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Copyright 2014 American Medical Association. All rights reserved.


Health Care at the VA
Recommendations for Change
Thecurrent controversysurroundingVeterans Affairs
(VA) medical centers has reachednational concern, with
Congress enacting new law in a matter of weeks. Dis-
turbing reports are emerging daily of VAfacilities keep-
ing double sets of appointment books and a report re-
centlyreleasedfromtheOfficeof theInspector General
described one VA as claiming that its veteran patients
average wait time for new appointments was 24 days,
whereas theOIGfoundit tobe115days.
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Of evengreater
concern were the 1700 veterans found to have no ap-
pointments made in the system, still awaiting care.
VA physicians (all 3 of us work at VA hospitals) are
concerned about howthis situation will affect the care
of veterans. Even following the enactment of new leg-
islation, change is necessary so that public trust in the
VA system will be restored. There are concerns about
other inefficiencies andbarriers tothedeliveryof health
caretoveterans withintheVAsystem, andtheseshould
also be reported. If all of these issues were addressed,
effective and timely delivery of care to veterans could
be improved and the VA could be transformed into a
world-class health care system.
The VA health care systemhas come a long way in
terms of modernizing care and ensuring patient safety.
Inthe mid1990s, several strategies were implemented
toimprove efficiency andhealthcare quality at VAhos-
pitals, including decentralization, integrating informa-
tionsystems, andemphasizingpreventivehealthcare.
2
Theuniversal implementationof anelectronichealthrec-
ordsystemfacilitatedthe provisionof care toveterans,
and because the system could be used to track treat-
ment outcomes, it facilitatedqualityassuranceandalso
promoted important research. In addition, the VA lev-
eraged other technology, including telehealth, to en-
hance patient access and improve care.
3
The newly disclosed deceptions within the VA sys-
temare harmful to veterans and offensive to physicians
andotherhealthcareworkerswhoworkdiligentlytoserve
thesepatients. Designingandimplementingalastingso-
lutionwill requireunderstandingtheroot causesof these
actions. Therehasbeenalargeinfluxof newenrolleesinto
the VA health care systemand VA statistics showa con-
sistent upwardtrendinenrollment numberssince2000.
4
Funding for VA health care has also increased,
4
but not
enough to compensate for increasingly heavy work-
loads, inflation, and rising national health care costs.
5
In
the past 3 years, primary care appointments have in-
creasedby 50%, yet the staff of primary care physicians
has increased by only 9%.
6
The systemhas been cluttered and constrained by
theaccumulationof rulesandregulationsimposedat the
national level, effectivelyneutralizingthebenefits of the
decentralization implemented in the 1990s. For the VA
tostaytruetoits mission, Tocarefor himwhoshall have
borne the battle and for his widow, and his orphan, it
needs to address all of the veterans concerns swiftly.
Thefollowing10suggestionscouldhelpimprovethe
care of veterans, create a work environment more con-
ducive to collaboration and teamwork, and develop a
more streamlined health care delivery system.
First, with the resignation of the US Secretary of Veter-
ans Affairs, thepresident shouldconsider appointingan
outstanding leader with experience in the nonmilitary
health care industry, especially given the current con-
troversies that exist with the Veterans Health Adminis-
tration system.
Second, access to care must be improved for all veter-
ans. With the increased number of veterans enrolled in
the VA health care system, more physicians, nurses,
and support staff should be hired to remain commen-
surate with this growth rate. Although advocated by
some, hiring nurse practitioners and physician assis-
tants to replace primary care physicians may be an
unwise strategy. This is not the time to test unproven
and controversial solutions. Resources must be priori-
tized and directed to follow demand. The Veterans
Equitable Resource Allocation, the financial model
developed to distribute the VA health care dollars to VA
facilities across the nation, is intended to for this pur-
pose, but it is constrained by artificial regional boundar-
ies and poor adjustment for high-cost conditions and
therapies.
Third, the US governments administrative hours con-
cept, defined as 8:00AMto 4:30PM, does not apply to
clinical care any more than it does to military opera-
tions. There must be a realization that health care de-
liveryshouldoccur at all hours of thedayandnight, and
resources should be allocated accordingly. This change
alone could substantially shorten wait times and re-
ducepatients failuretokeepappointments byexpand-
ingclinic hours andincreasingtheavailability of operat-
ing and interventional suites and recovery areas.
Extensionof workhours has alreadybeeninitiatedinse-
lect VA facilities, with notable success. In addition, the
requirement for 2-week service and pay periods with a
defined tour of duty is challenging for the recruitment
and retention of physicians, and in particular, specialty
physicians. Changingthis practicewouldallowtheVAto
retain the services of much-needed specialty physi-
cians, thereby reducing the costs of outsourcing these
services andprovidingmorecomprehensivecarewithin
the VA health care system.
Fourth, VA hospitals should reassess and update their
academic affiliation agreements with emphasis on fair
terms and mutual benefit. Favorably negotiated con-
VIEWPOINT
Faisal G. Bakaeen, MD
Division of
Cardiovascular Surgery,
Michael E. DeBakey
Veterans Affairs
Medical Center,
Department of
Cardiovascular Surgery,
Texas Heart Institute,
Houston, Texas; and
Division of
Cardiothoracic Surgery,
Michael E. DeBakey
Department of Surgery,
Baylor College of
Medicine, Houston,
Texas.
AlvinBlaustein, MD
Division of Cardiology,
Michael E. DeBakey
Veterans Affairs
Medical Center,
Houston, Texas; and
Division of Cardiology,
Department of
Medicine, Baylor
College of Medicine,
Houston, Texas.
Melina R. Kibbe, MD
The Surgical Service,
Jesse Brown Veterans
Affairs Medical Center,
Chicago, Illinois; and
Department of Surgery,
Northwestern
University Feinberg
School of Medicine,
Chicago, Illinois.
Corresponding
Author: Faisal G.
Bakaeen, MD, The
Michael E. DeBakey
Veterans Affairs
Medical Center, OCL
112, 2002 Holcombe
Blvd, Houston, TX
77030(fbakaeen
@bcm.edu).
Opinion
jama.com JAMA Published online June 19, 2014 E1
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Copyright 2014 American Medical Association. All rights reserved.
tractingfor clinical services withaffiliatehospitals couldexpandac-
cess to clinical care to veterans and reduce waiting lists.
Fifth, partnershipwiththe private sector may be the key tomaking
health care delivery timelier. Logistics experts specializing in work-
flow and transportation, working closely with clinicians, can im-
provetheefficiency of patient schedulingandtransportationtoas-
sure that timely appointments are made and fulfilled. At the same
time, providing veterans who live far froma VAfacility with private
care insurance could improve health care access and eliminate the
need for long-distance travel.
Sixth, accountability is more important than ever before. By incen-
tivizing individuals to meet an arbitrary goal (ie, newappointment
within14days), theVAhasunwittinglycreatedanadministrativepro-
cess that became too focusedon numbers andis vulnerable to ma-
nipulationandfabrication. If therearetobeincentives, they should
be based on overall performance with respect to patient-centered
outcomes, and these incentives should depend on measurable in-
dicators of better health, as well as efficiency. Manipulating quality
assurance measures cannot be tolerated.
Seventh, the quality of care at the VA should be compared to that
at non-VA hospitals to showcase the VAs outstanding clinical out-
comes in many disciplines and to identify areas for improvement.
Of note, the National Surgical Quality Improvement Program
(NSQIP), the criterion standard in measuring risk-adjusted surgical
outcome, was originally developed in the VA system in direct
response to a law that mandated the VA to report surgical out-
comes in comparison to national averages. However, the current
VA Surgical Quality Improvement Program (VASQIP) is now main-
tained independently from NSQIP. Harmonizing VASQIP and
NSQIP data collection and definitions would allow for direct com-
parisons in patient outcomes between VA and nonfederal hospi-
tals. Given the differences that exist in patient populations
between VA and nonfederal hospitals, robust risk adjustment of
NSQIP and VASQIP databased on nearly 100 risk-adjustment vari-
ables will be crucial.
Eighth, the VAs federal workforce must be modernized by recruit-
ing fromoutside the systeminsteadof relying onwhat has become
aninternal systemof promotions andrelocations. At thesametime,
VAhospitals shouldretainandincentivizecommittedandloyal phy-
sicians and other health care workers. This will require a redesign
of the VAs human resources policies that could also facilitate vet-
ting and hiring of newstaff. Also, the VA has a long history of mini-
mizing terminations of ineffective and poorly performing employ-
ees by repeatedly shifting themtoother departments. Instead, the
employment of thosewhodonot performtoahighstandardshould
be terminated.
Ninth, the VAs purchasing, acquisition, and inventory processes
should operate more efficiently to meet clinical needs. Competi-
tive contracting will reduce costs, but only if a nimble contracting
process is inplace. TheVAs current systemfor obtainingbids oncon-
tracts is complex, archaic, wasteful, and slow. Contracts should be
developed by personnel with the content expertise in the area in
which the contract is being considered.
Tenth, the VA needs to implement changes to attract the best and
brightest work force. Currently, VAhospitals are viewedas second-
tier facilities, and the majority of physicians do not seek VA hospi-
tals as their first employment option because of lower pay, limited
resources, and system-wide inefficiencies. Matching its favorable
benefit package and rich educational environment with an attrac-
tive work environment will allow the VA to obtain a quality work-
force. Toattract the best physicians, the VAmust compensate phy-
sicians at a level commensurate with the private sector. Although
thecreationof theVATitle38PhysicianandDental PayRangestables
was an attempt to address this issue nearly a decade ago, the pay
tables have not kept pace with the AAMC or MGMAcompensation
tables.
Legislative efforts to address the problems within the VA are
important. However, feedback from employees is paramount,
and VA clinicians and scientists should be empowered to help
solve their local problems. What is effective in one community
might not be equally effective in another. This is an ideal opportu-
nity to analyze and redesign the VA system, to make it not only
the largest integrated care system in the country, but a model in
every measurable sphere. This will require the commitment, inno-
vation, and resources necessary to provide the best care possible
for veterans.
ARTICLE INFORMATION
Published Online: June 19, 2014.
doi:10.1001/jama.2014.8054.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Formfor
Disclosure of Potential Conflicts of Interest. Dr
Bakaeen reports serving as a nonpaid advisory board
member for JACE Medical, receipt of speaker
honoraria fromthe CME organizers for an
AstraZenecasponsored event, and serving as a local
primary investigator for an National Heart, Lung, and
Blood Institutesponsored study, and receipt of a
grant fromthe VACooperative Studies Program. Drs
Blaustein and Kibbe report no disclosures.
Disclaimer: The authors are VA employees, but the
views expressed in this document are those of the
authors and not of the VA, or of the authors
academic affiliates.
REFERENCES
1. Veterans Health Administration. Interimreport:
reviewof patient wait times, scheduling practices,
and alleged patient deaths at the Phoenix Health
Care System. http://www.va.gov/oig/pubs/vaoig
-14-02603-178.pdf. Accessed May 30, 2014.
2. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of
the transformation of the Veterans Affairs Health
Care Systemon the quality of care. N Engl J Med.
2003;348(22):2218-2227.
3. Chumbler NR, HaggstromD, SaleemJJ.
Implementation of health information technology
in Veterans Health Administration to support
transformational change: telehealth and personal
health records. Med Care. 2011;49(suppl):S36-S42.
4. National Center for Veterans Analysis and
Statistics. Trends in the utilization of VA programs
and services, prepared by the National Center
for Veterans Analysis and Statistics, August 2013.
http://www.va.gov/vetdata/docs/quickfacts
/Utilization_trends_2012.pdf. Accessed May 30, 2014.
5. Centers for Disease Control and Prevention.
National health expenditures, average annual
percent change, and percent distribution, by type
of expenditure: United States, selected years
1960-2011. http://www.cdc.gov/nchs/data/hus
/2013/114.pdf. Accessed May 30, 2014.
6. Oppel RA Jr, Goodnough A. Doctor shortage is
cited in delays at VA Hospitals. The NewYork Times.
May 29, 2014. http://www.nytimes.com/2014/05/30
/us/doctor-shortages-cited-in-va-hospital-waits
.html. Accessed May 30, 2014.
Opinion Viewpoint
E2 JAMA Published online June 19, 2014 jama.com
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MEMORANDUM

October 22, 2013

Project ARCH Evaluation Update Site Visit Report (VISN 15) Page 1


To: Ms. Colette Alvarez, Project ARCH Program Manager
From: Dr. Abby Woodroffe, Project ARCH Evaluation Principal Investigator
Subject: Project ARCH Evaluation Update Fall 2013 Site Visit Report (VISN 15)
An Altarum team visited Robert J. Dole VAMC and the Pratt area pilot site on September 17 and
18, 2013. We met with VHA Project ARCH staff, a VHA provider, and contracted providers. We
also conducted a focus group with Veterans participating in Project ARCH. Our conversations
during the visit yielded a number of common themes which we summarize briefly below. We
also present a map indicating the home zip codes of Veterans in Kansas who received care
through Project ARCH (Exhibit 1) and results from the patient satisfaction survey administered
to Veterans participating in Project ARCH (Exhibits 2a and 2b).
1. Veterans continued to be very pleased with the program. The Veterans with whom we
met were vocal and effusive in their appreciation for Project ARCH, and particularly for
the Care Coordinator and Program Support Assistant. Veterans cited a number of
examples where, because of Project ARCH, they received needed care in a timely
fashion, including:
One Veteran reported that he had a long-standing knot under his arm and had
delayed having it examined due to travel time to his VHA provider. When it began
to swell up about a month ago, he contacted VHA Project ARCH staff and was quickly
evaluated by his primary care physician, resulting in a referral to a surgeon to have
the problem addressed.
Another Veteran with multiple chronic conditions said that Project ARCH helped him
seek necessary care. He is not able to drive and his health care needs, while
pressing, frequently were ignored because getting care required his wife to take a
full day off of work due to travel time. For example, he had three appointments a
week in Wichita just to provide lab samples for monitoring his conditions. The travel
burden had become so significant (and the delays in receiving travel pay so lengthy)
that he began cancelling appointments. Through Project ARCH he now has his office
visits and lab tests done locally and he reported a dramatic reduction in the number
of appointments that he cancels. In addition, he stated that the high level of service
provided by VHA Project ARCH staff had been particularly helpful, meeting him in
the hospital or an outpatient clinic in Wichita to touch base or to provide expedited
travel reimbursement for gas money to drive home. This Veteran credited Project
ARCH with changing his life.

