University, and Orangeburg-Calhoun Technical College. There are over 700 students in various medical fields in training at Columbia. Columbia employs 7 J-1 Visa Physicians who were highly sought after by recruitment for their high level of expertise; these physicians are all fulfilling their obligations. The entire state of South Carolina is experiencing a nursing shortage, but Columbia has been able to get many of its nurse recruits through its LPN training program. Columbia is also in preparation to apply for accreditation of its nursing program and is exploring the possibility of seeking magnet status. Columbia is experiencing physician shortages in its recruitment of a variety of specialists: Radiologists, Urologists, Cardiologists, and Surgeons. Columbia utilizes fee/contract physicians in the following areas: Dental,

Radiology, C&P Exams, Medical Officer of the Day, Surgery, Orthopedics, Ophthalmology, OB/GYN, Allergists, Neurosurgery, Dermatology, endocrinology, Nursing, Audiology, and Mental Health. There are ten OIF/OEF veterans/employees who work at the Columbia VAMC and are currently activated. To address this shifting of manpower, Columbia has strived to be innovative, splitting up duties among existing staff members and utilizing Fee Basis appointments, work study, temporary appointments, and overtime. Physical Plant The Wm. Jennings Bryan Dorn VA Medical Center is located just outside the southwest corner of Fort Jackson Military Installation. It is a 216-bed facility, encompassing acute medical, surgical, psychiatric, and long-term care. The hospital provides primary, secondary, and some tertiary care. With regard to minor projects, the renovation of 4W has been funded for the full scope. Columbia’s nursing home renovation project has also been approved for a cost limit increase. Major projects to improve specialty and diagnostic care and to renovate critical care areas based on CARES data have yet to be approved. But overall funding for minor projects at Columbia is reported to be adequate. Columbia does operate a hoptel and is still hoping to add a new CBOC, per CARES, in Spartanburg, SC. Long Term Care, Mental Health, and Homelessness Long Term Care services at The Columbia VA Medical Center consists of a Geriatrics and Extended Care Program that offers veterans In-Home Nursing Care, Home Based Primary Care. It is renovating an entire floor in its Nursing Home, which has 60 authorized beds and 90 assigned. After the renovation, the full 90 will be operable. Long Term Care at Columbia also provides Hospice Triage Care and Respite Beds--providing a total of 31 days a year of Respite Care to give stressed out caregivers a break. Columbia has some Nursing Home Care beds in the community and also provides hoptel facilities for visiting family members. For Columbia, the Mental Health Strategic Plan has meant the funding of six new FTEE at CBOCs, expressly in Mental Health to ensure that mental health services are provided at each CBOC. Mental Health services at Columbia include Mental Health Intensive Case Management, providing needed follow up for veterans suffering from chronic mental illness—improving the consistency of their mental health care. Mental Health provides Primary Care Teams (PCT), helping mental health care patients easily access needed physical medical care and appropriately accounting for their mental illness. Mental Health at Columbia includes Substance Abuse Services. This branch of MH has just been funded to obtain 2 new Social Workers. The Substance Abuse Treatment is done on an outpatient basis. Columbia’s Mental Health services are moving into the use of tele-mental health at its CBOCs. A Supportive Employment Program is available for employers who employ veterans who suffer from PTSD or Schizophrenia; this program allows veterans to receive payment for completing their assigned duties, as well as collect their benefit checks with no prohibition or penalty.

Homeless Services at Columbia are comprehensive, including outreach as well as employment services. Programs consist of Compensative Work Therapy, Food Clinic, and a Healthcare for the Homeless Program. Healthcare for The Homeless at Columbia was awarded a 3 year reinstatement of its accreditation by CARF. There has been talk of moving the Columbia program into the community. Columbia has actually found a few OIF & OEF veterans using its homeless veteran services. In addition to seriously considering moving Columbia’s Homeless Services into a more residential area in the community, Columbia is also working to establish a Women’s Home for homeless female veterans. Patient Surveys A total of ten surveys were completed. Six were Outpatient; two were Inpatient; two were Family Member Questionnaires. For outpatients, the average distance traveled was twenty miles. Four of the Outpatients polled suggested the care they received was above average, while two suggested their care was “ok” & “fairly well.” Of the two inpatients polled, one had traveled six-hundred miles from New York to be there and the other only two miles. Both characterized their care at Columbia as fair. One suggested the food was fair, while the other suggested the food was “sometimes good.” One family member had to travel three miles to get to Columbia to see his loved one, while the other had traveled fifty miles. Both family members felt that the quality of the care their loved ones had been provided was excellent. Augusta VA Medical Center The American Legion visit to Augusta VAMC January 25, 2006 Task Force Member: Donald Lanthorn Field Service Representatives: Daryl H. Puryear The Augusta VA Medical Center (VAMC) is a two-division medical center providing tertiary care in medicine, surgery, neurology, psychiatry, rehabilitation (rehab) medicine, and spinal cord injury. The Downtown Division is authorized 155 beds (58 medicine, 37 surgery, and 60 spinal cord injury). The Uptown Division, located approximately three miles away, is authorized 123 beds (68 psychiatry, 15 blind rehab, and 40 rehab medicine beds). In addition, a 132 bed Restorative/Nursing Home Care Unit and a 60 bed Domiciliary are located at the Uptown Division. The Augusta VAMC serves as a network resource for the treatment of spinal cord injury, blind rehab, post-traumatic stress disorder (PTSD), and psychiatry patients. In 2004 the U.S. Army Southeast Regional Medical Command & VA Southeast Network Active-Duty Rehab Unit was opened to treat military personnel who required rehabilitation after serving in Iraq or Afghanistan. The Augusta VA Medical Center and Eisenhower Army Medical Center at Fort Gordon have numerous agreements, which provide for the cost-effective sharing of resources between these two federal health care facilities in the Augusta metropolitan area.

