Opportunities Exist for Improving Veterans' Access to Health Care Services in the Pacific Islands
From General Accounting Office, GAO-18-288: Published: Apr 12, 2018
For the sample of veterans' medical records that GAO reviewed, most veterans received primary and mental health care from the Department of Veterans Affairs (VA) Pacific Islands Health Care System (VAPIHCS) within timeliness goals set by VA's Veterans Health Administration (VHA). However, GAO also found that some of these veterans experienced delays related to the processing of their enrollment applications, contacting them to schedule appointments, and completing comprehensive mental health evaluations. These delays were similar to some GAO had identified in previous work pertaining to veterans' access to care nationwide.
For the sample of veterans' medical records that GAO reviewed, VAPIHCS referred nearly all specialty care to non-VA providers within VHA's timeliness goal, but the time taken to provide care was variable and sometimes lengthy. Specifically, VAPIHCS sent specialty care referrals to
- the Veterans Choice Program (Choice Program)—for veterans that GAO reviewed, the number of days to receive care from the Choice Program was, on average, 75 days.
- Department of Defense (DOD) military treatment facilities—for veterans that GAO reviewed, the number of days to receive care from the two DOD facilities for which VAPIHCS has agreements was, on average, 37 days from one facility and 47 days from the other.
GAO identified weaknesses in VAPIHCS' management of its referral process for sending veterans for specialty care services at one of the two military treatment facilities. GAO found VAPIHCS did not always manage referrals to the military treatment facility in a timely way and there was inconsistent guidance describing the roles and responsibilities of the VAPIHCS staff involved in the process. These weaknesses may have contributed to the amount of time it took for veterans to receive specialty care services.
GAO also found that VAPIHCS faces challenges recruiting and retaining physicians. As of October 2017, 17 of approximately 100 VAPIHCS physician positions were vacant, as were several other types of health care providers. Some of the challenges VAPIHCS faced are unique to the Pacific Islands, such as the availability of only one local medical school from which to recruit, along with travel burdens and a high cost of living that may discourage physicians from relocating there. Other challenges were similar to those GAO has previously identified as faced by VA medical centers across the country, such as differences in interpretation of hiring and recruiting policies. VAPIHCS officials said they use several strategies to help recruit and retain physicians, including VHA strategies used by other VA medical centers such as financial incentives and an educational debt reduction program. Although they described limits to the success of some of these strategies, they have not evaluated their effectiveness. Without completing an evaluation of its strategies, VAPIHCS may not be optimizing its resources to improve its hiring efforts and may continue to struggle with physician shortages.
Why GAO Did This Study
Veterans' access to timely health care at VA medical facilities has been a long-standing problem identified by GAO and VA's Office of Inspector General. The remote nature of the Pacific Islands creates some unique challenges for VAPIHCS, which may affect its ability to provide the approximately 50,000 veterans it serves in American Samoa, Guam, Hawaii, and the Commonwealth of the Northern Mariana Islands with timely access to primary, mental health, and specialty care.
House Report 114–497 included a provision for GAO to review VHA's efforts to provide timely access to health care within VAPIHCS. Among other things, this report examines: the extent to which the VAPIHCS veterans received (1) timely primary and mental health care, and (2) timely specialty care; and (3) any challenges VAPIHCS faced in recruiting and retaining physicians, and strategies to resolve them. GAO reviewed relevant policy documents and a randomly selected, non-generalizable sample of 164 medical records, and interviewed VHA, VAPIHCS, and DOD officials.
What GAO Recommends
GAO makes four recommendations, including that VAPIHCS improve monitoring of referrals to one DOD facility and evaluate the effectiveness of physician recruitment and retention strategies. VA concurred with three recommendations and partially concurred with the fourth. GAO maintains that monitoring referrals to the DOD facility is needed, as discussed in the report.
PDF: Full Report 67 pgs
Guam: Staff shortage, distance bog down care for veterans
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Improving Access to Health Care Services in the Pacific Islands
News Release from Veterans Affairs Health Care System (VAPIHCS) April 13, 2018
HONOLULU — In response to a report released by the Government Accountability Office’s (GAO), “Improving Access to Health Care Services in the Pacific Islands,” the Veterans Affairs Health Care System (VAPIHCS) released the following statement:
The GAO study found that due to the remote nature of the Pacific Islands creates some unique challenges for VAPIHCS, which may affect its ability to provide the approximately 50,000 veterans it serves in American Samoa, Guam, Hawaii, and the Commonwealth of the Northern Mariana Islands with timely access to primary, mental health, and specialty care.
The report included a provision for GAO to review VHA’s efforts to provide timely access to health care within VAPIHCS. Among other things, this report examines: the extent to which the VAPIHCS Veterans received (1) timely primary and mental health care, and (2) timely specialty care; and (3) any challenges VAPIHCS faced in recruiting and retaining physicians, and strategies used to resolve them. GAO reviewed relevant policy documents, reviewed a randomly selected, non-generalizable sample of 164 medical records, and interviewed VHA, VAPIHCS, and DOD officials.