7
Project ARCH Evaluation Update Site Visit Report (VISN 15) Page 2
2. There were a number of recent improvements in the program. We heard that in the
six months since our previous site visit, there had been substantial positive changes in
the program, including:
Excellent internal coordination between Project ARCH and elements within the
Wichita VAMC, including the community care team, specialty physicians, and the
pharmacy service.
Significant growth in Project ARCH volumes. The program now serves approximately
320 Veterans, up from a total of 20 Veterans in Spring 2012.
Institution of a weekly conference call with the contracted care network to address
cases where additional coordination is necessary.
Development and implementation of a Microsoft Access database to replace a
system where patients were tracked through two separate, unsynchronized
spreadsheets. Now, the Care Coordinator and the Program Support Assistant can
track and assign tasks to each other, improving efficiency.
Improved staff effectiveness due to co-location of VHA Project ARCH staff in space
where they can communicate easily from adjacent workstations.
Addition of services to the care coordination function, such as advance directives,
medical power of attorney and File for Life documents. File for Life is a set of
essential documents that detail patient wishes for medical care and are placed in
locations in the home where they can be seen by paramedics or other medical
personnel.

3. There appeared to be excellent communication between VHA Project ARCH staff,
contracted providers, and participating Veterans. However, communication with the
contracted care network was reportedly less effective. Both the Care Coordinator and
Program Support Assistant were perceived as highly responsive and caring. However, it
was reported that communication with the contracted care network had gotten worse
in the last several months. We were told that because of turnover at the contracted care
network, emails often came back as undeliverable. It was reportedly difficult to get talk
to a human being on the phone at the contracted care network. However, once a
human being was reached, the level of service was deemed acceptable. Also reportedly
of concern was the communication from the contracted care network to the contracted
providers about missing documentation. We heard that the form letter that contracted
providers received listed all the possible documents that might be missing (lab, notes,
etc), but did not indicate which specific ones were omitted. Therefore, it had been
challenging to identify and supply the missing documentation.

4. Processes for referrals were functioning well in most cases, except for a few
specialized needs. We heard that referral processes for VHA specialty care were
running smoothly. However, we were told that obtaining VHA services other than
specialty care was occasionally more challenging. We heard about a Veteran who was
having difficulty caring for himself at home (difficulty following medicine dosing, not
testing blood sugar) and needed home support or an alternative living arrangement. His
Project ARCH Evaluation Update Site Visit Report (VISN 15) Page 3
contracted provider had reportedly contacted Kansas adult protective services, but
there was concern that the Veteran was falling through the cracks between VHA and
the State of Kansas systems.

5. Confusion among contracted providers had shifted to new focus areas. We continued
to hear that contracted providers were uncertain about some Project ARCH processes,
but the topics of confusion changed over time. Where, in the early months of Project
ARCH, there had been questions about basic procedures for billing and securing
authorizations for care, we heard that current confusion was related to identifying and
managing Project ARCH panels, including:
a) whether under the Affordable Care Act the contracted providers can
continue to bill secondary insurance (e.g. Medicare) for Veterans being
seen under Project ARCH,
b) which Project ARCH initial paperwork (e.g. primary care clinical quality
indicators, TBI screen) needed to be completed annually, particularly for
contracted providers who see a large number of Project ARCH Veterans
(30-40)
c) which Veterans had met their required annual visit and who had not, and
d) which Veterans needed a renewal of their authorization to continue in
Project ARCH.
It was suggested that an electronic registry of Project ARCH patients or a monthly report
from VHA Project ARCH staff enumerating the Veterans who are part of each panel
would be beneficial in helping contracted providers track their Project ARCH Veterans.

6. There was concern over how participating Veterans will receive care after the Project
ARCH pilot project ends. We heard that various options to replace Project ARCH after
August 2014 were being discussed. It was suggested that there may be some local
contracts made with existing Project ARCH providers. Development of satellite clinics
was another possibility mentioned.

Project ARCH Evaluation Update Site Visit Report (VISN 15) Page 4
Exhibit 1: Count of Veterans Receiving Care through Project ARCH at the Pratt Pilot Site by Zip
Code from June 1, 2013 to August 31, 2013 (N=120)


Project ARCH Evaluation Update Site Visit Report (VISN 15) Page 5
Exhibit 2a: Satisfaction as Reported by Veterans Receiving Care through Project ARCH at the
Pratt Pilot Site from August 29, 2011 to April 30, 2013 (N=200)*

*Not all respondents answered all questions

Project ARCH Evaluation Update Site Visit Report (VISN 15) Page 6

Exhibit 2b: Satisfaction as Reported by Veterans Receiving Care through Project ARCH at the Pratt Pilot Site from August 29, 2011
to April 30, 2013 (N=200)*


Project
ARCH
program,
overall
(N=196)
Travel time
to providers
site
(N=200)
Time from
referral to
appointment
(N=195)
Time spent
in waiting
room
(N=200)
Health care
received
(N=200)
Amount of
time with
provider
(N=199)
Follow-up
care
received, if
needed
(N=58)
Completely satisfied 141 (72%) 189 (95%) 131 (67%) 161 (81%) 159 (80%) 164 (82%) 48 (83%)
Somewhat satisfied 35 (18%) 8 (4%) 35 (18%) 19 (10%) 26 (13%) 25 (13%) 7 (12%)
Neither satisfied nor dissatisfied 8 (4%) 2 (1%) 14 (7%) 12 (6%) 5 (3%) 6 (3%) 0 (0%)
Somewhat dissatisfied 5 (3%) 0 (0%) 7 (4%) 6 (3%) 4 (2%) 2 (1%) 2 (3%)
Completely dissatisfied 7 (4%) 1 (1%) 8 (4%) 2 (1%) 6 (3%) 2 (1%) 1 (2%)
*Not all respondents answered all questions



1.0 Executive Summary
Project ARCH (Access Received Closer to Home) care is available for Veterans who meet Project ARCH
Veterans Health Administration (VHA) health care criteria
1
, meet drive time criteria
2
, and live in one of
the five pilot sites across the country (Farmville, VA; Pratt, KS; Caribou, ME; Flagstaff, AZ; and
Billings, MT). The Altarum team has been tasked with assessing the programs progress in meeting its
stated goals. Our synthesis and analysis of the data for the first two years of Project ARCH revealed
notable findings.
1. Project ARCH has matured and grown over the first two years:
A total of 3,931 unique Veterans received clinical care through Project ARCH, with
significantly more Veterans receiving Project ARCH care at pilot sites offering specialty care
services (896 Veterans in Caribou, 1,226 Veterans in Flagstaff and 1,167 Veterans in
Billings), compared to sites offering primary care (304 Veterans in Farmville and 338
Veterans in Pratt).
Across all sites, there were 14,874 outpatient encounters and 671 inpatient discharges.
The most common type of care utilized by Veterans through Project ARCH at the specialty
care sites was orthopedics. At primary care sites, the most common diagnosis for a Project
ARCH health care visit was hypertension.
The majority of Veterans receiving care through Project ARCH were over 65 years old and
93 percent were male.
Drive time for Veterans receiving care through Project ARCH was, on average, 63 minutes
one-way to the Project ARCH health care site. This is less than a third of the estimated one-
way drive time to receive analogous care at a VHA facility (224 minutes).
Ninety-three percent of all primary care appointments occurred within 14 days of the
appointment request, exceeding the VHA-specified benchmark that 90 percent must be within
14 days. For specialty care appointments, only 62 percent occurred within 14 days of the
request. This did not meet the VHA benchmark of 90 percent within 14 days.
The contracted care networks reported receiving 8 complaints and 5 grievances and have
identified 14 potential safety issues associated with care provided through Project ARCH.
All potential safety issues were reportedly resolved.
The contracted care network that serves both primary care pilot sites reported on 26 clinical
metrics for primary care. In the first year of Project ARCH, 65 percent of the metrics met the
VHA benchmark. The percent meeting the VHA benchmark increased to 77 percent in the
second year of Project ARCH.
Based on the patient satisfaction survey administered to Veterans receiving care through
Project ARCH, 76 percent of Veterans responding to the survey reported being completely
satisfied with Project ARCH overall.

1
Were enrolled in VHA health care as of August 29, 2011 or were engaged in Operation Enduring
Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND)
2
Live more than 60 minutes driving time from the nearest primary care VHA health care facility, if the Veteran is
seeking such care; more than 120 minutes driving time from the nearest acute hospital care VHA facility, if the
Veteran is seeking such care; or more than 240 minutes driving time from the nearest tertiary care VHA health care
facility, if the Veteran is seeking such care.
8
The cost of Project ARCH-provided clinical care was estimated to be $26 million in the first
two years of operation. The average outpatient visit was $714 and the average inpatient stay
was $23,650.
Interviews were conducted with VHA Project ARCH staff, VHA providers, contracted care
network staff, and contracted providers, as well as with participating and non-participating
Veterans. These stakeholders cited a number of successful program elements of Project
ARCH that should be retained for future implementation of the project or for a Non-VA care
follow-on program, including co-location of VHA Project ARCH staff and contracted care
network staff, management of VHA Project ARCH staff and the non-Veterans Affairs (Non-
VA) care department, close working relationship with VHA Project ARCH staff, and data
collection and dissemination related to contracted care network performance metrics and
patient satisfaction.
Stakeholders also identified challenges and, where applicable, successful mitigations related
to Project ARCHs processes and operations, including overall care coordination, Project
ARCH policies and procedures, project communication, access to specialty care providers,
prescription management, billing and estimating expenditures, and coordination with the
contracted care networks.

2. The following are recommendations for the last year of Project ARCH:
We continued to hear about challenges with Project ARCH processes that had not yet been
resolved, particularly related to care coordination and authorizations, therefore we
recommend improving communication and coordination between VHA Project ARCH staff,
contracted care networks, and contracted providers on Project ARCH processes. These
meetings should be held on a regular basis and, where possible, in person.
To alleviate confusion expressed by participating Veterans about Project ARCH, we
recommend increasing efforts to educate Veterans prior to enrollment in Project ARCH and
throughout their participation in the program.
To determine the feasibility and usefulness of allowing primary care providers access to
VHAs electronic medical records, we recommend that VHA staff ensure that a contracted
provider is able to pilot test the use of VHAs Computerized Patient Record System (CPRS).
Although there have been noted improvements in prescription processes, we recommend
further increasing efficiency by creating a notification system for new or changes in
prescriptions and allowing contracted providers and VHA pharmacy staff to communicate
directly via phone or email.
To help primary care contracted providers track Project ARCH patients and their health care
needs, we recommend providing updated patient lists to contracted providers on a routine
basis.
VHA has established an integrated project team (IPT) to discuss the follow-on to Project
ARCH. This IPT should have representatives from both the specialty and primary care pilot
sites. We recommend that the IPT create a written plan (1) describing whether Veterans will
be transitioned to other care or if they will remain with the contracted provider, (2) outlining
how this information will be communicated to the contracted providers and Veterans, and (3)
providing contact information so that Veterans and contracted providers can reach out with
questions or receive additional information. The plan needs to include a timeline for
communicating information and any transitioning of patients.
Although most specialty care is based on an episode of care, primary care is provided on an
on-going basis. Therefore, continuity of care for Veterans receiving primary care through
Project ARCH deserves extra consideration. We recommend that the IPT discuss the benefits
and drawbacks of a wide variety of options to devise the most appropriate plan for Veterans
currently receiving primary care through Project ARCH.
In an effort to improve Non-VA care in general, we recommend capturing successful
practices, lessons learned, and recommendations about Project ARCH from VHA staff at
each of the pilot sites, as well as from contracted care networks and contracted providers.
3. We also provide recommendations for VHA to consider if there is a follow-on program after the
Project ARCH pilot ends.
Technical recommendations:
o Create standard operating procedures for: roles and responsibilities of VHA staff,
contracted care networks, and contracted providers; forms and instructions for new
and additional authorizations; training for contracted providers that allows for
completion of CPRS requirements for primary care providers if it is deemed useful
based on the pilot test.
o Include drive time from VHA facilities in the eligibility criteria for Non-VA care.
o Allow Veterans to decide whether or not to enroll in the new program and to choose
their contracted provider, including allowing the Veterans to suggest providers who
should be added to the network.
Care coordination recommendations:
o Allow bundled care, including pre- and post-surgical tests, durable medical
equipment, prescriptions, and physical therapy or other ancillary care to be included
in the authorization.
o Develop templates - in collaboration with contracted providers - detailing needs
based on diagnosis (e.g., regular testing needed) or procedure (e.g., pre/post-surgical
needs).
o Create a database of Veterans receiving primary care to track care received, clinical
goals of care, lab test results, and communications.
VHA and contracted care network staffing recommendations:
o Have specified VHA nurse case managers or care coordinators as points of contact
for the Veteran, contracted care network staff, and contracted providers to ensure
follow-up care within and outside of the VHA system is managed for the Veteran and
clinical goals are tracked.
o Co-location of and regular communication between VHA staff with contracted care
network staff and contracted providers.
o Ensure that the contracted care network has nurses on staff to review all requests for
authorizations and progress notes.
o Have a full-time VHA pharmacist to assist in medication reconciliation, filling
medications, and educating contracted providers about long-term prescriptions.
o Assign VHA financial staff to aid in estimation of Project ARCH health care costs to
reduce over- or under-budgeting.
o Utilize creative approaches to providing specialty care in rural areas (e.g., providers
from urban areas who provide care part-time, tele-health).