Fiscal Augusta VAMC’s FY 2005 budget was $191.5 million and the FY 2006 budget is $194.2 million, a difference of $2.7 million; this represents a budget increase of just over 1%. The MCCF collections goal from FY 2005 was $15 million, whereas the actual collections were only $13.6 million, a shortfall of roughly $1.4 million--which represents a collections percentage rate of just over 90%. Augusta reported that the FY 2005 collections goal was a significant stretch goal from FY 2004. The MCCF collections goal for FY 2006 is $16.2 million and, as of the date of The American Legion’s visit, it was reported that the prescribed collections goal would likely be met. Augusta VAMC reports that it has not used any capital investment dollars to supplement its medical care budget. The major budgetary challenge reported was overtime usage and that only minimal costs go into the maintenance of unused building. Building 18, which is slated for demolition, is being used as swing space while renovations are underway in the main hospital at the uptown division. These renovations should be completed by the end of March 2006. The building will then be decommissioned and no longer maintained. Furthermore, no equipment dollars have had to be used for capital improvement projects at Augusta VAMC. Enrollment and Access The Augusta VAMC reported that it takes less than seven days to process new enrollee applications and 22 days for the new enrollee to receive their initial primary care appointment. Approximately 22,000 patients are currently enrolled in primary care and 499 OIF/OEF combat veterans have been seen. The Active Duty Rehab Unit reports that approximately 200 service personnel have already been processed through the unit this year. The unit currently reports a patient census of about 37 service members. 1,116 priority group 8 veterans have applied for enrollment since the January 17, 2003 cut-off. Although the Augusta VAMC maintains contact data on these veterans in the event their access to health-care is re-opened, it does not maintain the total amount of lost revenue (i.e. co-payments & third party re-imbursements) these denied veterans represent to the facility. Community Based Outpatient Clinics Currently, Augusta VAMC has no Community Based Outpatient Clinics (CBOC) in operation. However, it has submitted a business plan for construction of a CBOC in Athens, GA and desires to establish another CBOC as a joint venture project with the Department of Defense (DoD) in Aiken, GA. Staffing & Affiliation The Augusta VAMC prides itself on continually improving and expanding its health care knowledge. The medical center enjoys a strong affiliation with the Medical College of Georgia. The Augusta VAMC provides medical and allied health training to an average of more than 700 students and residents annually. Additional health training affiliations exist with 44 academic institutions. Augusta noted they do have a few J-1 Visa physicians but added that they do not hire them until the physicians have H-1-B status. Once the physician has H-1-B status, the medical center does all it can to help them apply, noting these physicians are usually of high quality and caliber.

