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Health Care at the VA

Recommendations for Change

Thecurrentcontroversysurrounding VeteransAffairs

(VA) medicalcenters has reachednationalconcern, 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-

cently releasedfrom theOffice ofthe Inspector General

described one VA as claiming that its veteran patients’

average wait time for new appointments was 24 days,

whereastheOIGfoundittobe115days. 1Ofevengreaterconcern 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 situationwill affect thecare

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 tothe deliveryof health

careto veterans withinthe VAsystem, andtheseshouldalso 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 healthcaresystem has come a long way in

termsof modernizing care and ensuring patient safety.

In themid 1990s, several strategies were implemented

to improve efficiency andhealth carequalityat VAhos-

pitals, including decentralization, integrating informa-

tionsystems,and emphasizingpreventivehealthcare.2

Theuniversalimplementationofanelectronichealthrec-

ord system facilitated the provisionof careto veterans,

tostaytruetoitsmission,“Tocareforhimwhoshallhave

borne the battle and for his widow, and his orphan,” it

needs to address allof theveterans’ concerns swiftly.

Thefollowing10 suggestions couldhelpimprovethe

careof veterans,create a workenvironment morecon-

ducive to collaboration and teamwork, and develop a

more streamlined health care delivery system.

First,with the resignationof theUS Secretaryof Veter-

ansAffairs, thepresident should considerappointingan

outstanding leader with experience in the nonmilitary

health care industry, especially given the current con-

troversiesthat 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 distributethe VA healthcare dollarsto 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.

VIEWPOINT

FaisalG. Bakaeen,MD

Divisionof

Cardiovascular Surgery,

Michael E. DeBakey

Veterans Affairs

Medical Center,

Departmentof

Cardiovascular Surgery,

Texas HeartInstitute,

Houston, Texas;and

Divisionof

Cardiothoracic Surgery,

Michael E. DeBakey

Departmentof Surgery,

BaylorCollege of

Medicine, Houston,

Texas.

AlvinBlaustein,MD

Divisionof Cardiology,

Michael E. DeBakey

Veterans AffairsMedical Center,

Houston, Texas;and

Divisionof Cardiology,

Departmentof

Medicine,Baylor

Collegeof Medicine,

Houston, Texas.

MelinaR.Kibbe,MD

TheSurgical Service,

JesseBrown Veterans

AffairsMedical Center,Chicago, Illinois; and

Departmentof Surgery,

Northwestern

Opinion

2



tractingfor clinicalserviceswith affiliatehospitalscould expand ac-

cess to clinical care to veterans andreduce waiting lists.

Fifth, partnershipwith theprivatesectormay be the keyto making

health care delivery timelier. Logistics experts specializing in work-flow and transportation, working closely with clinicians, can im-

prove theefficiencyof patient scheduling andtransportation to as-

sure that timely appointmentsare made and fulfilled. At the same

time, providingveterans wholivefar from a VA facilitywithprivate

care insurancecouldimprove healthcare accessand eliminatethe

need for long-distance travel.

Sixth, accountability is moreimportantthan ever before. By incen-

tivizing individuals to meet an arbitrary goal (ie, new appointment

within 14days), theVA hasunwittinglycreatedan administrative pro-cess that became toofocused onnumbersand isvulnerable toma-

nipulation andfabrication.If thereare to be incentives, theyshould

be basedon 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 VA’s 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-

VAhospitalsshould retain andincentivize committed andloyalphy-

sicians and other health care workers. This will require a redesign

of the VA’s human resources policies that could also facilitate vet-

ting and hiringof new staff. Also, the VAhas a long history of mini-

mizing terminations of ineffective and poorly performing employ-

ees by repeatedlyshiftingthem to other departments. Instead,the

employmentofthosewhodonotperformtoahighstandardshould

be terminated.

Ninth, the VA’s 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

processis inplace. TheVA’scurrentsystem forobtainingbidson con-

tracts is complex, archaic, wasteful, and slow. Contracts should be

developed by personnel with the content expertise in the area in

whichthe contract is beingconsidered.

Tenth, theVA needs to implementchanges to attract thebest and

brightestwork force. Currently, VAhospitals are viewed as second-

tier facilities, and the majority of physicians do not seek VA hospi-

tals as their first employment optionbecause of lower pay, limited

resources, and system-wide inefficiencies. Matching its favorable

benefit package and r ich educational environment with an attrac-

tive work environment will allow the VA to obtain a quality work-

force. To attract thebest physicians, theVA mustcompensatephy-

sicians at a level commensurate with the private sector. Although

thecreationoftheVATitle38PhysicianandDentalPayRangestables

was an attempt to address this issue nearly a decade ago, the pay

tableshavenot kept pace with theAAMC or MGMA compensation

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

Opinion Viewpoint



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MEMORANDUM

October 22, 2013

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 haddelayed having it examined due to travel time to his VHA provider. When it began

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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 ofessential 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 andProgram Support Assistant were perceived as highly responsive and caring. However, it

h h h k h



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 cancontinue 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, andd) 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



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)



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 provider’s

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, ifneeded

(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

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1.0 Executive Summary

Project ARCH (Access Received Closer to Home) care is available for Veterans who meet Project ARCHVeterans Health Administration (VHA) health care criteria1, meet drive time criteria2, and live in one ofthe 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 program’s progress in meeting itsstated goals. Our synthesis and analysis of the data for the first two years of Project ARCH revealednotable 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, withsignificantly more Veterans receiving Project ARCH care at pilot sites offering specialty careservices (896 Veterans in Caribou, 1,226 Veterans in Flagstaff and 1,167 Veterans inBillings), compared to sites offering primary care (304 Veterans in Farmville and 338Veterans 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 specialtycare 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 and93 percent were male.