At this time, we recommend continuing the pilot program at all five sites currently being served by
Project ARCH so we can fully and accurately assess this pilot program. Further, we do not recommend
terminating Project ARCH, extending the pilot program to other VISNs, nor making Project ARCH
permanent until full analyses are completed.

1


DEPARTMENT OF VETERANS AFFAIRS (VA)
VETERANS HEALTH ADMINISTRATION (VHA)
EXECUTIVE DECISION MEMO (EDM)

TO: Under Secretary for Health (10)

SUBJECT: Alternatives for Expansion, Extension, or Expiration of Project Access
Received Closer to Home (ARCH) Authority in PL 110-387 and PL 111-163 Sec 308

FROM: Project ARCH Follow-On Integrated Project Team


For Further Information Contact: Colette Alvarez, Project ARCH Program Manager,
Colette.Alvarez@va.gov, 775-326-5721.

ACTION REQUESTED: Request for approval
Request for funding/staffing
Request for new FTEE
Other (specify)
(Check all that apply)

STATEMENT OF ISSUE: An Integrated Project Team (IPT) examined alternatives for
expanding, extending, or ending Project Access Received Closer to Home (ARCH).
Specifically, we investigated a potential expansion of contracted primary care services
to rural and highly rural Veterans in identified areas of need. This Executive Decision
Memo reports the IPTs research on areas of need, estimated costs of staffing and
administration, and estimated costs of care for a potential follow-on of contracted
primary care services after the pilot period of Project ARCH ends.

RECOMMENDATION: Allow Project ARCH to end after the pilot period ends on
September 30, 2014. Convene a second IPT, commencing in February of 2014, to
research a potential follow-on of contracted primary care services for Veterans in rural
and highly rural areas of need.


9
2

1. STATEMENT OF ISSUE: Project Access Received Closer to Home (ARCH) is a
contracted care pilot program that provides Veterans in rural and highly rural areas with
access to primary care and in-patient and specialty care closer to home. Veterans
eligible for Project ARCH met Veterans Health Administration (VHA) health care criteria
1

and drive time criteria,
2
and live in one of five pilot sites across the country (primary care
in Farmville, VA and Pratt, KS; in-patient and specialty care in Caribou, ME; Flagstaff,
AZ; and Billings, MT). The three-year Project ARCH pilot is scheduled to end on August
29, 2014, with contracts expiring September 30, 2014. In October 2013, an Integrated
Project Team (IPT) was chartered to conduct analysis and make recommendations on
the potential for service expansion of Project ARCH. Altarum Institute provided
information on patient satisfaction, success strategies, and lessons learned to the IPT.
Due to the recent implementation of the contracts for Patient-Centered Community Care
(PC3), recommendations are limited to Primary Care only. The purpose of this memo is
to provide an analysis of need and cost, and a final recommendation regarding the
potential expansion of contracted primary care services after the pilot period of Project
ARCH ends.

2. SUMMARY OF FACTS AND/OR BACKGROUND: Studies have indicated that long
travel distances to health care facilities may hinder Veterans in rural and highly rural
areas from receiving accessible VHA health care. To improve access to care for
enrolled Veterans, VHA has implemented a number of initiatives, including Community
Based Outpatient Clinics (CBOCs), mobile units, and telemedicine. Continuing the effort
to provide more accessible health care, a three-year pilot program, Project ARCH
(Access Received Closer to Home), is being administered by VHAs Chief Business
Office and funded by VHAs Office of Rural Health (ORH). The program provides an
additional mechanism for Veterans to seek care from non-VHA, community health care
providers closer to where the Veterans live. Project ARCH began providing care to
eligible

Veterans on August 29, 2011 in five pilot sites across the country: Farmville, VA;
Pratt, KS; Caribou, ME; Flagstaff, AZ; and Billings, MT. The first two pilot sites offer
primary care services, while the latter three provide inpatient and outpatient specialty
care. Due to the recent implementation of PC3 for inpatient and outpatient contracted
specialty care, this memo focuses exclusively on future primary care solutions in
identified rural and highly rural areas of need.
A. OUTCOMES OF THREE-YEAR PILOT: The two Project ARCH primary care
pilot sites served a total of 642 Veterans (304 Veterans in Farmville, VA and 338
Veterans in Pratt, KS) between August 29, 2011 and August 31, 2013and will
continue to serve Veterans until the pilot ends on September 30, 2014.
Ninety-three percent of Veterans receiving ARCH primary care services
were completely satisfied with how long it took them to travel to the
Project ARCH provider site, with eighty percent citing travel times of 30
minutes or less.

1
Were enrolled in VHA health care as of August 29, 2011 or were engaged in Operation Enduring
Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND).
2
Live more than 60 minutes driving time from the nearest primary care VHA health care facility, if the Veteran is
seeking such care; more than 120 minutes driving time from the nearest acute hospital care VHA facility, if the
Veteran is seeking such care; or more than 240 minutes driving time from the nearest tertiary care VHA health care
facility, if the Veteran is seeking such care.
3

Seventy-seven percent of Veterans receiving ARCH primary care services
were completely satisfied with the overall care they received from Project
ARCH providers, and sixty-nine percent were completely satisfied with
Project ARCH overall.
Ninety-three percent of all primary care appointments occurred within 14
days of the appointment request, exceeding the VHA-specified benchmark
that 90 percent must occur within 14 days.

B. PILOT SUCCESSES AND CHALLENGES:
Successful program elements to be considered for a possible future
contracted primary care follow-on program include: management of VHA
staff and the non-Veterans Affairs (Non-VA) care department; close
working relationships with VHA program staff; and data collection and
dissemination related to contracted care network performance metrics and
patient satisfaction.
3

Challenges in primary care that should be addressed in a possible future
contracted primary care follow-on program include: high administrative
burden for VHA staff; issues with pharmacy coordination of refills; need for
coordination of care and feedback loops between mid-level providers at
home Veterans Administration Medical Centers (VAMCs) and non-VA
providers; and lack of individual-level performance measures per
Veteran.
3


3. SYNOPSIS OF SIGNIFICANT RELATED ISSUES:
A. NEED FOR ACCESSIBILITY TO CARE FOR RURAL VETERANS: According to
VHA ORH, individuals living in rural areas have traditionally been underserved
with regard to health care access. The reasons for this are multiple and varied,
but mainly stem from the need to travel long distances to health care facilities,
lack of health insurance, lack of specialized care and an inadequate number of
health care providers working in rural areas. As a result, rural populations tend to
be in poorer health; in fact, a study by the Department of Health and Human
Services Office of Rural Health Policy estimates that half of the adults living in
rural areas suffer from a chronic health condition. With regard to rural Veterans,
there are the additional health complications associated with combat exposure
such as PTSD, depression, and traumatic brain injury.
4


B. PATIENT-CENTERED COMMUNITY CARE (PC3): PC3 is a VHA enterprise-
wide health care contracting strategy that will provide the option for eligible
Veterans to access most inpatient and outpatient specialty care and mental
health care across all VAMCs by April 2014. Veterans are eligible for PC3 when
their local VAMCs cannot provide the services, such as when there is a lack of
available specialists, long wait times, or an extraordinary distance from the

3
Based on interviews conducted by Altarum Institute with VHA Project ARCH staff, VHA providers, contracted care
network staff, and contracted providers, as well as with participating and non-participating Veterans.
4
See http://www.ruralhealth.va.gov/about.
4

Veterans home. The six-month implementation period for PC3 runs from
October 2013 to April 2014.
5
Due to the upcoming implementation of PC3,
theres no longer a need to continue inpatient and outpatient specialty care
services as part of a follow-on program to ARCH. For this reason, IPT
discussions focused exclusively on assessing the need and estimating the costs
of extending primary care services only.

C. CURRENTLY UNFUNDED REQUIREMENT: Any of the recommendations made
in this memo for services occurring beyond the contract period of August 2014 do
not have guaranteed funding from ORH or other VHA entities. ARCH is currently
funded by ORH based on available resources.

D. OPTIONS FOR A PROJECT ARCH FOLLOW-ON PROGRAM: Before
conducting research and making recommendations, our IPT arrived at a
consensus regarding the potential expansion of ARCH contracted primary care
services. Due to the specialty care coverage of PC3, an expansion of contracted
care services would focus only on primary care. A contracted primary care follow-
on program to Project ARCH would address the primary care needs of Veterans
in rural and highly rural areas with geographic inaccessibility, high drive times,
and/or long wait times. This new solution may expand contracted primary care
services to other VISNs.

Option 1 (Contracted Solutions to Provide Primary Care Closer to Home):
Charter another IPT to explore options for expanding contracted primary care
services via a follow-on program to Project ARCH in identified rural and highly
rural areas of need across all VISNs at a national VACO level. This new IPT
would conduct a market assessment/RFI to gather information from VHA CBO on
available options for primary care in identified areas of need, and explore and
build recommendations for contracted primary care solution(s) to serve those
identified areas of need across all VISNs.
Pros: Exploring options for contracted primary care solutions would inform
any future acquisition strategy. This option could increase accessibility to
primary care for a larger number of rural and highly rural Veterans in a
way that transcends VISN boundaries. In addition, a contracted solution
could potentially alleviate wait times in all localities. According to IPT
research, the administrative costs of managing a contracted primary care
solution would be neutralized after three years based on economies of
scale (see Section 4B below). Economies of scale would also be achieved
in the administration of these contracts. Quality standards and access
standards would be consistent across VISNs, and as a result, a contracted
solution could provide standardization and address rural and highly rural
Veterans access to primary care.


5
See http://www.nonvacare.va.gov/PC3/ for more information on PC3.
5

Cons: Research, administrative support, funding, and a needs
assessment will be needed to support a contracted primary care follow-on
program. A new IPT will need to be convened and funded.

Option 2 (Status Quo): Do not expand contracted primary care services via a
follow-on program to Project ARCH.

Pros: No research, administrative support, or funding is needed for this
option.

Cons: Veterans in rural and highly rural areas will continue with current
wait times and drive times to receive primary care services.

IPT Consensus: Option 1 (Contracted Solutions to Provide Primary Care
Closer to Home)

4. CRITERIA FOR DECISION MAKING: The IPTs final recommendation to convene a
second IPT to explore a follow-on program is based on four major decision-making
criteria: a) the areas of need for rural and highly rural Veterans; b) estimated
administrative and staffing costs versus Veterans Equitable Resource Allocation
(VERA) funds; c) estimated costs of care; and d) contracting options.
A. ANALYSIS FOR DETERMINING AREAS OF NEED: Options for determining
areas of need were evaluated based on the following criteria: 1) improves access
to primary care for Veterans in rural and highly rural areas by reducing Veteran
drive times and improving geographic accessibility, and 2) improves wait times
for Veteran primary care appointments in rural and highly rural areas. The IPT
analyzed and discussed the following options that should be considered by the
second IPT:
i. Continue services at two primary care pilot sites only. This option
allows for a continuation of services at Project ARCHs two current primary
care pilot sitesFarmville, VA and Pratt, KSonly, and does not address
the larger needs of all Veterans in rural and highly rural areas.
ii. Expand primary care services to all rural and highly rural VA areas.
This option addresses the needs of Veterans in rural and highly rural
areas, but it does not prioritize care services based on greatest need.
iii. Expand primary care services to rural and highly rural VA areas of
greatest need. The IPT agreed that a contracted primary care follow-on
program should address rural and highly rural areas with the greatest
need.
a. To determine areas of greatest need, the IPT used as its reference
the VA standard goal of a 14-day wait period between scheduling
and receiving primary care services for new and established
patients. VA facilities delivering primary care with wait times greater
than 30 days, or double the VA standard goal of 14 days, were
determined as sites with highest need.
b. To narrow areas of need to rural and highly rural areas, the IPT
6

conducted analysis with the GIS to determine the number of
Veterans with a drive time of 60 minutes or more from the nearest
VA facility delivering primary care in a rural area or zip code.
c. In addition, the IPT determined VA primary care areas outside the
60-minute drive time band where Veterans are enrolled for Primary
Care, but not necessarily receiving VA services, which is a potential
indicator of inaccessibility to care for rural and highly rural
Veterans.
d. Final determination of need: Veterans who live outside the 60
minute drive time band from a VA facility delivering primary care
with wait times for Primary Care that are 30 days or greater. Table
1 (below) features preliminary data on the number of Veteran
enrollees living in ZIP codes where the closest facility has a high
wait-timedefined as an average wait-time of over 30 days for
primary care appointments for new patients.
e. Consider ORH funding a limited expansion of contracted primary
care services, pending additional research, analysis, and available
resources.

Table 1: Number of Veteran Enrollees in Identified Areas of Need, By VISN

VISN
# Enrollees living in ZIP
codes where the
closest facility has a
high wait-time
# Rural (R) # Highly
Rural (HR)
Average High
Rural
Wait-Times
(in days)*
Average High
Highly Rural
Wait-Times
(in days)*
1 10,104 8,895 (88%) 1,152 (11%) 36.1 35.9
4 0 0 0 41.1 43
6 12,309 11,843 (96%) 0 53.2 59.4
7 32,382 31,096 (96%) 0 37.9 47.6
8 5,778 5,778 (100%) 0 49.8 37.7
9 8,560 8,560 (100%) 0 41.4 0
10 234 234 (100%) 0 38.4 0
15 0 0 0 0 0
16 10,849 0 586 (5%) 0 48
17 4,300 740 (17%) 0 34.6 0
18 448 407 (91%) 41 (9%) 43.5 36.5
19 8,914 7,029 (79%) 1,885 (21%) 36.5 33.7
20 17,077 15,861 (93%) 1,216 (7%) 42 42
21 10,345 6,986 (68%) 3359 (32%) 40.9 33.5
7

22 3,391 3,148 (93%) 243 (7%) 40 0
Percentages may not equal 100 when some ZIP code enrollees live in urban areas.
*Wait-times are for primary care appointments for new patients.