Augusta is currently utilizing fee/contract physicians in plastic surgery, opthalmology, general/vascular surgery, optometry, orthopedic, radiology, vascular radiology, radiation safety, neuroradiology, radiation therapy, teleradiology, EMG, hemodialysis, neuropsychology, emergency room (ER), cardio thoracic, teledermatology, pathology, environmental agents (agent orange, gulf war, ionizing radiation)/compensation and pension (C&P) exams, primary care, Moh’s surgery, psychiatry, ENT, general medicine and special ancillary testing. The Augusta VAMC suggests it has less of a problem recruiting nurses as they do with retaining them after recruitment. The Physician’s Pay Bill was noted as a major piece that will help Augusta VAMC as it tries to secure cardiologists and ER physicians. Physical Plant The Augusta VAMC consists of two divisions; the Downtown and Uptown Division. The two hospitals are well maintained. Replacement of the roof at Augusta Uptown Division is nearly complete and will thereby eliminate the one critical physical plant issue at Augusta VAMC. Ongoing improvements are being made, such as the opening of the new critical care unit (CCU), additional Spinal Cord Injury beds, and ward renovations at Augusta Uptown Division. Though the finishing of the replacement of the roof at Augusta Uptown Division is a critical piece, in terms of dollars it is not considered major construction. Augusta has no ongoing major construction projects. Funding has been provided, however, for the various minor projects mentioned according to VISN priority. Long Term Care, Mental Health, Homelessness The Augusta VAMC has a 124 bed Nursing Home Care Unit (NHCU) which is full. Two units within the NHCU are set up with decorative wide panel ceiling fans, park benches to resemble a more home-like atmosphere, and the single person rooms provide more personal space and privacy. In geriatric care, Augusta VAMC offers geriatric psychiatry and provides treatment for dementia. It also provides care to older veterans through a geriatric hypertensive cardiovascular program. Its Palliative Care Unit has 8 beds and offers outpatient hospice care. Augusta VAMC also provides home-based hospice care through a private contractor and has approximately 68 contract nursing home beds in the community that it reviews and monitors on a consistent and regular basis. It is well publicized that Augusta VAMC also serves the active duty population through a joint venture program with DoD, more specifically the U.S. Army Southeast Regional Medical Command & the VA’s Southeast Network Active Duty Rehab Unit. The collaborative working agreement was originally established in 2004 to provide rehabilitative services to military personnel injured while serving in Iraq and Afghanistan. The Active Duty Rehab facility provides spinal cord injury treatment, and blind rehab. Augusta VAMC is making a strong effort to reach out to OIF/OEF veterans by actively traveling to various military units to help facilitate their transition from the military health care system to the VA healthcare system as well as disability claims

submission. Augusta has stationed a social worker at Fort Gordon to address the needs of those separating from the military The Strategic Mental Health Plan has made funding available to allow Augusta VAMC to provide various mental health services. Mental Health Services at Augusta provides PTSD counseling, treatment for substance abuse, care for those suffering from multiple mental health issues and chronic mental illness, and detoxification treatment. Augusta provides mental health intensive case management (MHICM) for some of its veterans suffering from chronic mental illness to help them maintain prescribed treatment directives and appointments. Services available for homeless veterans include a 60 bed domiciliary, which is not solely for Homeless veterans, a compensation work therapy (CWT) program; a mental health program to treat an array of mental conditions, including chronic mental illness and PTSD; and a substance abuse/rehab program. Augusta has submitted a proposal to establish a separate domiciliary designated specifically for homeless veterans. Patient Surveys A total of 12 patient surveys were completed: six inpatient surveys, two outpatient surveys and four family member questionnaires. Inpatients surveys indicated that the average distance traveled was 135.11 miles. Five inpatients commented that the quality of the care was outstanding and exemplary; one simply commented that it could be better. Four of the inpatients noted that the food was good and two noted the food was fair. The two outpatients’ average distance traveled was 20 miles. They indicated that the quality of their care was above average and exemplary. The four family members’ average distance traveled was 203 miles. All of the family members felt that their loved one was receiving excellent healthcare, but two suggested that healthier snack foods (particularly snack foods between meals) should have been offered. Birmingham Veteran Affairs Medical Center The American Legion site visit to Birmingham Veteran Affairs Medical Center January 27, 2006 Task Force Member: Don Lanthorn Field Service Representatives: Daryl H. Puryear The Birmingham VA Medical Center is a 313-bed acute tertiary care facility located in the historic Southside district of the city. The facility provides acute tertiary medical and surgical care to veterans of Alabama and surrounding states. The medical center serves as a referral center for this population area with 135 operating beds. Recent construction provides state-of-the-art facilities and equipment in all clinical programs. Care is provided in practically all medical and surgical specialties and subspecialties.