VAPIHCS appreciates the work of the Government Accountability Office (GAO). This report confirms that despite unique challenges, VA Pacific Islands Health Care System has made significant improvements to its processes and practices, as well as to levels and types of employees to increase access to care.
The report found that the majority of VAPIHCS patients reviewed, received primary care and mental health services within timeliness goals set by VA’s Veteran Health Administration (VHA). The report also identified some opportunities for improvement, and VA’s initial response to the findings are:
Recommendation 1. The Secretary of VA should ensure that VAPIHCS review its referral process for referrals to DOD providers, including referral cancellation, to determine why VHA policy is not being adhered to and make changes as needed
What’s being done: Veterans Affairs Pacific Island Health Care System (VAPIHCS) has reviewed its process to refer Veterans to DOD providers, and revised the procedure. Specifically, for Tripler Army Medical Center (TAMC) the procedure was changed for scheduling attempts. TAMC now schedules all Veterans that are referred to TAMC. If TAMC is unable to contact the Veteran within three days of receipt of the consult, the consult will be returned to VAPIHCS for further action. To remedy inconsistencies in consult management practices, VAPIHCS Care in the Community (CITC) staff underwent refresher training February 15, 2018. The training focused on appropriate reasons for cancelling consults, as well as which staff are authorized to cancel consults. Only registered nurses have the authority to cancel consults. Effective March 2018, the CITC Nurse Manager will conduct monthly audits of cancelled consults to ensure adherence. The audits will continue until VAPIHCS achieves a minimum of 90 percent adherence rate over three consecutive months.
Recommendation 2. The Secretary of VA should ensure that VAPIHCS clarify guidance to clearly define and document roles and responsibilities for VAPIHCS staff involved in the referral process with U.S. Naval Hospital Guam (NHG).
What’s being done: VAPIHCS has defined the roles and responsibilities for VAPIHCS staff involved in the referral process with U.S Naval Hospital Guam (NHG). VAPIHCS Care in the Community staff are operating under National Care Coordinator functional statements, which define their roles and responsibilities. VAPIHCS will develop a signed memorandum of understanding with NHG to clearly define the roles and responsibilities of all staff. These roles and these responsibilities will be added to the existing sharing agreement between VAPIHCS and NHG.
Recommendation 3. The Secretary of VA should ensure that VAPIHCS improves the monitoring of referrals and communication with Naval Hospital Guam (NHG) to ensure the timely management of referrals to NHG, including verifying the availability of services for Veterans; ensuring referrals are entered into NHG's electronic medical record system; and obtaining information about the status of scheduling appointments for veterans.
What’s being done: VAPIHCS agrees with improving the monitoring of referrals to U.S Naval Hospital Guam (NHG) by verifying the availability of services for Veterans and obtaining the status of scheduling appointments for Veterans. VAPIHCS is developing a standard operating procedure for referral notification, disposition, scheduling and completion, with monitoring of referrals weekly to resolve issues. VAPIHCS will collaborate with NHG to monitor the availability and status of services and appointments and follow-up on discrepancies.
VAPIHCS does not agree with ensuring referrals are entered into NHG's electronic medical record system. VA does not have any authority to monitor NHG's electronic medical record system and does not concur with this part of the recommendation.
As long as VAPIHCS staff continue to be responsible for entering referrals into NHG’s electronic medical record system, we believe that it will be our responsibility to monitor the status of these referrals, including ensuring that referrals are entered correctly and timely. VAPIHCS is currently working to develop a process to improve the monitoring of referrals to U.S Naval Hospital Guam (NHG).
Recommendation 4. The Secretary of VA should ensure that VAPIHCS evaluates the effectiveness of strategies it currently uses to promote physician recruitment and retention, including how the strategies could be improved. The plan should also include an assessment of whether additional strategies currently offered by VHA would be beneficial.
What’s being done: VAPIHCS is organizing a Systems Re-Design project that will bring together a multi-disciplinary group of staff and leadership to review our recruitment strategies, actions and outcomes. The facility will consult with VA Workforce Management to determine any further strategies that can be implemented. A lessons-learned approach from this process will be adopted, reviewing best practices and developing specific actions.
Additionally, exit interviews involving departing VA providers will be scheduled to assist with identifying targeted actions to improve retention.
VAPIHCS has already identified several best practices related to physician recruitment and retention by implementing a systems-redesign best practice to ensure sufficient recruitment and retention are in place. Additionally, exit interviews involving departing VA providers will be scheduled to assist with identifying targeted actions to improve retention.
“VAPIHCS is committed to improving our Veterans’ experience,” said Jennifer Gutowski, director VAPIHCS, “we want them to choose VA to receive their care, because they want to; not because they have to.” “We will continue to work with our partners in the community to implement the changes we all agree need to be made.”
To read the entire GAO report: https://www.gao.gov/products/GAO-18-288