**The number for Highly Rural, 243, is for the Enrollees in those ZIP codes that have a
closest facility with a high average wait-time for New Rural Patient.


B. ANALYSIS FOR ESTIMATING ADMINISTRATIVE AND STAFFING COSTS:
The IPT recognizes Project ARCHs improved ability to create access closer to
home and the very important need to maintain the quality and safety of patient
care by staffing a potential follow-on program appropriately. This section
estimates the administrative and staffing costs and revenues for fully coordinated
contracted primary care for 1000 unique Veterans, based on either: 1) primary
care costs at the Wichita, KS pilot site, or 2) Non-VA Care Coordination (NVCC).

Option 1: Costs of Care for VAMC Facility, Based on Wichita Pilot Site:
According to the estimates in Table 2 below, contracted primary care is cost
neutral to the facility after 3 years of operation, considering VERA reimburses
the participating VISN. By increasing the number of new rural and highly rural
Veterans served, VISNs will receive higher reimbursements from VERA, and
some of those costs will go to participating VAMCs.

Table 2: Estimated Administrative Costs and Revenues

Cost Estimates for 1,000 Unique Veterans
Mid Level Provider Coordinator: 0.25 FTEE ($30,000)
RN Coordinator: 1.00 FTEE ($100,000)
Medical Support Assistant (MSA): 1.00 FTEE ($50,000)
Non VA care Fiscal Tech: 0.1 FTEE ($5,000)
Pharmacist: FTEE 0.25 ($30,000)
NON VA cost for services: ($600,000)
Travel & Transportation Costs (inc. ground/air ambulance): ($200,000)
TOTAL ESTIMATED COST: $1,015,000

Revenue Estimates for 1,000 Unique Veterans
Assuming all unique Veterans are reimbursed at the basic rate
(~$2000.00 per Unique)
Assuming the facility keeps 80% of PRP (Pro Rated Person), the
potential VERA reimbursement to VISN = $1,600,000
Assuming 70% of the VERA will go to the facility
EXPECTED INCREASE IN FUNDING TO FACILITY = $1,120,000

TIME (IN YEARS) TO PROGRAM COST NEUTRALITY: 3 years

Facilities would also be encouraged to enroll qualifying patients in the Care
Coordination Home Telehealth (CCHT) program, and have the care coordinator
and the VA provider manage this in coordination with contracted providers in the
8

community. This will increase VERA reimbursements from basic ($2000 per
patient) to a higher level (~$14,000 per patient).

Option 2: Administrative and Staffing Costs, Based on NVCC (Status Quo):
Costs for this option would be based on the facilitys number of Veterans served
through non-VA care programs. This approach would utilize a program
management model similar to PC3. PC3 is supported centrally by the CBO and
de-centrally at the VAMC level through NVCC personnel. In addition, field
assistants are hired to facilitate in communication between the field and CBO
mitigating, resolving, and reporting issues to the Contracting Officer
Representatives (CORs). A primary care contracted solution could attempt to
utilize a similar model, but tailor it to specific primary care requirements.

C. ANALYSIS FOR ESTIMATING COST OF CARE: We recommend using percent
of Medicare rates as a starting point for estimating the cost of care provided in
the areas of need indicated in Section 3A above. The estimation would be
completed in the follow-on IPT.

D. ANALYSIS OF CONTRACTING OPTIONS: We recommend that a second IPT
be formed to look at contracting solutions.

5. CROSSCUTTING ISSUES: Potential crosscutting issues between PC3 and a future
follow-on of contracted primary care services are discussed in Section 3B above.

6. STAKEHOLDER INVOLVEMENT: VHAs Office of Rural Health, VHAs Chief
Business Office, Denver Acquisitions and Logistics Center and/or local contracting
offices, VAMCs, non-VA community providers, and members of Congress and Senate
are all stakeholders.

7. OPTIONS AND ARGUMENTS: See Section 3D above.

8. RECOMMENDED OPTION: Option 1 (Contracted Solutions to Provide Primary
Care Closer to Home): Allow Project ARCH to end after the pilot period ends on
September 30, 2014. Convene a second IPT to research a potential follow-on of contracted
primary care services for Veterans in rural and highly rural areas of need.

9. DISSENTING OPINIONS REGARDING RECOMMENDED OPTION: There were no
dissenting opinions.

10. EFFECT OF RECOMMENDED OPTION ON EXISTING PROGRAMS AND/OR
FACILITIES: VHA is currently developing sustainment options and a potential bridge
contract for the 600+ Veterans currently enrolled in Project ARCH primary care pilot
sites in VISN 6 (Richmond) and VISN 15 (Wichita) to ensure there is no gap in care.
PC3 will be available to Veterans in the three specialty care Project ARCH pilot sites.

11. LEGAL OR LEGISLATIVE CONSIDERATIONS OF THE RECOMMENDED
OPTION: VHA is addressing any and all legal considerations for the 600+ currently
enrolled Veterans.
9


12. ETHICAL CONSIDERATIONS OF THE RECOMMENDED OPTION: VHA is
addressing any and all ethical considerations for the 600+ currently enrolled Veterans.

13. BUDGET OR FINANCIAL CONSIDERATIONS OF THE RECOMMENDED
OPTION: A second IPT will address budget and financial considerations.

14. PUBLIC RELATIONS OR MEDIA CONSIDERATIONS OF THE RECOMMENDED
OPTION: Any communication will be processed through standard VA communication
channels.

15. CONGRESSIONAL OR OTHER PUBLIC OFFICIAL OR AGENCY
CONSIDERATIONS OF THE RECOMMENDED OPTION: Any discussion of
Congressional and/or other public official or agency notification or involvement
considerations will be processed through standard VA communication channels.

16. IMPLEMENTATION: A second IPT would be formed immediately after authority is
granted from this EDM. CBO would be the lead office. There are no anticipated
obstacles.

17. MEASUREMENT OF PROGRAM SUCCESS: Metrics and/or evaluation
mechanisms for program success will be determined by the second IPT.



RECOMMEND OPTION 1 (Contracted Solutions to Provide Primary Care Closer to
Home): Allow Project ARCH to end after the pilot period ends on September 30, 2014.
Convene a second IPT to research a potential follow-on of contracted primary care
services for Veterans in rural and highly rural areas of need.


APPROVE/DISAPPROVE

COMMENT: ___________________________________________________

______________________________________________________________


______________________________________________ ________
Robert A. Petzel, M.D. Date
Under Secretary for Health

Effective October 11, 2009
Pay Ranges must be reviewed every 2 years based upon salary surveys.
Two additional pay tables (Pay Tables 5 and 6) apply to VA Chiefs of Staff
and physicians and dentists in executive level administrative assignments.
They have not been used by NIH.
NIH delegated PDP limit is $350,000 annual pay, $375,000 total compensation.
VA Title 38 Physician and Dentist Pay Ranges
(Base Pay + Market Pay)

Pay Table 1 Clinical Specialty

Allergy and Immunology
Endocrinology
Endodontics
General Practice Dentistry
Geriatrics
Hospitalist
Infectious Diseases
Internal Medicine/Primary Care/
Family Practice
Neurology
Periodontics
Preventive Medicine
Prosthodontics
Psychiatry
Rheumatology
Assignments that do not require
a specific specialty training or certification
Pay Table 7 Clinical Specialty

Cardio-Thoracic Surgery
Interventional Cardiology
Interventional Radiology
Neurosurgery
Orthopedic Surgery
Pay Table 2 Clinical Specialty

Critical Care (Board Certified)
Emergency Medicine
Gynecology
Hematology Oncology
Nephrology
Pathology
Physical Medicine & Rehabilitation/
Physiatry/Spinal Cord Injury
Pulmonary
Pay Table 3 Clinical Specialty

Cardiology (Non-invasive)
Dermatology
Gastroenterology
Nuclear Medicine
Ophthalmology
Oral Surgery
Otolaryngology
Pay Table 4 Clinical Specialty

Anesthesiology
General Surgery
Plastic Surgery
Radiology (Non-invasive) combined
Radiology and Therapeutic Radiology
from 2007 issuance
Urology
Vascular Surgery

MINIMUM MAXIMUM
TIER 1 $ 96,539 $195,000
TIER 2 $110,000 $210,000
TIER 3 $120,000 $235,000
TIER 4 $130,000 $245,000

MINIMUM MAXIMUM
TIER 1 $ 96,539 $375,000
TIER 2 $140,000 $385,000

MINIMUM MAXIMUM
TIER 1 $ 96,539 $220,000
TIER 2 $115,000 $230,000
TIER 3 $130,000 $240,000
TIER 4 $140,000 $250,000

MINIMUM MAXIMUM
TIER 1 $ 96,539 $265,000
TIER 2 $120,000 $275,000
TIER 3 $135,000 $285,000
TIER 4 $145,000 $295,000

MINIMUM MAXIMUM
TIER 1 $ 96,539 $295,000
TIER 2 $125,000 $305,000
TIER 3 $140,000 $325,000
TIER 4 $150,000 $335,000
10
11
Perspective
The NEW ENGLAND JOURNAL of MEDICINE
n engl j med nejm.org 1
I
t has been nearly 20 years since the Veterans
Health Administration (VHA), the subcabinet
agency that oversees the Department of Veterans Af-
fairs (VA) health care system, implemented a series
of sweeping reforms that mark-
edly improved quality, boosted
access, and increased efficiency.
1,2

Recent revelations about long wait
times for veterans compounded
by systematic cover-up by VHA
administrators make it clear that
reforms are again needed. Ap-
parent manipulation and falsifi-
cation of wait-time data at more
than 40 facilities indicate a serious
systemic problem.
To some observers, the VAs
problems confirm that govern-
ment cannot manage health care.
To others, they tell a simple story
of insufficient funding: the VA
needs more money to care for the
large number of veterans return-
ing from the wars in Iraq and
Afghanistan and for aging Viet-
nam veterans. Unfortunately, nei-
ther narrative adequately captures
the challenges facing this orga-
nization or provides guidance on
how we might address them.
Inadequate numbers of pri-
mary care providers, aged facili-
ties, overly complicated schedul-
ing processes, and other difficult
challenges have thwarted the VAs
efforts to meet soaring demand
for services. For years, it has been
no secret that the VAs front lines
of care delivery are understaffed
for the needs. And though there
can be no excuse for falsifying
data, we believe that VA leader-
ship created a toxic milieu when
they imposed an unrealistic per-
formance standard and placed
high priority on meeting it in the
face of these difficult challenges.
They further compounded the sit-
uation by using a severely flawed
wait-timemonitoring system and
expressing a no excuses man-
agement attitude.
Without diminishing the seri-
ousness of the problems of data
manipulation and prolonged wait
times, we would argue that these
are symptoms of deeper patholo-
gy. Quite simply, the VA has lost
sight of its primary mission of
providing timely access to con-
sistently high-quality care. Al-
though it has garnered less atten-
tion than the wait-time problems,
a disturbing pattern of increas-
ingly uneven quality of care has
also evolved in recent years. To be
sure, the quality of health care
provided by VA hospitals is, on
average, similar to or better than
that in the private sector.
1-3
When
Restoring Trust in VA Health Care
Kenneth W. Kizer, M.D., M.P.H., and Ashish K. Jha, M.D., M.P.H.
The New England Journal of Medicine
Downloaded from nejm.org on June 24, 2014. For personal use only. No other uses without permission.
Copyright 2014 Massachusetts Medical Society. All rights reserved.
12
PERSPECTI VE
n engl j med nejm.org 2
VA hospitals are compared with
top-tier integrated delivery sys-
tems, however, their quality ad-
vantage diminishes. Some VA hos-
pitals excel, but others are
struggling with the basics. The
Phoenix VA Medical Center
ground zero of the wait-time
scandal has mortality rates
for common conditions that are
among the highest within the VA
and higher than those in many
private hospitals. Its rates of
catheter-related bloodstream in-
fections are nearly three times
the national average.
After the VA gained a hard-
won reputation for providing su-
perior-quality care 15 years ago,
how did cracks appear in its de-
livery of safe, effective, patient-
centered care? We believe there
are three main causes: an unfo-
cused performance-measurement
program, increasingly centralized
control of care delivery and as-
sociated increased bureaucracy,
and increasing organizational in-
sularity.
The performance-measurement
program a management tool
for improving quality and increas-
ing accountability that was intro-
duced in the reforms of the late
1990s has become bloated and
unfocused.
4
Originally, approxi-
mately two dozen quality mea-
sures were used, all of which had
substantial clinical credibility.
Now there are hundreds of mea-
sures with varying degrees of clini-
cal salience. The use of hundreds
of measures for judging perfor-
mance not only encourages gam-
ing but also precludes focusing on,
or even knowing, whats truly im-
portant.
In addition, the tenor of man-
agement has changed substantial-
ly over the past decade. During
the reforms of the 1990s, decen-
tralization of operational deci-
sion making was a core princi-
ple. Day-to-day responsibility for
running the health care system
was largely delegated to the local
facility and regional-network man-
agers within the context of clear
performance goals, while cen-
tral-office staff focused on set-
ting strategic direction and hold-
ing the field accountable for
improving performance. In recent
years, there has been a shift to a
more top-down style of manage-
ment, whereby the central office
has oversight of nearly every as-
pect of care delivery.
4
Concomi-
tantly, the VHAs central-office
staff has grown markedly
from about 800 in the late 1990s
to nearly 11,000 in 2012.
Finally, the VA health care
system has become increasingly
insular and inward-looking. It now
has little engagement with pri-
vate-sector health care, and too
often it has declined to make its
performance data public. For ex-
ample, it contributes only a small
proportion of its data to the na-
tional public reporting program
for hospitals, Hospital Compare,
and has declined to participate
in other public performance re-
porting forums such as the Leap-
frog Groups efforts to assess
patient safety.
So how can the VA turn the
ship around? We propose a few
first steps.
First, after ensuring that all
veterans on wait lists are screened
and triaged for care, the VA should
refocus its performance-manage-
ment system on fewer measures
that directly address what is most
important to veteran patients and
clinicians especially outcome
measures. The agencys recently
developed Strategic Analytics for
Improvement and Learning (SAIL)
dashboard, which focuses on 28
meaningful metrics including ac-
cess to care, mortality rates, in-
fection rates, and patient satisfac-
tion, is a good start that will
improve with use and would help
hold the VA accountable for re-
sults.
Second, conceptualizing access
to care in terms of a continuous
healing relationship,
5
the agency
should design a new access strat-
egy that draws on modern infor-
mation and advanced communi-
cations technologies to facilitate
caregiverpatient connectivity and
that uses personalized care plans
to address patients individual ac-
cess needs and preferences. Facil-
ity-by-facility assessments should
determine whether VA facilities
are using technology to leverage
the best possible care delivery
return on investment and wheth-
er personnel are working at the
top of their skills. Perhaps some
of the resources supporting the
central and network office bu-
reaucracies could be redirected to
bolster the number of caregivers.
Third, we believe the VA needs
to engage more with private-sector
health care organizations and the
general public participating
fully in performance-reporting ini-
tiatives, expanding learning-and-
improvement partnerships with
outside entities (as it did in the
late 1990s in spearheading na-
tional patient-safety improvement
efforts
1
), and making performance
data broadly available. Transpar-
ency may expose vulnerabilities,
but it is easier to improve when
weaknesses are publicly acknowl-
edged.
VA health care is at a cross-
roads. We learned from the last
round of reforms that the VAs
problems can be fixed. The agency
continues to employ an army of
highly dedicated clinicians and
administrators who are deeply
committed to providing high-qual-
Restoring trust in VA Health Care
The New England Journal of Medicine
Downloaded from nejm.org on June 24, 2014. For personal use only. No other uses without permission.
Copyright 2014 Massachusetts Medical Society. All rights reserved.
n engl j med nejm.org
PERSPECTI VE
3
ity care to veterans. New leader-
ship should help them succeed.
The views expressed in this article are
those of the authors and do not necessarily
ref lect those of the Department of Veterans
Affairs.
Dr. Kizer reports serving as Under Secre-
tary for Health in the Department of Veter-
ans Affairs from 1994 through 1999. Dr.
Jha is a staff physician at the Boston VA
Healthcare System.
Disclosure forms provided by the au-
thors are available with the full text of this
article at NEJM.org.
From the Institute for Population Health
Improvement, UC Davis Health System; the
Department of Emergency Medicine, Uni-
versity of California Davis School of Medi-
cine; and the Betty Irene Moore School of
Nursing all in Sacramento, CA (K.W.K.);
and the Department of Health Policy and
Management, Harvard School of Public
Health; and the Division of General Medi-
cine, Brigham and Womens Hospital
both in Boston (A.K.J.).
This article was published on June 4, 2014,
at NEJM.org.
1. Kizer KW, Dudley RA. Extreme makeover:
transformation of the veterans health care
system. Annu Rev Public Health 2009;30:313-
39.
2. Jha AK, Perlin JB, Kizer KW, Dudley RA.
Effect of the transformation of the Veterans
Affairs health care system on the quality of
care. N Engl J Med 2003;348:2218-27.
3. Trivedi AN, Matula S, Miake-Lye I, Glass-
man PA, Shekelle P, Asch S. Systematic re-
view: comparison of the quality of medical
care in Veterans Affairs and non-Veterans
Affairs settings. Med Care 2011;49:76-88.
4. Kizer KW, Kirsh SR. The double edged
sword of performance measurement. J Gen
Intern Med 2012;27:395-7.
5. Institute of Medicine. Crossing the quality
chasm: a new health system for the 21st cen-
tury. Washington DC: National Academy
Press, 2001.
DOI: 10.1056/NEJMp1406852
Copyright 2014 Massachusetts Medical Society.
Restoring trust in VA Health Care
The New England Journal of Medicine
Downloaded from nejm.org on June 24, 2014. For personal use only. No other uses without permission.
Copyright 2014 Massachusetts Medical Society. All rights reserved.
13
Attachment A