Fiscal The Birmingham VAMC FY 2005 budget was $156.1 million and in FY 2006 was increased by $15.6 million representing a 10 percent increase from the previous year. Birmingham’s MCCF goal for FY 2005 was $16.2 million, with actual collections totaling $16.4 million. The MCCF collections goal for FY 2006 is $18.6 million and as of December they are at 107 percent of goal for this time last year, they are on target to meet the MCCF goal for FY 2006. Birmingham’s coders have generally been coding for 12-15 years and possess a high skill set. They have not had to use capital investment dollars to supplement there medical care budget. They list managing an ever-increasing workload as their major budgetary challenge. Enrollment and Access There were not any veterans waiting over 30 days for initial primary care appointments. With regard to specialty care referral waits from primary care, out of some 16 different specialty care clinics, three reported waits over 30 days: new urology appointees were at 43.3 days, new combined eye care appointees at 52.3 days, and new GI appointees at 36.8 days. Close to 100 percent of enrollees are enrolled in Primary Care. Birmingham enrolled 1021 OIF/OEF veterans, representing two percent of total unique patients’ treated. CBOCs Birmingham currently operates six Community Based Outpatient Clinics (CBOCs) and is anticipating the next to open in Bessemer. The six CBOCs currently operating at or near capacity are Anniston PC Clinic, Decatur/Madison PC Clinic, Gadsden PC Clinic, Huntsville PC Clinic, Jasper PC Clinic, and Shoals Area PC Clinic. Psychiatric Services are provided at each CBOC. Staffing and Affiliation Care is provided in practically all medical and surgical specialties and subspecialties. Most staff physicians have joint appointments with VA and its primary affiliation, University of Alabama at Birmingham (UAB). With the exception of about 15 to 20 physicians at the Birmingham VAMC, all the rest are both faculty at UAB and staff at the VA Medical Center. UAB has over 17,000 health care professionals; consequently, there is trouble recruiting because of the competitive environment. Birmingham has difficulty retaining and recruiting LPNs, RNs (mostly RNs), Allied Health care professionals and radiologist. Birmingham uses recruitment or sign on bonuses, travel and relocation bonuses, real estate reimbursement, placing an application at a higher step upon hire, Education Debt Reduction and Student Loan Repayment benefits for difficult to fill and/or retain positions to pay off student loans, competitive salary/special salary rates based on rates paid in the local area, excellent coverage for health insurance at a reduced rate, Flexible Spending Accounts, Flexible work schedules, and excellent Leave Benefits. Birmingham is currently using Fee/Contract Physicians for the following services: Anesthesiology, Emergency Medicine, Neurosurgery, Obstetrics and Gynecology, Cardiology, and Radiology. About 10 employees have been activated for Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) duties. Their work is reassigned, temporary employees are hired or other accommodations are made so the duties are covered until the employee returns.

Physical Plant The Birmingham VA Medical Center is a 313-bed acute tertiary care facility located in the historic Southside district of the city. Recent construction provides state-of-the-art facilities and equipment in all clinical programs. With regard to availability and adequacy of funding for ongoing major and minor construction project through 2006, all FY 2005 projects were adequately funded, however FY 2006 projects have not been funded at this time. Finally, due to space constraints it is challenging to manage increases in workload. Birmingham has some projects scheduled that will provide additional space and they are evaluating the leasing and/or purchase of additional space. They are fee-basing some care in the community until additional space is available. Birmingham does operate a hoptel and also contracts with a hotel a few blocks away from the VA Medical Center. Long Term Care, Mental Health, and Homelessness Birmingham does not offer a Nursing Home Care Unit, but contracts 9 NH beds out in the community. Birmingham also has the premier Palliative Care Unit in the VISN 7. In November 2005, Birmingham opened and staffed a new five-bed Palliative Care Inpatient Unit christened “Safe Harbor”. The Palliative Care Unit also provides accommodations for family members that desire to stay overnight. Dr. Amos Bailey, the founder of the nationally recognized “Balm in Gilead” palliative care unit, also in Birmingham, is the director of the Birmingham VAMC’s palliative care unit. Additionally, Birmingham has a Geriatric Research, Education, and Clinical Center (GRECC). Birmingham’s affiliate UAB is certainly nationally renown for its’ emphasis on research with over 1 to 1.2 million square feet of space dedicated specifically to research. Kathryn Burgio, PhD, Associated Director of the GRECC and head of the GRECC’s Research Department along with Dr. Amos Bailey were awarded a grant from Health Services Research and Development to implement a model end of life care program at five other VA medical centers in the Southeast. Mental health is establishing an Advisory Board consisting of OIF/OEF veterans, in efforts to better understand the needs of these returning veterans. The medical center is providing mental health services in all six CBOCs with a psychiatrist assigned to each. In the interest of providing a full continuum of care, Birmingham has taken measures to equip each CBOC with the necessary staff for primary care, but also sufficient staffing for solely mental health. Birmingham offers a crises intervention team available 24 hours a day; the teams are staffed with a psychologist, nurse, and a social worker and a psychiatrist moonlights after hours. Birmingham also offers Mental Health Intensive Case Management for some of its’ most chronically mentally ill patients to ensure that patients have assistance in following through with their psychiatric medical directives. Birmingham has little space and refers homeless veterans requiring assistance to the Tuscaloosa Domiciliary Program. Birmingham assisted Tuscaloosa in writing its’ grant for the Domiciliary Program. Birmingham also has about 31 contract beds for homeless veterans in the community. To date, Birmingham has not had to make any referrals for homeless OIF/OEF veterans. Patient Surveys A total of six patient surveys were completed. Four were outpatient questionnaires and two were inpatient. The average distance traveled for outpatients was a little over ten miles. All four outpatient’s comments about how they were treated at Birmingham VAMC were positive; with two commenting that the treatment was “well”

and another two saying “very good.” The two inpatients queried commute about 10 miles; both suggested their individual care was above average and thought the food was “good as well.”