This document is intended to provide additional detail regarding some of the scheduling
process changes addressed in the memorandum to which it is attached. This guidance
should provide assistance to facilities in implementing these changes and will follow the
outline below:


1. Definitions

2. Summary of Established Patient Internal Demand AUD/Desired Date Audits

3. Documenting the AUD

a. Setting up the order template (Clinical Application Coordinators)

b. Documenting AUD in an order (Providers)

4. Viewing AUD in an order (Schedulers)

5. Entering AUD as Desired Date (Schedulers)

6. Completing the order (Schedulers)

7. Conducting AUD/DD audits (Scheduling Supervisors)

8. Background for Established Patient External Demand Desired Date Audits

9. Desired Date Methodology for External Demand

10. Conducting scheduler DD audits (Scheduling Supervisors)


14

1. Definitions
Desired Date (DD): The desired appointment date is the date on which the
patient or provider wants the patient to be seen. Schedulers are responsible for
recording the desired date accurately.
Internal Demand is work we make for ourselves, i.e. demand generated by the
practice itself in the form of requests for return visits.
External demand is that demand that originates from the world. In Primary
Care (PC), the world is the panel (the universe from which demand for
appointments comes). In Specialty Care (SC) the world is all the panels of
providers of providers in PC who generate requests for consults
Agreed Upon Date (AUD): is the specific date selected by the patient and
provider for a return to clinic visit
Prospective Wait Time Report: provides information on the prospective wait
times for established patients who have pending appointments as of a given
date. The wait time is calculated using the appointment desired date and the
scheduled appointment date. Below is the VSSC link for the Prospective report:
o https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewe
r.aspx?%2fSystems+Redesign%2fProspective+Wait+Times&rs:Command
=Render
New Patient: is any patient not seen by a qualifying provider type within a
defined stop code or stop code group at the facility within the past 24 months.
Established Patient: is any patient seen by a qualifying provider type within a
defined stop code or stop code group up to but not exceeding a 24 month period.
New Enrollee: a previously non-enrolled Veteran who applies for VA health care
benefits by submitting VA Form 10-10EZ. Application for Health Benefits is to be
determined as eligible and is enrolled.



2. Summary of Established Patient Internal Demand AUD/Desired Date Audits

Internal demand is defined as requests for appointments that originate from patients in
the clinic seeking a follow-up appointment based on a specific return to clinic date, or
Agreed Upon Date (AUD), selected together by the provider and the patient. The
provider will document the AUD in an order.
The scheduling clerk will enter the AUD date into the scheduling package as the
Desired Date. Annual audits will be conducted to determine how consistently the
documented AUD is entered as the Desired Date by the scheduling clerks. The
procedures described below are recommended for documenting the Agreed Upon Date
and auditing its use as Desired Date.

3. Documenting the AUD

a. Setting up the order template

Facilities Clinical Application Coordinators will need to set up an order template
based on a specific orderable item titled Return to Clinic.

The start date field of the order template should be renamed AUD/Desired
Date. Renaming of this field will not alter the actual field.

A clinic drop down box should be set up to include all facility clinics





The following screenshot is an example of the process used by a pilot site to set up an
order template in a Mental Health clinic.

Select ORDER DIALOG NAME: ORGBU RTC MENTAL HEALTH START DATE
NAME: ORGBU RTC MENTAL HEALTH START DATE
DISPLAY TEXT: Return to Clinic Mental Health
SIGNATURE REQUIRED: ORES//
VERIFY ORDER: NO//
ASK FOR ANOTHER ORDER: NO//
DESCRIPTION:
created per request for MH rtc dlg 2012

Edit? NO//
DISPLAY GROUP: CLINIC ORDERS//
Select PROMPT:
Answer with ITEMS, or SEQUENCE
Choose from:
1 OR GTX ORDERABLE ITEM
1.5 OR GTX START DATE
2 OR GTX WORD PROCESSING 1

You may enter a new ITEMS, if you wish
Type a Number between .1 and 999.9, 1 Decimal Digit

Select PROMPT: 1 OR GTX ORDERABLE ITEM
SEQUENCE: 1//
PROMPT: OR GTX ORDERABLE ITEM// pointer to a file
DISPLAY TEXT: Order: //
REQUIRED: YES//
MULTIPLE VALUED:
ASK ON EDIT ONLY: YES//
ASK ON ACTION:
HELP MESSAGE:
DEFAULT: RTC-BU MENTAL HEALTH
ORDER TEXT SEQUENCE: 1//
FORMAT:
OMIT TEXT:
LEADING TEXT:
TRAILING TEXT:
START NEW LINE:

Select PROMPT: 1.5 OR GTX START DATE
SEQUENCE: 1.5//
PROMPT: OR GTX START DATE// relative date/time
DISPLAY TEXT: Agreed upon date (must match the order EXACTLY):
Replace
REQUIRED: YES//
MULTIPLE VALUED: NO//
ASK ON EDIT ONLY: NO//
ASK ON ACTION:
HELP MESSAGE:
DEFAULT:
ORDER TEXT SEQUENCE: 1.5//
FORMAT:
OMIT TEXT:
LEADING TEXT: Agreed upon date://
TRAILING TEXT:
START NEW LINE:

Select PROMPT: 2 OR GTX WORD PROCESSING 1
SEQUENCE: 2//
PROMPT: OR GTX WORD PROCESSING 1// word processing
DISPLAY TEXT: Scheduling://
REQUIRED: YES//
MULTIPLE VALUED: NO//
ASK ON EDIT ONLY: NO//
ASK ON ACTION:
HELP MESSAGE:
DEFAULT:

==[ WRAP ]==[ INSERT ]===============< DEFAULT >=============[ <PF1>H=Help
Please schedule an appointment for the agreed upon date of:
{FLD:DATE (*)} in clinic {FLD:MH CLINIC NAMES}.


<=======T=======T=======T=======T=======T=======T=======T=======T=======T
ORDER TEXT SEQUENCE: 2//
FORMAT:
OMIT TEXT:
LEADING TEXT:
TRAILING TEXT:
START NEW LINE: YES//
WORD-WRAP: DON'T WRAP//

Select PROMPT:
Auto-accept this order? NO//

Do you want to test this dialog now? N


b. Documenting AUD in an order

The provider will select the clinic from the drop down box

The provider will enter a specific date (not a date range or time frame) into the
AUD/Desired Date field


The following screen shot from one of the pilot sites demonstrates how the provider can
document the AUD in the order:



Complete the template, by
selecting the date and the
clinic. Then select ok.
Enter the agreed upon date/time
AGAIN, then ACCEPT ORDER.
Sign your order.




4. Viewing AUD in an order


Facilities should consult their Clinical Application Coordinators to determine how
best to view the orders documenting the AUD

Schedulers should be trained that although the order will be marked Scheduled
an appointment still needs to be made.

One way the orders can be viewed is for the scheduler to set up a custom view.

The following screen shots from one of the pilot sites demonstrate how the scheduler
can set up a custom view:
1
Open CPRS, select any patient.
Under the Tools tab select OPTIONS.
Select OTHER PARAMETERS.

2
Under INITIAL TAB WHEN CPRS STARTS select
ORDERS.
Select OK.
Then OK again on the next screen.
For changes to take affect sign out of CPRS. From
now on when you log into CPRS you will go directly
to the Orders Tab.
CUSTOM ORDER VIEW (CLINIC ORDERS)
Select your patient in CPRS.
Go to the ORDERS tab.
Select VIEW.
Select CUSTOM ORDER VIEW.
3
Select View, then SAVE
AS DEFAULT VIEW.
5
Your view will consist of only orders placed under the
service of CLINIC ORDERS.
6
Under ORDER STATUS, keep
Active (includes pending, recent
activity) highlighted.
Under the SERVICE/SECTION
scroll down and select CLINIC
ORDERS listed under M.A.S.
4
Detailed order view.
ORDER VIEW on the Orders Tab


Periodically the scheduler should run a report to ensure that all orders
documenting AUD have been completed and all appointments made as
appropriate. Facility Clinical Application Coordinators can advise whether this
report may be automated.
The following method was used by a pilot site to run a report of pending orders
documenting AUD:

This option will print the 'Return To Clinic' orders for
your site or a count of the RTC orders written per location.

The search is done by the Start Date of the orders, so to find
future orders use T as a starting date.

Enter search starting date: T-365 (SEP 19, 2011)
Enter search end date: T-350 (OCT 04, 2011)

Enter a 2 character RTC suffix (RTC-xx): BU

Select one of the following:

A ACTIVE RTC ORDERS
S SCHEDULED RTC ORDERS
C COUNT OF RTC ORDERS

Report To Run: ACTIVE RTC ORDERS

**Display must be set to 132 columns in order for this report to be
formatted correctly.

DEVICE: HOME// 0;132 SSH VIRTUAL TERMINAL

RTC-BU RETURN TO CLINIC ACTIVE ORDERS 09/19/11 - 10/04/11

ORDERING LOCATION ORDERABLE ITEM PATIENT (LAST4) ORDER DATE ORDERING PROVIDER
--------------------------------------------------------------------------------------------------------------------------------------------------

5. Entering AUD as Desired Date

The scheduling clerk enters the documented AUD into the Desired Date field
of the scheduling package

The scheduler then proceeds to make the appointment

Appointments requested beyond 120 should follow the Recall Appointment
process as usual

As indicated in the scheduling directive, a patients desire to schedule an
appointment outside of the desired date should be honored. In such
instances the provider should be consulted to prevent any unwanted clinical
outcomes

6. Completing the order

Once the appointment has been made the scheduler completes the order

The following screen shot shows how the scheduler can complete the order

1
Select and high light the order.
Select ACTION.
Select COMPLETE
Enter your electronic signature code, then OK.
COMPLETING AN ORDER


7. Conducting the Established Patient Internal Demand AUD/Desired Date audit

Annually scheduling supervisors should run a report reviewing a sample of
appointments made by each scheduler to ensure accuracy and consistency of
scheduler entry of AUD as Desired Date. A national report will soon be
available on the VSSC website which supervisors can use to conduct these
audits.

Until the national audit reporting tool is available, facilities may run a local audit report.
The following screen shot demonstrates the logic used for a report run by a pilot site in
a Mental Health clinic:

1. Find Orders with an Orderable Item name of 'rtc-bu mental health%' or 'rtc bu-
mental health%'

2. Find matching Appointments with
a. the same appointment date/time as the Order Start Date
b. the same clinic location as the order

3. Find matching Appointments with
a. an appointment date/time within one month before or 7 months after the Order Start
Date
b. for the same clinic location as the order or in an MH clinic (primary stop code 502 or
513)
c. the appointment made date/time the same day as the order entry date
d. not found in step 2

4. Find matching Appointments with
a. an appointment date/time within 7 months after the Order Start Date
b. for the same location as the order or in a clinic with a primary stop code of 540 and
secondary stop code of 125
c. and the appointment made date/time on or after the day of the order entry date
d. (and not found in step 2 or 3)

5. Find matching Appointments with
a. an appointment date/time within 7 days of the Order Start Date
b. for the same location as the order or in a clinic with a primary stop code of clinic of 160
and secondary stop code of 502
c. and the appointment made date/time on or after the day of the order entry date
d. (and not found in step 2, 3 or 4)

Note: The Order Start Date is the field used to store the AUD date

StopCode StopCodeName
502 MENTAL HEALTH CLINIC - IND
513 SUBSTANCE USE DISORDER IND
540 PTSD CLINICAL TEAM PTS IND
125 SOCIAL WORK SERVICE
160 CLINICAL PHARMACY
502 MENTAL HEALTH CLINIC - IND


8. Background for Established Patient External Demand Desired Date Audits

External demand is defined as requests for appointments by patients that are calling
from outside the clinic. This would not include the normal follow-up appointments
made at the request of the patient/provider in the clinic or the artificial inflation of
external demand through the rescheduling of no shows. Reducing the no show rate is a
very powerful way to decrease overall demand. One of the strategies to reduce
external demand is to not only decrease the waiting times but to track and monitor the
accuracy of scheduler input.
The desired date timestamp is entered into the system by the scheduling clerk who is
responsible for designating the accurate desired date when a patient expresses the
date he requests to be seen regardless of when they are able to be seen in an open
slot. The strength of the desired date stamp reflects the patients /providers wishes; the
weakness of the desired date stamp is the accuracy in which the scheduler selects and
maintains the initial request as the desired date. The desired date should not be
influenced by differences in local scheduling practices.
Internal audits by the OIG of VAs scheduler performance in 2005 found desired date
entered correctly only 60% of the time. VHA agreed with the OIGs findings and
undertook renewed educational efforts and scheduler training. In December 2011,
VHA conducted an audit of 43,643 appointments that indicated that Mental Health
schedulers correctly entered the desired date 91.6% of the time.
Although desired date accuracy has improved substantially, barriers still exist to monitor
the accurate entry of the desired date.
Schedulers attention to understanding and ascertaining the correct desired date
for the situation
Turnover rate of the scheduling staff
Ability to audit negotiations between patient and scheduler
o There is no electronic method of auditing the accuracy of conversations
between patient/scheduler when negotiating patients desired date.

The VHA is working to improve the reliability of the data by proposing standardization of
communications between the provider and the patient to manage the accuracy of the
return appointment date of internal demand through the use of an Agreed-Upon-Date
or AUD. Managing the accuracy of external demand will involve a more of a hands
on approach by scheduling leads and supervisors. The purpose of this section of the
document is to outline the current barriers and potential solutions to management of the
desired date when approached from an external demand point of view.

9. Desired Date Methodology for External Demand
In accordance with VHA Directive 2010-027, VHA Outpatient Scheduling Processes
and Procedures, it is the VHAs commitment to provide clinically appropriate quality care
for eligible Veterans when they want and need it. This requires the ability to create
appointments that meet the patients needs with no undue waits or delays. Wait times
for patients to be seen through scheduled appointments in primary care and specialty
care clinics are monitored. In addition, patients (both new and established) are
surveyed to determine if they receive an appointment when they wanted one.
Purpose: Monitoring of ongoing compliance with VHA Directive 2010-027, VHA
Outpatient Scheduling Processes and Procedures on the proper use of the desired date
(DD) for external demand, to include measurement and monitoring of ongoing
performance.
Scheduling Menu Option Requirements: The following requirements must be
completed to gain access to the VistA Scheduling option.
Creation and maintenance of a Master List of all staff members that have any of
the VistA scheduling options:
o PCMM menu options for primary care team
o Provider assignments
o Menu options for entries on the EWL
o Direct supervisors of all such individuals.
Successful completion of VHA Scheduler Training by all individuals on the
Master List. (schedulers must proof of the training)
Successful completion of the Soft Skills training
Quarterly audits (10 patients) of scheduling accuracy, to include desired date,
agreed upon date and create date.
Standardized yearly scheduler audit of timeliness and appropriateness of
scheduling actions and of the accuracy of the desired date.
Metrics for External Demand: There is no one sure fired method to electronically
monitor the desired date since the origin of the accuracy begins with the negotiation
process between the scheduler and the patient. The following are recommendations for
scheduling supervisors to be in compliance with the VHA Outpatient Scheduling
Processes and Procedures.

10. Conducting Scheduler DD audits

Facility External Demand Monitoring/Tracking Accurate Desired Date
Review each schedulers understanding of the desired date with a review of the
scheduling directive.
o
2010 Scheduling
Directive.pdf

o Scheduler Training on TMS:
https://www.tms.va.gov/plateau/user/login.jsp
Listen in on a sample of phone calls between the patient and scheduler to
confirm the desired date is accurately entered.
o This method may be easier if your facility has a call center where a
supervisor can not only listen in but has the potential to record.
Direct Observation Stand at the desk or check-out window to physically
observe scheduler interaction with patient on desired date.
Secret Shopper: This can be someone who works in another section or it can be
a patient
o Contacting the Veteran as a customer service call
Review the charts for documentation.
o Interaction with the schedulers is important as well but if not possible, the
charts will provide some information in the documentation.

ELECTRONIC WAIT LIST (EWL) - FREQUENTLY ASKED QUESTIONS

1

Electronic Wait List (EWL) Frequently Asked Questions
The primary way we function in healthcare is through healing relationships between providers
and patients. These relationships are carried out through many face-to-face and non-face-to-
face venues between patients and healthcare providers and their team members. The
scheduling systems function is to order or match the requests for care with the resources
available to deliver the care. This is done practically by making appointments in the desired
face-to-face or non-face-to-face venue into the future. Appointment requests are either for
new patients (that a particular provider or clinic has not seen the patient in the past 24
months), or for established patients with whom the provider has a relationship.
What is the Electronic Wait List?
The Electronic Wait List (EWL) is the official VHA wait list. The EWL is used to keep track of
patients waiting to be scheduled, or awaiting a panel assignment. The EWL is used to keep
track of patients with whom the clinic does not have an established relationship (e.g., the
patient has not been seen before in the clinic). The official EWL report is located on the VSSC at
the following link: http://vssc.med.va.gov/WaitTime/EWL_List.asp This report is currently
updated twice monthly (on the 1
st
and 15
th
), but will soon be updated daily. The EWL report
can also be extracted from the VistA system under the appointment menu option: [SD WAIT
LIST MENU] and updates on a daily basis.
Data Dimensions:
The information in the EWL report helps VISNs and Medical Centers view the data in detail as
they monitor and analyze their facilitys EWL. The VSSC EWL report displays the following
parameters:
Clinic: Displays one row for each of the Performance Clinic Groups selected.
Patients Waiting =< 30 Days on the EWL displays the count of patients waiting less
than or equal to 30 days for the Performance Clinic Groups selected.
Patients Waiting > 30 Days on the EWL displays the count of patients waiting more
than 30 days on the EWL for the Performance Clinic Groups selected.
Total Patients Waiting on EWL displays the count of patients on the EWL. This total is
the sum of Patients Waiting =< 30 Days on EWL + Patients Waiting > 30 Days on the
EWL.
The Detail Report provides a drill down to the SSN level along with several dates such as
desired date and number of days on the EWL.


15
ELECTRONIC WAIT LIST (EWL) - FREQUENTLY ASKED QUESTIONS

2

Why change the EWL process?
VHA has used an Electronic Wait List (EWL) for many years as a way to help manage requests
for care. Before 2008, there were many specific rules governing both when to schedule a
patient (vs. enter them on a EWL) and the order of addition to, and removal from, the list.
These rules ultimately proved overly restrictive. With publication of a new scheduling policy in
2009, and later VHA policy 2010-027, the EWL guidance became more flexible. While this
current approach is better, two problems have emerged: 1) Clinics vary in when patients are
offered an appointment vs. a waiting list. (For example, some clinics offer patients
appointments up to 90 days into the future before putting them on a EWL and other clinics 6
months.) 2) Despite the fact that the EWL is intended for new patients (except for a transfer
list) and the recall system for established patients, some clinics use the EWL for both new and
established patients. These problems have limited the ability of some clinics to manage
timeliness along with VHAs ability to effectively understand delays and deploy resources.
What are the changes to the EWL process implemented about October, 2012?
Only NEW patients will be placed on an Electronic Waiting List (EWL). New patients are defined
as those who have not been seen in the corresponding stop code for the past 24 months. (An
exception is allowed when a patient is established in a stop code, but is being seen for a new
problem in that stop code less than 24 months from their last contact.)
a. New patients who request an appointment anytime within the next 90 days, but
cannot be scheduled due to unavailable clinic capacity, will be placed on the EWL.
b. Transfer requests will continue to use the EWL software. Transfer requests,
however, must be contained on a list that starts with the word Transfer and is
assigned the administrative stop code 674.
How are wait times calculated when a new patient is scheduled from the EWL?
The time spent on the Electronic Wait list is calculated into the wait times when a patient is
removed and scheduled for an appointment. For example, if a patient spent 31 days on the
EWL and is then scheduled into the clinic within 14 days, the wait time for this patient is the
total days spent on the EWL + the wait time days for the clinic appointment. The total wait
time for this patient is 45 days.
Is there ever a situation where established patients can be placed on the EWL?
There are two occasions when an establish patient is placed on the EWL:
Transfer requests. An established patient can be placed on the EWL using the non-
count clinic stop code (674) while maintaining a scheduled appointment at the parent
ELECTRONIC WAIT LIST (EWL) - FREQUENTLY ASKED QUESTIONS

3

facility. Primary Care patients who are assigned to a provider at the parent facility but
have requested assignment at a Community Based Outpatient Clinic (CBOC) once the
Primary Care providers have capacity in their panel size to accept patients. Once the
patient is transferred to the CBOC, he/she is removed from the EWL and from the
providers panel at the parent facility.
If a patient has been seen in a specialty care clinic within the past 2 years but has a new
problem, a consult will be written as a new consult but the patient will be established.
This is a great opportunity for communication between the PC/ED and SC. The specialty
provider will determine if the patient needs to be seen as a new patient or as a follow-
up to his last appointment.
Regardless of which of the two scenarios, there must be a 7 day turn-around to
schedule or wait list the patient.
After receiving the initial request for a new patient appointment, when can the patient be
placed on the electronic wait list if the clinic has no access?
All appointment requests must be acted upon within 7 business days. Acting on a request
means the patient is either scheduled a future appointment or placed on the EWL. If a clinic is
experiencing backlog, loss of a provider, etc and the decision has been made to wait list new
patients, it is important that key stakeholders (clinic staff, requesting providers, schedulers,
customer service, etc) are aware of the EWL and EWL status is communicated to the patient.
Any new appointment requests held beyond 7 days is considered a paper wait list.
What constitutes a paper wait list?
A paper wait list can take on many forms and can be detrimental to the efficiency and flow of
patients through a clinic. Any patient/providers request for an appointment that is not
dispositioned within 7 days of receipt is considered a paper wait list. Any form of tracking
patients awaiting an appointment other than the official Electronic Wait List is considered a
paper wait list. Examples of paper wait lists would include but are not limited to the following:
Word Documents
EXCEL Spreadsheets
Record Books, Notebooks or Logs
Sticky notes
Holding Consults
Printing consults for review and processing
ELECTRONIC WAIT LIST (EWL) - FREQUENTLY ASKED QUESTIONS

4

When attempting to schedule a follow-up appointment for established patient in VistA and
the clinic does not have capacity within 120 days of the desired date, a prompt to place the
patient on the EWL appears on the screen.
The EWL prompt for established patients should immediately throw up red flags to the
scheduler since established patients must not be placed on the EWL. If a provider wants a
patient back in 3 months and there is no capacity in the clinic, the immediate reaction is to
communicate the backlog to the provider who must then make a clinical decision to either
overbook the patient, schedule the patient for a nurse visit, adjust the return to clinic orders,
etc The disposition of the appointment should then be communicated to the patient.
What steps can be taken for a provider who does not have capacity to schedule follow-up
visits timely?
Any provider with access issues where there is no capacity for 3 4 months, should consider a
Systems Redesign Deep Dive team to get to the root of the problem. Some preliminary
questions to ask might be:
How long has the clinic been without capacity?
o Isolate the issue by going back to when the clinic had normal workload and up
until the clinic overbooks increased.
Is the providers clinic profile set up accurate and mirrors DSS Labor Mapping?
o Request a copy of the DSS Labor Mapping to verify the hours mapped to a
certain clinic/stop code
Are all patients returned in a certain time-frame?
o Provider can go back and review records to determine if some of the healthier
patients can have an extended return time or telephone visit.
Are the clinic types reduced to combine like services/stop codes?
Reducing clinic types, can allow for additional capacity, flexibility and ease of scheduling