VISN 8……………………………………………………………………. Bay Pines VA Medical Center

Tampa Polytrauma Center

Bay Pines VA Healthcare System The American Legion visit to Bay Pines April 4, 2006 Task Force Member: Tom Mullon Field Service Representative: Daryl Puryear The Bay Pines VA Healthcare System provides comprehensive and extended medical care, including acute medical, surgical, and psychiatric care, rehabilitative inpatient care and outpatient. In addition, the medical center supervises a community nursing home (NH) care program, which is one of the largest in the VA system. Fiscal The Bay Pines FY 2005 budget was $383.7 million and the FY 2006 budget is $396.8 million, a difference of $16.1 million and a budget increase of 4.2%. The MCCF collections goal for FY 2005 was $36 million and Bay Pines reported that it made its collections goal exactly. The MCCF collections goal for FY 2006 is $40 million. Bay Pines suggests that it will meet this collections goal. To improve collections efficiency, Bay Pines has implemented insurance ID scanning software, moved staff offsite, factored in the national pharmacy co-pay increase of one dollar, and contracted with a company to review closed claims for possible appeals. Bay Pines’ collections have always been solid and goals have been consistently met or exceeded. It expects to make 95-98% of the FY 2006 goal. Bay Pines reported that it has used capital investment dollars to supplement its medical care budget. Bay Pines reports increased workload and two year lags in VERA budget appropriations as its major budgetary challenges. In reviewing Bay Pine’s fiscal disposition, another issue to consider is that Bay Pines receives no additional funding to operate Physician’s Pay Bill activities, i.e. hiring new staff and/or increasing provider salaries. Funding for the Physicians Pay Bill is absorbed by Bay Pines. Bay Pines, in some instances, was provided new construction resources, but none for activation of the new space (i.e. no funding to hire providers or to purchase necessary equipment). Enrollment and Access Bay Pines reported that about 95% of current enrollees are enrolled in primary care. Although uniques workload—workload generated by new enrollees--increases have gone from 61,639 uniques to 93,823 uniques between 2001 and 2005, Bay Pines reported that workload increases appear to be leveling off. Current workload increases suggests a projected total FY 2006 workload of close to 96,000. Veterans presenting a 1010EZ in person are seen same day, if necessary. However, it normally takes 3-5 business days to process an enrollment application. From the time of final processing, more than 90% of veterans are seen for their initial primary care appointment within 30 days. All veterans rated 50% service connected or greater are seen within 30 days. With regard to DoD and VA collaboration through seamless transition, Bay Pines reported that veterans are seen within 30 days of application for services through the VA. They are given the option of being seen at the main Bay Pines hospital or a CBOC.