Where are resources available to make these changes?
The best place to start is this virtual Access Education Series. This is a short course in
improving Access, which every clinic must consider in order to manage waiting times.
How to See: (EES-021 Access Education 11853 - Access How to See)
http://vaww.vakncdn.lrn.va.gov/cl_popup.asp?mode=popup&Media_ID=4832&M_Cat_ID=113
How to Do:
http://vaww.vakncdn.lrn.va.gov/cl_popup.asp?mode=popup&Media_ID=4972&M_Cat_ID=98
Access FOR an Appointment: (EES-021 Access Education 11856)
ELECTRONIC WAIT LIST (EWL) - FREQUENTLY ASKED QUESTIONS

5

http://vaww.vakncdn.lrn.va.gov/cl_popup.asp?mode=popup&Media_ID=4833&M_Cat_ID=113
Access AT an Appointment: (EES-021 Access Education 11854)
http://vaww.vakncdn.lrn.va.gov/cl_popup.asp?mode=popup&Media_ID=4834&M_Cat_ID=113
Access BETWEEN Appointments: (EES-021 Access Education 11855)
http://vaww.vakncdn.lrn.va.gov/cl_popup.asp?mode=popup&Media_ID=4835&M_Cat_ID=113

Systems Redesign Resource Documents: This web site has thousands of documents,
examples of strong practices, care coordination agreements, and tools. It is searchable.
https://srd.vssc.med.va.gov/Pages/default.aspx
NIRMO Website: Missed Opportunity. This site provides resources aimed at improving
the no-show (missed opportunity) performance.
https://vaww.visn4.portal.va.gov/pittsburgh/home/verc/Missed%20Opportunities/default.aspx
In what order are patients removed from the EWL?
Except for medical emergencies or urgent medical needs, Veterans are removed in this order:
Service Connected (SC) 50% and greater, Veterans less than 50% SC requiring care for a SC
disability, followed by first on first off.
Caution: Schedulers must not ignore the existence of the EWL when scheduling new patients.
In other words, schedulers must consider both the waiting time (the schedule) and the waiting
list (the EWL) when scheduling new patients. This will ensure the patients who have been
waiting the longest will have first choice at appointment slot.
What about patients who cancel and reschedule same day new appointment slots?
In this case, the scheduler can do one of two things:
Check the demographics of the patients on the EWL and highlight those who are local
and/or requested an earlier appointment if one came available. This would be a short-
list for quick turn-around.
If the new patient appointment slot occurs just prior to the appointment time and is too
late to contact local patients , check with the major requesting services such as the ED,
Primary Care, Specialty Care, etc for new consult requests. Chances are, the patient
may still be in the facility and can be offered a same day appointment.
ELECTRONIC WAIT LIST (EWL) - FREQUENTLY ASKED QUESTIONS

6

What about patient who were on the EWL, is removed from the EWL and scheduled. The
patient then cancels his appointment for whatever reason and is placed back on EWL. How is
wait time calculated?
If the clinic cancels and the patient is placed back on the EWL (which should never happen) the
wait time would be the date that they were placed on the EWL the first time. Providers should
make efforts to see the patients prior to or shortly after the scheduled appointment date. If a
patient cancels, the wait time is starts over again.
Who manages the Electronic Wait List?
Overall management of the EWL may vary throughout the VISNs. What remains static is the
role a scheduler or designee has when a clinic with an EWL has open capacity to schedule wait
list patients. Scheduler or designee on a daily basis should:
Review the clinic schedules first thing in the morning, mid-day and end of day to identify
capacity from a cancelled or rescheduled appointment.
Run the EWL list for clinic using the VSSC or VistA report. The VistA report will be
beneficial as it updates on a day to day basis.
Contact patients on the EWL to offer the open appointment slots. Do not schedule the
patient prior to contacting.
If a new patient appointment slot opens suddenly and there is no time to contact
patients from the list, pull the consult tracking report to see if a consult was submitted
today.
Communicate your plan with the specialist to obtain approval to schedule the patient
for a same day consult.
Contact the requesting clinic to see if the patient is still in the waiting area and have
them send the patient to the clinic.

To assist you in response to specific query only
not to be distributed as an external document

Department of Veterans Affairs

Electronic Wait List (EWL) Questions & Answers

To assist you in response to specific query only
not to be distributed as an external document

May 2014


Q: What is the Electronic Wait List?
A: The Electronic Wait List (EWL) is the official VHA wait list, which is a list of patients
waiting for an appointment or assignment to a primary care provider or team. It is used
to keep track of new patients who have requested care, but cannot be scheduled within
90 days. The EWL is maintained on the VA computer system for use by staff.

Q: How does the EWL Process work?
A: Electronic Wait List (EWL) is the official Veterans Health Administration (VHA) wait
list. The EWL is used to list patients waiting to be scheduled, or waiting to be assigned
to a primary care provider or team. In general, the EWL is used to keep track of new
patients (those who have not been seen before in the specific clinic in the previous 24
months) for whom appointments cannot be scheduled in 90 days or less.

The EWL assists Department of Veterans Affairs (VA) Medical Centers and clinics in
managing Veterans access to outpatient health care. When a new patient requests
care, every attempt is made to give the patient an appointment within 30 days of their
desired date. If a patient cannot be scheduled for an appointment in the next 90 days,
they are listed on the EWL.

The EWL allows patient appointments to be made as soon as clinic access becomes
available. This approach reduces appointment no-shows and cancellations. The EWL
allows managers to see areas of increased appointment demand and make decisions
about how best to accommodate the patients needs, including when to purchase care
outside VA.

Q: How many wait lists does VHA maintain at each VA Medical Center?
A: The EWL is the VHA appointment wait list. Appointment requests can be placed on
the EWL through channels such as the telephone or face-to-face interactions.
Appointment requests are also made by way of electronic consults or the New Enrollee
Appointment Requests (NEAR), which communicates requests for appointments from
patients who are new to VA care. All of these requests are met either by making an
appointment or entering the patient into the EWL.



16

To assist you in response to specific query only
not to be distributed as an external document


Q: Is there a secret wait list being maintained at each VA Medical Center?
A: VA does not maintain secret waiting lists the EWL is VAs official wait list. The
Privacy Act of 1974, 5 U.S.C. 552a, requires that federal agencies maintaining
information retrievable by the individuals name, social security number or other unique
identifier publish in the Federal Register notice concerning the system of records in
which the information is maintained. The EWL is a part of the VHA system of records
identified as Veterans Health Information Systems and Technology Architecture (VistA)
Records-VA (79VA10P2). The purpose of the EWL is to provide a transparent list of
patients who cannot be scheduled for an appointment within 90 days and are waiting for
an appointment. This computerized list is managed, tracked, and reported at multiple
levels in VA.

Q: What are the changes to the EWL process implemented in March, 2013?
A: The EWL has been in use by VA since 2001. In the past, some facilities listed both
new and established patients on the EWL. In an effort to remedy this inconsistency,
VHA issued a clear policy statement in March, 2013 that only new patients should be
placed on the EWL. With minor exceptions, new patients are defined as those who
have not been seen in the clinic for which the appointment is requested for the past 24
months. VHA endeavors to schedule new patients within 30 days of their desired date.
However, when this cannot be accomplished due to clinic capacity, and the patient
cannot be accommodated within the 90 days, the facility is required to place that
individual on the EWL.

Q: How are wait times calculated when a new patient is scheduled from the EWL?
A: VHA tracks both EWL and appointment wait times for new patients with scheduled
appointments. EWL wait time is tracked from the time a patient is placed on the EWL
until the time that patient is removed from the EWL. Appointment wait times are tracked
from the time a patient is scheduled for an appointment until the appointment is
completed. A new patients total wait time for an appointment is calculated by adding
the wait time on the EWL and appointment systems. For example, if a patient spent 31
days on the EWL, and is then scheduled for an appointment 14 days later, the total wait
time for this patient is the total days spent on the EWL (31 days) + the wait time days for
the clinic appointment (14 days) for a total of 45 days.

Q: Is there ever a situation where established patients can be placed on the EWL?
A: Yes, it does happen on occasion. Any patient who has not been seen in the specific
clinic (or specialty) they are requesting for the past 24 months is considered new.
Patients are seen in specialty for follow up visits until their problem is resolved and they
return to Primary Care. If a patient develops a new problem requiring return to the
specialist, they may be placed on the EWL even though they have been seen in the
past.

Q: After receiving the initial request for a new patient appointment, when can the
patient be placed on the electronic wait list if the clinic has no access?

To assist you in response to specific query only
not to be distributed as an external document

A: If the clinic has no appointments available, the appointment request can be placed on
the EWL immediately.

Q: What constitutes a paper wait list?
A: The EWL is the VHA appointment wait list. No other wait list formats (paper,
electronic spreadsheets) are to be used for tracking requests for outpatient
appointments.

Q: What steps can be taken for a provider who does not have capacity to
schedule follow-up visits timely?
A: Facility managers must evaluate the reason for any lack of capacity, take appropriate
steps to identify the source of such and resolve the problem.

Q: In what order are patients removed from the EWL and scheduled for
appointments?
A: Except for medical emergencies or urgent medical needs, Veterans are removed in
this order: Service Connected (SC) 50% and greater, Veterans less than 50% SC
requiring care for a SC disability, followed by first on first off.

Q: How are patients who cancel and reschedule appointments the same day
handled?
A: Patients who cancel appointments are offered future available appointment slots.

Q: The patient then cancels his appointment for whatever reason and is placed
back on EWL. How is wait time calculated?
A: If the patient cancels his appointment, then the wait time is calculated from the date
of the new request following cancellation. However, if the clinic cancels an appointment
the wait time is calculated using the date the patient was initially placed on the EWL.

Q: Who manages the Electronic Wait List?
A: The EWL is managed by clinic managers and scheduling staff.

Q: Where are resources available to employees and managers responsible for
scheduling patient appointments?
A: VHAs Employee Education System provides online courses to VHA staff to assist in
learning how to schedule appointments in VHAs scheduling system. Mandatory
training, and successful completion, is required of all employees who have responsibility
for scheduling patients as well employees who supervise those individuals.

Using the Recall Reminder System
RECALL / REMINDER
1
G.V. (Sonny) Montgomery VA Medical Center
1500 E. Woodrow Wilson Drive
J ackson, MS 39211
601-362-4471
17
Recall Reminder - What is the Purpose?
2
Statistics show that the VA has a great number of No Shows when appointments are
scheduled so far in advance.

The Recall Reminder software:
is designed to allow facilities to implement recall scheduling.
This will help clinics to efficiently track and schedule Veterans who need appointments to
be scheduled beyond 90 days.

The primary desired outcome of the software implementation is:
a reduction of appointment No Shows.

Recall Reminder How Does it Work?
3
The Recall Reminder (RR) software creates a holding area for Veterans who will need to
return to a clinic in the future. This time period has been determined to be a visit greater
than 3-4 months (90-120 days) in the future.

At the discretion of the provider or Veteran, individual Veterans may be scheduled further into
the future.





Veterans are entered into RR with a specified desired date for the appointment to be
created a desired date specified by Veteran and a desired date specified by the provider.

Veterans are notified by a letter generated from the site of their need to call to
schedule an appointment.

Recall Reminder How Does it Work?
4
RR parameters are set by each site to specify the number of days prior to the recall
date the notification letters should be printed.




The letters will provide instructions for the Veteran on how to contact the
facility/clinic to schedule an appointment. An appointment is not made in VistA
Scheduling system until the Veteran makes the appropriate contact, as per the
instructions provided in the letter.

If the Veteran does not contact the facility, the facility must follow local policy
that outlines actions to be taken to make contact, the number of attempts
necessary and documentation required.

Recall Reminder Example
5
Veteran A is seen by the VA doctor his/her primary care physician on August 18,
2012. The clinician states Veteran A is to return to be seen by the Primary Care
Provider in about 6 months (180 days).



The Veteran will be reminded when the provider advised he/she should be seen again,
and then allowed to specify his/her desired date for an appointment.

Because the appointment is greater than 90 days out, the scheduler enters Veteran A into
the RR system, and does NOT make an appointment at this time unless the physician
advises to do so.

A Notification Letter will be sent to Veteran A on January 18, 2013 -- one month ahead
of the clinicians request for Veteran A to be seen again by his/her Primary Care
Provider.

Recall Reminder Example
6
Upon receipt of the Notification Letter, Veteran A contacts the individual/clinic
specified in the letter to schedule an appointment.

The Veteran will be reminded of when the provider advised he/she should be seen again,
and then allowed to specify his/her desired date for an appointment.

The scheduler will consult with the provider if the Veterans specified desired date differs
significantly from instructions given originally by the provider.

Unless the provider objects, the scheduler will offer an appointment on or as close
as possible to the desired date specified by the Veteran.
Recall Reminder Software
7
The primary way to access the Recall Reminder action item is in the PCE Veteran
Encounter Data (PCE) screen by entering RR at the prompt.










The other option to access the RR action item is through the ADD/EDIT CLINIC RECALL VETERAN [SDRR CARD
ADD] option. This option allows a user to enter or edit a Veteran into the RR file without using PCE.

Recall Reminder Main Menu Options
8
What are the Recall Reminder Main Menu Options?