Veterans are assigned a primary care team and are able to work with a case manager, who will complete a bio-psychosocial assessment, link them with resources, advocate for them and help them navigate the system. For FY 2005, Bay Pines saw approximately 10,250 inpatients in the hospital, over 939,000 unique veteran patients. Overall, more than 3,000 veterans per day receive health care services at Bay Pines, the Fort Myers Outpatient Clinic, and CBOC’s. Bay Pines strives to provide physical, emotional, and psychological support for the healing and wellness process. Bay Pines has seen 406 OIF/OEF veterans, which represents about .5% of the current patient care workload. It has had approximately 10,973 PG 8 veterans to apply for enrollment to VAMC healthcare since the January 17, 2003 cut off and their information is kept on file, in the event enrollment should reopen for them. CBOCs Bay Pines has seven Community Based Outpatient Clinics (CBOCs) in its jurisdiction. All but two of those CBOCs are currently at capacity. There are no known new CBOC additions planned. However, the Ft. Myers CBOC is scheduled to undergo an expansion that will add an additional floor, expanding the facility to a multi-specialty clinic status. MH services are offered at each CBOC, except one. The facility also operates a large outpatient clinic in Ft. Myers, and CBOCs in Dunedin, St. Petersburg, Ellenton, Sarasota, Port Charlotte, Naples and Sebring, Florida. Staffing and Affiliations Bay Pines is primarily affiliated with University of South Florida, College of Medicine and also the Nova Southeastern University, School of Osteopathic Medicine along with an additional 80 active affiliation agreements with Medical Allied Health Programs throughout the Southeastern U.S. Currently, Bay Pines has 23 residents at its facility. Most of the residents currently in use at Bay Pines work in surgery, along with a handful in medical sub specialty areas. However Bay Pines reports it is working to increase the number of residents in use at the facility; it notes major increases in workload as causing a reciprocal need for additional providers. It further notes that residency levels at other Florida VAMCs are nearly 5 times as high, but Bay Pines’ “residency slot distribution” given by the VISN has only provided for 23. Bay Pines reports that it currently has one J-1Visa physician, an interventional cardiologist, who they expect to transition to regular staff. Bay Pines reports it has not had any great difficulty in recruiting nurses. Bay Pines uses contract providers to supplement VHA staff and minimize waiting time for next available appointment in the following areas: ophthalmology, radiology, psychiatry, radiation oncology, eye surgery, orthopedic surgery and gynecology. Bay Pines also supplements in-house staffing with fee providers for the following specialties: plastic surgery, thoracic surgery, gynecology, MH and behavioral sciences, internal medicine, emergency medicine, GI and radiology. Bay Pines currently has 6 employees activated and deployed. Their work responsibilities are being covered in a number of different ways; fee basis care, permanent and/or temporary hires, and the use of overtime or “comp” time.

Physical Plant The Bay Pines VA Healthcare System has been providing care since 1933. Family members who visit with loved ones interned at Bay Pines may use the Fisher House on the campus. With regards to funding for ongoing major and minor construction projects, the President’s FY 2007 budget, as proposed, does not include funding to consummate Bay Pine’s land deal in Lee County or support the Major Construction Project entitled, “Resolve CARES Inpt/Outpt Deficiencies (MH/PTSD)”. Over the last two years, Bay Pines has submitted six minor construction projects that have totaled $30.8 million, none of which have been funded. Those six projects are succinctly described as following: in FY 2005, the Eye Clinic/Education Center at a cost of $6.5 million, addition of 1 nursing home care unit (NHCU) Ward, building 101 at a cost of $6.9 million, research addition at a cost of $6.8 million; and in FY 2004, electrical deficiencies at a cost of $5 million, Life Safety Phase 1 at a cost of $2.4 million, and Life Safety Phase 2 at a cost of $3.2 million. Long Term Care, Mental Health, Homelessness Long Term Care at Bay Pines VA Medical Center offers a NHCU with 80 beds, 114 NH beds in the community, hospice care, home maker home health aid, transitional care unit, geriatric management unit, geriatric primary care, tele-health, care coordination, and home-based primary care. Bay Pines is working to incorporate a more social and home-like setting in its NHCU. Another extended care service offered at Bay Pines is sexual trauma care via the Carol O’Brien Center for Sexual Trauma. The facility provides a 16 bed, six week program for both men and women in cyclic course, six weeks all women and the next six weeks all men. It is the only sexual trauma treatment program of this kind for men in the entire VA Healthcare System and, as such, this Bay Pines program receives veterans from all over the country. This program is funded through a VERA allocation, but if it were not for additional local funding the Center for Sexual Trauma receives, it would be in dire financial straits; VERA alone does not provide sufficient funding to care for the many men and women who have been and are being treated. In its MH program, Bay Pines also provides regular psycho-social domiciliary beds, a substance abuse treatment program, a MH intensive case management to assist those with chronic mental illness follow their treatment regiments, tele-mental health for easier access to MH services that do not require in-house visits, a PTSD program, and compensative work therapy (CWT) to help severely mentally ill veterans improve functioning and find purpose in life through employment. Bay Pines is also providing MH services at all but one of its CBOCs. In the Homeless Program at Bay Pines, they have found that many of the homeless veterans suffer from severe forms of mental illness. Many of the homeless veteran population also participate in the CWT Program. Bay Pines Homeless Program approaches homelessness and mental illness from a recovery model perspective as opposed to a model of institutionalization. Bay Pines, through a grant per diem program, provides 50 beds for homeless veterans at a community shelter called Center of Hope.

Bay Pines conducts a routine review is to ensure that veterans residing at the center are receiving quality care.

Patient Surveys A total of 10 patient surveys were completed: five inpatient surveys and five outpatient surveys. Of the five inpatients, four of them resided within a 30-mile radius; one traveled approximately 826 miles. Of the five inpatients, four of them expressed satisfaction with the quality of the food, whereas one was completely dissatisfied. Finally, with regards to the quality of the care the inpatients received, four described their care as above average; one inpatient was less than satisfied with the care. Of five outpatients completing surveys, the average distance traveled to get to the facility was 18 miles. Four outpatients felt they would be able to get an appointment when they needed one with no problem; one indicated that he felt the new Advanced Clinical Access system was very impersonal. Four outpatients who completed surveys felt the quality of the care they received was exemplary; one suggested that the quality of care varied from clinic to clinic. Tampa Poly Trauma Center The American Legion site visit to the Tampa Poly Trauma Center Monday, April 3, 2006 Task Force Member: Tom Mullon Field Service Representative: Daryl Puryear The mission of the Poly-Trauma Rehabilitation Center is to provide comprehensive inpatient rehabilitation services for individuals with complex sequelae of severe and disabling trauma. Due to the complexity of these injuries and the impact on the family unit, intensive case management needs are an integral component of care. In addition, rehabilitation is coordinated as the patient moves from acute hospitalization, ultimately back to his/her home community. The goals of the Tampa Poly-Trauma Rehabilitation Center are to provide post-acute medical assessment to patients injured by blasts; provide medical, rehabilitation, and psychological treatment services; coordinate care as patients move from acute hospitalization through rehabilitation and ultimately back to the home and community; provide case management and family support through all phases of treatment; monitor short and long-term outcomes for these individuals; and finally begin a program of research to better understand the effectiveness of treatments for blast injuries. In the early 1990’s, Tampa became one of the first VA Medical Facilities to be accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). Tampa provides unique forms of care with regard to pain management. Tampa’s Pain Management Program has the only non-narcotic pain management system in the country. In the past, Tampa’s Traumatic Brain Injury (TBI) section has devoted much time and emphasis upon the directly obvious residuals of head/brain impact injuries; now, relatively new studies are beginning to consider post concussion effects that appear to share similar symptoms consistent with PTSD, but are not mental but organic in nature.

“Transforming Care at The Bedside” is a program sponsored by The Robert Wood Johnson Foundation and is dedicated to improving the quality of healthcare in medical and surgical wards through a focus on four areas: safe and reliable care, vitality and teamwork, patient-centered care and, value-added care processes. This quality improvement initiative is currently in operation in 13 medical centers across the country; the VA’s Tampa Poly Trauma Center is the only VA and/or Federal medical facility. Funding With regards to funding for the Tampa Poly Trauma Center, starting in FY 2005, VA Central Office began providing supplemental funding to the Polytrauma Rehabilitation Centers (PRCs). There are separate budget object classes for FTEE, equipment, training, consultants, education, and information management. Additionally, the Department of Defense (DoD) reimburses VHA, under a national Memorandum of Agreement (MOA), for solely the care of active duty associated with Spinal Cord Injury, Traumatic Brain Injury and Blind Rehabilitation. The reimbursement is based on interagency rates set by the Office of Management and Budget (OMB). VHA Directive 2005-058 lists the rates used for those diagnoses that fall under the MOA. These cases are managed and paid by DoD through the Military Medical Support Office (MMSO). Any other admission with a different diagnosis is covered and billed according to the service member’s TRICARE region of enrollment. As stated previously, Tampa is working with the MMSO out of the Great Lakes area. The arrangement appears to be working well, except at Mc Dill AFB where Tampa is providing care. The re-imbursement rate paid out through TRICARE is not equitable. TRICARE seems to be slow and “fractioning” in its reimbursement approach to care provided by the Tampa Poly Trauma Center. The VERA Funding Model provides Tampa Poly Trauma with fiscal resources today that apply to system needs from two years ago. Funding resources do not match the needs being caused by today’s increasing workloads; obviously this does not serve the needs of the facility well. In 2005, Tampa’s workload (as an entire VA Medical Center) grew by 400,000 veterans. Additionally, the VERA Model appears to fund other medical services, such as Long Term Care, better than services for head injuries in the TBI Unit--although the head injuries often require a more intrusive medical care approach. Access & The Referral Process The VA has developed a system with regards to how military personnel are referred to the Poly Trauma Center. The Department of Veterans Affairs (VA) has social work liaisons assigned to those Military Treatment Facilities (MTFs) receiving the majority of the returning combat injured. These social workers facilitate access to VA care including referral and transfer to the Polytrauma Rehabilitation Centers (PRC). They are the interface between the MTF and the PRCs, ensuring there is a smooth transition. Each VA facility has points of contact (POC) to receive and expedite referrals and transfers of care from the VHA social work liaison and to ensure appropriate linkage is made for the requested clinical or administrative follow-up services.