1. DELETE/CANCEL CLINIC RECALL ENTRY - Allows a user to change the status of a clinic recall.
2. ADD/EDIT CLINIC RECALL PATIENT - Allows a user to enter or edit a Veteran into the RR file (#403.5)
without using PCE.
3. RECALL LIST DELINQUENCES - Provides a report on the number of days each Veteran is delinquent. The
user is asked for the recall date range, a set of clinics, and whether the report should break on clinic. It
includes Veterans who have been sent recall reminders but have not called to schedule an appointment.
4. RECALL LIST DELETIONS - Provides a report on the Veterans who were deleted from the Recall List by a
clerk.
5. SCHEDULED RECALL APPOINTMENTS - Lists Veteran appointments which caused Veterans to drop off the
recall list.
6. RECALL LIST W/AVAILABLE SLOTS - Essentially the same report as that produced by the Recall List Print,
except it also reports on slot availability by month for each clinic. User is asked for a date range, a set of
clinics, and whether the report should page break on clinic.
7. RECALL LIST PRINT - Allows users to print clinic recalls by division, clinic or outpatient clinic recall teams. It
will ask for a date range and must be queued to printers.
8. RECALL PATIENT INQUIRY - Allows users to select a range or a full Veteran inquiry.


Recall Reminder Add/Edit Clinic Recall Patient
9
How do you add a Veteran to the Recall Reminder List?









The criteria to add a Veteran to the Recall Reminder List is when the provider requests an
appointment beyond 3 months.
To add a Veteran to the Recall Reminder List - Select #2 ADD/EDIT CLINIC RECALL PATIENT
this option allows a user to enter/edit a Veteran into RR file without using PCE.
Recall Reminder Add/Edit Clinic Recall Patient
10
After selecting the command to add a Veteran, this screen will display. Only enter
Yes at the Do you have this information prompt when you have all of the
necessary information.


Recall Reminder Add/Edit Clinic Recall Patient
11
A definition of each field is as follows:

1. RECALL DATE Date the provider has requested the Veteran to return. All notifications for the Veteran will
be looking at recall date for this field.
2. RECALL DATE (PER PATIENT) Date the Veteran would like to return or be sent a notice to return.
3. PROVIDER Recall Reminder Provider EX: Name of the Provider is RECALLPROVIDER,ONE and is part
of the OD RED TEAM ACTIVE of the Red Team.
4. CLINIC Clinic at which the Veteran should be scheduled for their future appointment in PRIMARY CARE.
5. LENGTH OF APPOINTMENT The length needed for the appointment, i.e., 10 120 minutes.
6. TEST/APP. Different appointment types that display on the CPRS cover sheet and other reports for
informational purposes indicating the reason for the appointment. EX: This is a FOLLOW-UP
APPOINTMENT and is a facility defined field.
7. FAST/NON-FASTING Has the provider requested fasting or non-fasting lab to be done prior to the next
scheduled appointment at that clinic? There is no default for this category.
8. COMMENT Free text comments can be added when it comes time to schedule an appointment for the
Veteran. Once the scheduler has edited and/or added Veteran As name to Recall Reminder list, the
information is stored. The same fields may be accessed via the PCE screen.

Recall Reminder Delete/Cancel Clinic Recall Entry
12
The Delete/Cancel Clinic Recall Entry allows for the deletion or cancellation of active
Recall entries.
To delete or cancel an active Recall Entry, select #1 DELETE/CANCEL CLINIC
RECALL ENTRY

Recall Reminder Delete/Cancel Clinic Recall Entry
13
The Delete/Cancel Clinic Recall Entry screen:
At the first prompt, enter the Veterans name. Then select Recall
The scheduler is then asked to delete the clinic name associated with that Recall entry. This changes the
status, and moves the appointment to inactive. Users can see all of the inactive recalls and a record of who
changed the status.









Enter the number associated with the reason the Veteran was deleted/cancelled from the RR application.
EX: In this instance, 4 (doesnt want VA services), is selected. The associated comment in the Comment Field
states that this patient is receiving care from Outside Hospital. The comments may be added by the Clerk.




Recall Reminder Generating Reports
14
Recall Reminder allows for the generation of several different reports.
Each report has its own purpose and provides invaluable information as to the status of appointments
and scheduling.


Recall Reminder Recall List Delinquencies
15
Recall List Delinquencies
Besides adding a name to the RR List, schedulers will also need to display delinquent Recall entries.
These are Veterans who have been sent a letter, but have not called the VA to schedule an appointment. If the Veteran
has not responded, the scheduler needs to follow local policy that outlines actions to be taken to make contact, the number of
attempts necessary, and documentation required.









EX: This report generates two lists for both the Allergy Clinic and the Anesthesia Clinic.
The Report displays the Veteran name, last four digits of the SSN, home phone, work phone, recall date, and the date the
notice was sent.
An asterik (*) in front of the reminder sent date indicates the Veteran has been sent two notices and has not yet
scheduled an appointment.

Recall Reminder Recall List Delinquencies
16
How to run a Recall List Delinquencies List:










Access #3 Recall List Delinquencies from the RR Menu.

Recall Reminder Recall List Delinquencies
17
Select a time period and a set of clinics to list all of the patients who are on the Recall List for
that time period at particular clinics who have been sent reminders, but havent yet made an
appointment.
EX: This screen shows the list between November 15, 2007 to November 14, 2008.









The November 14, 2008 date is listed because the default date is a day prior to the date the report is run.
Pressing return at the Select Medical Center Division will display all the Medical Center Divisions to
select the clinics.

Recall Reminder Recall List Delinquencies
18
Select R for a Range of Clinics, I for an Individual Clinic, and S for Clinic Stop Codes.
EX: In choosing I, were selecting the Allergy Clinic.
RECALLPROVIDER,ONE is the attending provider for the Clinic.
At times in selecting a clinic, a wildcard may be utilized to list clinics that start or end with the same
letter. For instance, TRI* displays ALL clinics starting with TRI.
The default when choosing I for individual clinic is ALL. But in this example, the scheduler enters Allergy
for the Allergy Clinic. After hitting return, the scheduler enters Anesthesia for the Anesthesia Clinic.
After he/she defaults YES to the page break by clinic, the scheduler is ready to display the results.
Recall Reminder Deletion Reports
19
This report provides a list of all Veterans who were deleted from Recall Reminder
but have not made an appointment.
Recall List Deletions can include those who have received care at another VA, are deceased,
have failed to respond or moved. Remember, it is required that the clinic attempt to contact
Veterans who have not scheduled an appointment.

Select Option #4 RECALL LIST DELETIONS from the Recall Reminder Menu.

Recall Reminder Deletion Reports
20
EX: - Deletion Report









This Report shows one Veteran (RECALLPATIENT,ONE 0000) who failed to respond (FTR) for the Primary
Care Appointment after several attempts were made to contact this person.
RECALLPATIENT,ONE was deleted from Recall Reminder.

Recall Reminder Deletion Reports
21
To generate a Recall Reminder Deletion Report:
Enter the start and end dates for the time period requested. In this example, its February 2, 2007 to
August 13, 2009.
Select R for Range of Clinics, I for Individual Clinic, and S for Clinic Stop Codes.
In choosing I, were selecting the primary care clinic. RECALLPROVIDER,ONE is the attending provider
for the clinic. This will be the only clinic, and we will not add or remove the clinic at the next prompt,
Another one (Select/De-Select <RET>
EX: - this report indicates one Veteran who was deleted from the Recall Reminder List from the Primary
Care clinic. The Veteran was sent three reminders: 4/14/08. The recall date was 5/5/08, and the
recall date was deleted on 5/6/08.
The report shares the Veteran name, the last four digits of the SSN (0000), dates and was deleted by
RECALLCLERK,ONE FTR (Failure to Respond.)
A clinic cannot remove a Veteran from the Recall List without making efforts to contact the Veteran.
If the Clinic is unable to contact the Veteran after multiple attempts, this must be documented in the
Veterans medical record.


Recall Reminder Schedule Appointments
22
Recall Reminder Working the Way Its Supposed to Work!
The Schedule Recall Appointments Report generates a list of Veterans who have been
removed from the Recall List because they received their recall reminder, and have contacted the
VA to schedule an appointment.
Select #5 Scheduled Recall Appointments Menu.


Recall Reminder Schedule Appointments
23
After selecting Option #5, Schedule Recall Appointments, then:
Select a date range this will produce a list of names requested. The default times are predetermined
in the Recall Reminder Removed file. In the example below, this will be the only clinic, and we will not
add or remove the clinic at the next prompt, Another one (Select/De-Select: <RET>.









If the default dates in this example are 02/02/07 07/23/09.
Select R Range of Clinics, I for an Individual Clinic, and S for Clinic Stop Codes. In choosing I, were
selecting the PRIMARY CARE clinic. RECALLPROVIDER,TWO is the attending provider for the clinic. This
will be the only clinic, and we will not add/remove the clinic at the Another one (Select/De-Select:)
<RET>.

Recall Reminder Schedule Appointments
24
EX: Schedule Appointments Report
The results show that RECALLPATIENT,One
(last of SSN are 0000, was sent a
reminder on 4/29/08.
RECALLPATIENT,ONE called on 6/11/08.
The appointment was set for 6/18/08,
and an EEG is required in the Neurology
clinic, as noted in the comment section.
The Days Diff indicates the number of
days between the Recall Date and the
appointment. In this case, it was 7 days (or
6/11/08 6/18/08).
Note: the recall date of 6/11/08 and the
date the appointment was made happens
to be the same day.

Recall Reminder Available Slots Report
25
Recall List with Available Slots Report
Select #6 RECALL LIST W/AVAILABLE SLOTS.
This report is done monthly. It is essentially the same report as the Recall List Print except that it
also reports on slot availability by month for each clinic.

Recall Reminder Available Slots Report
26
The next steps in running the Available Slots Report are:
Enter the start and end dates for the time period requested. In this instance, it is 11/01/08
01/31/09.
Select R Range of Clinics, I for an Individual Clinic, and S for Clinic Stop Codes. In choosing I, were
selecting the Adult Day Health Care Clinic. This will be the only clinic, and we will not add/remove the
clinic at the next prompt (Select/De-Select:) <RET>.

Recall Reminder Available Slots Report
27
The Report indicates:
There are 76 available appointments for these two Veterans for the Adult Day Health Care
Clinic (RECALLPATIENT,ONE and RECALLPATIENT,TWO and may be scheduled.
The slots are available 11/15/08 through EOM (End of Month).
The scheduler must ask for the desired dates for their appointments, and enter these dates.
Only after the Veterans desired date is obtained and documented can the scheduler offer a choice
of available appointments on or as close as possible to desired date specified by the Veteran.

Recall Reminder Recall List Print
28
Recall List Print option displays Veterans who are in Recall Reminder that have
not scheduled an appointment.
All or specific teams may be selected by choosing the Selected Teams option.
Select #7 RECALL LIST PRINT this menu allows users to print clinic recalls by division, clinic or out-
Veteran clinic recall teams. It will ask for a date range and must be queued to a printer(s).
Choosing ALL CLINICS will list all the clinics and associated Veterans alphabetized by clinic name.
SELECTED CLINICS by selecting up to 20 individual clinic names.
SELECT TEAM selecting one or all Recall Teams.


Recall Reminder Recall List Print
29
The results of the Recall List Print in this example are:
The user enters the start and stop dates. For this example, it is 11/14/08 through 11/24/08.
This will generate the report.
To print the report, it must be directed to a 132 column printer.
Only after the Veterans desired date is obtained and documented can the scheduler offer choice of
available appointments on or as close as possible to desired date specified by the Veteran.
Recall Reminder Recall Patient Inquiry
30
Recall Patient Inquiry allows sites to either view or print all Recall Reminders or a
date range of entries for a Veteran.
Select #8 RECALL PATIENT INQUIRY from the menu.
This option allows users to print clinic recalls by division, clinic or outpatient clinic recall teams. It will
ask for a date range, and must be queued to printers.

Recall Reminder Recall Patient Inquiry
31
To create this report which lists Veteran appointments which caused the Veterans to
drop off the recall list:
Enter the Veteran name at the Select PATIENT NAME: prompt.
Select a Range of Recall Dates or All Recall Dates for this Veteran. The default is ALL.
Do you want to print the profile? If YES, the report will go to the printer. If NO, the report will
go to the screen. The default is NO.

Recall Reminder Recall Patient Inquiry
32
What does the Recall Patient Inquiry Report look like?
EX: The report indicates all recall information for Veteran RECALLPATIENT,ONE, born MAR 31, 1942 and
whose last four digits of the SSN are 0000.
The Report displays active recall first: The 60-minute Follow-Up appointment, requiring a fast by
RECALLPROVIDER,ONE in the TRI-CITIES NUTRITION GROUP, has not been deleted or made. The recall
date is MAR 14, 2008 and the reminder was sent NOV 14, 2008 (perhaps the reminder was sent to far
in advance, especially for a fast.)
RECALLPATIENT,ONE has inactive reminders, which were deleted or were scheduled appointments.


Recall Reminder DO TIPS
DO Enter the Recall Reminder into the system when you have ALL the
information.

DO Enter CORRECT information into the system i.e. Clinic, Provider, Recall
Date.

DO Run the Recall List Delinquencies list to monitor your reminders. This
report provides the number of days each patient is delinquent. It includes
patients who have been sent recall reminders but have not called to
schedule an appointment.


33

Recall Reminder DONT TIPS
34
DO NOT edit a PAST Recall Reminder. Instead of editing the reminder, Delete (if
appropriate) and enter a new one.

DO NOT exit out of the system in the middle of doing a Recall Reminder. Instead of
exiting out of the system, continue then go back and correct or delete.

DO NOT enter a clinic that is not on the Recall Reminder system i.e., new pt clinics,
nursing, etc. Instead ensure the provider has entered the Reminder under the clinic in
which he/she would like the Veteran to return.
DO YOU HAVE ANY QUESTIONS?
If you any questions, please contact:
Cathedral Woodruff
Recall Reminder Coordinator
(601) 362-4471 ext. 5730

35
EDITING A PAST RECALL REMINDER

36


CHOOSING THE WRONG CLINIC LOCATION
THERE IS NO RECALL REMINDER FOR A LAB CLINIC

37
CHOOSING THE WRONG DATE FOR THE RECALL REMINDER
38
EXITING OUT OF RECALL REMINDER (CLOSING VISTA)

39
CHOOSING TWO DIFFERENT RR DATES
40