Inpatient DoD referrals of service members from Operation Iraqi/Enduring Freedom (OIF/OEF) begin by having the MTF social worker contact the James A. Haley Veterans’ Hospital transfer coordinator to request a transfer. The transfer coordinator enters the service member’s information in the electronic system and begins e-mail communication with the treatment team to notify them of the new referral. Needed referral information is obtained and provided to the Rehabilitation Admissions Coordinator. The PRC physician, in collaboration with Medicine, Mental Health and/or Surgery department(s), reviews information, contacts the MTF physician, evaluates rehabilitation readiness, and documents the communication with MTF in the electronic patient record (CPRS). Screening information is updated on a multi-disciplinary spreadsheet, which is shared with PRC staff. Once the patient is accepted, the VA transfer coordinator obtains needed authorizations from the DoD Military Medical Support Office (MMSO) or TRICARE and notifies VA billing of these authorizations. The transfer coordinator makes arrangements for transfer with referring social worker and military transportation. VA social work PRC case manager contacts the service member and family to answer any questions they may have, arrange for lodging for family members, and assist as needed in pre-admission coordination. The social work case manager also contacts the MTF social worker. The VA social work liaison at the MTF assists in notifying all parties by e-mail of necessary contacts and needed information to ensure seamless transition. Transportation arrangements are made by the MTF. The DoD/Military liaison stationed at Tampa “meets and greets” the service member at the airport and provides transportation for family member to VA; the patient is provided a special mode of transportation. The social work PRC case manager meets them at the hospital at any time to insure the active duty service member and family needs are met. CD ROM of summaries, operation reports, and films are obtained from patient/family and provided to the physician. Tampa also receives referrals from military personnel stateside who may require their services. Tampa is striving to address its’ challenges and emulate its best practices. Active-duty service members injured state-side are transferred from private hospitals to the James A. Haley Veterans’ Hospital PRC for rehabilitation. The case manager at the private hospital is the primary point of contact. The same referral process outlined above ensues. The VA social work case manager makes contact with military case manager to insure appropriate rehabilitation services are arranged. Additionally, the MTF may discharge a patient (home in the Tampa area) on convalescent leave and request outpatient rehabilitation services and medical treatment. The PRC physician and/or Physical Medicine & Rehabilitation Services (PM&RS) Chief sees the patient in the outpatient “Blast Injury Clinic”. The VA seamless transition social work case manager and utilization review nurse in Billing at Tampa work closely with the MTF social worker and VHA social work liaison to obtain these authorizations prior to rendering of care. Over 2,000 combat veterans are enrolled at the James A. Haley Veterans’ Hospital. Clinical reminders screen for mental health, post-traumatic stress disorder (PTSD), and other combat related medical issues. Social workers provide case management and collaborate with Veterans Benefits Administration counselors to apply

for appropriate benefits. The case manager identifies mental health treatment needs and readjustment counseling needs and makes referrals as necessary. Staffing Issues/Concerns There apparently has been a new emphasis in research, but only a few FTEE and fiscal resources actually designated to the task. Tampa’s Spinal Cord Injury Unit (SCI) was recently given approval to add 30 more beds, however nothing, as yet, has been stated about the additional monies to provide the needed staff for the expansion. To date the SCI Unit has 33 FTEE. However, 76 are needed. In recent years nursing staffing has been better, but additional nursing staff is still needed for nights and evening work. Suggestions were put forward to make pay more attractive for the night and evening shifts. Tampa continues to maintain Magnet Status for its nursing staff. Moreover with regards to pharmacists, Tampa is down 16 and has been given approval to hire. It is now offering potential pharmacists a $10,000 bonus. Tampa is feeing out its Radiology work and has a radiologists among the top needs on its staffing needs list. Tampa is also in need of an Oncologist and Urologists. Challenges & Needed Changes Obtaining TRICARE authorizations prior to the treatment of the service members are sometimes problematic. The process would become more seamless if DoD would ensure that those service members without MMSO coverage have TRICARE authorization prior to being admitted. VA needs to improve its method of caring chronically ill TBI patient/military personnel that remain on active duty; the active duty status limits the VA from providing as much care as it could to these military personnel. Tampa is finding that DoD is keeping military personnel on active duty for some reason, although in many cases the injuries are obviously career ending. Another area is the need for a DoD-VA Registry for severely combat injured service members, whether active duty or veteran status, that tracks them for a specific number of years; this way proper follow up could be done as well as useful research data for care improvement. The issue of space is certainly no secret at VAMCs in Florida and holds true at the Tampa facility as well. It is considering an additional space of some 75-100 thousand square feet at a location off-campus. Currently it appears that the expansions it has made seem to somehow funnel patients back to the main facility.