Drive time for Veterans receiving care through Project ARCH was, on average, 63 minutesone-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 within14 days. For specialty care appointments, only 62 percent occurred within 14 days of the

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The cost of Project ARCH-provided clinical care was estimated to be $26 million in the firsttwo years of operation. The average outpatient visit was $714 and the average inpatient staywas $23,650.

Interviews were conducted with VHA Project ARCH staff, VHA providers, contracted carenetwork staff, and contracted providers, as well as with participating and non-participatingVeterans. These stakeholders cited a number of successful program elements of ProjectARCH that should be retained for future implementation of the project or for a Non-VA carefollow-on program, including co-location of VHA Project ARCH staff and contracted carenetwork 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 datacollection and dissemination related to contracted care network performance metrics and

patient satisfaction.

Stakeholders also identified challenges and, where applicable, successful mitigations related

to Project ARCH’s processes and operations, including overall care coordination, ProjectARCH policies and procedures, project communication, access to specialty care providers, prescription management, billing and estimating expenditures, and coordination with thecontracted 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 beenresolved, particularly related to care coordination and authorizations, therefore werecommend improving communication and coordination between VHA Project ARCH staff,contracted care networks, and contracted providers on Project ARCH processes. Thesemeetings should be held on a regular basis and, where possible, in person.

To alleviate confusion expressed by participating Veterans about Project ARCH, werecommend 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

VHA’s electronic medical records we recommend that VHA staff ensure that a contracted



and drawbacks of a wide variety of options to devise the most appropriate plan for Veteranscurrently 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 ateach 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 theProject 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 newand additional authorizations; training for contracted providers that allows forcompletion 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 whoshould 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 includedin 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-surgicalneeds).

o Create a database of Veterans receiving primary care to track care received, clinicalgoals 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 contactfor the Veteran, contracted care network staff, and contracted providers to ensurefollow up care within and outside of the VHA system is managed for the Veteran and

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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 AccessReceived 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,[email protected], 775-326-5721.

ACTION REQUESTED: Request for approvalRequest for funding/staffing

Request for new FTEEOther (specify)(Check all that apply)

STATEMENT OF ISSUE: An Integrated Project Team (IPT) examined alternatives forexpanding, extending, or ending Project Access Received Closer to Home (ARCH).Specifically, we investigated a potential expansion of contracted primary care servicesto rural and highly rural Veterans in identified areas of need. This Executive Decision

Memo reports the IPT’s research on areas of need, estimated costs of staffing andadministration, and estimated costs of care for a potential follow-on of contracted

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mailto:[email protected]





1. STATEMENT OF ISSUE: Project Access Received Closer to Home (ARCH) is acontracted care pilot program that provides Veterans in rural and highly rural areas withaccess to primary care and in-patient and specialty care closer to home. Veterans

eligible for Project ARCH met Veterans Health Administration (VHA) health care criteria1 and drive time criteria,2 and live in one of five pilot sites across the country (primary carein 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 August29, 2014, with contracts expiring September 30, 2014. In October 2013, an IntegratedProject Team (IPT) was chartered to conduct analysis and make recommendations onthe potential for service expansion of Project ARCH. Altarum Institute providedinformation 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 isto provide an analysis of need and cost, and a final recommendation regarding thepotential 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 ruralareas from receiving accessible VHA health care. To improve access to care forenrolled Veterans, VHA has implemented a number of initiatives, including CommunityBased Outpatient Clinics (CBOCs), mobile units, and telemedicine. Continuing the effortto provide more accessible health care, a three-year pilot program, Project ARCH(Access Received Closer to Home), is being administered by VHA’s Chief BusinessOffice and funded by VHA’s Office of Rural Health (ORH). The program provides anadditional mechanism for Veterans to seek care from non-VHA, community health care

providers closer to where the Veterans live. Project ARCH began providing care toeligible Veterans on August 29, 2011 in five pilot sites across the country: Farmville, VA;



Seventy-seven percent of Veterans receiving ARCH primary care serviceswere “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 benchmarkthat 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 VHAstaff and the non-Veterans Affairs (Non-VA) care department; closeworking relationships with VHA program staff; and data collection anddissemination related to contracted care network performance metrics andpatient satisfaction.3

Challenges in primary care that should be addressed in a possible futurecontracted primary care follow-on program include: high administrativeburden for VHA staff; issues with pharmacy coordination of refills; need for

coordination of care and feedback loops between mid-level providers athome Veterans Administration Medical Centers (VAMCs) and non-VAproviders; and lack of individual-level performance measures perVeteran.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 underservedwith 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



Veteran’s home. The six-month implementation period for PC3 runs fromOctober 2013 to April 2014.5 Due to the upcoming implementation of PC3,there’s no longer a need to continue inpatient and outpatient specialty care

services as part of a follow-on program to ARCH. For this reason, IPTdiscussions focused exclusively on assessing the need and estimating the costsof extending primary care services only.

C. CURRENTLY UNFUNDED REQUIREMENT: Any of the recommendations madein this memo for services occurring beyond the contract period of August 2014 donot have guaranteed funding from ORH or other VHA entities. ARCH is currentlyfunded by ORH based on available resources.

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

Option 1 (Contracted Solutions to Provide Primary Care Closer to Home): Charter another IPT to explore options for expanding contracted primary careservices via a follow-on program to Project ARCH in identified rural and highlyrural 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 onavailable options for primary care in identified areas of need, and explore and



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

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

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

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 CareCloser to Home)

4. CRITERIA FOR DECISION MAKING: The IPT’s final recommendation to convene asecond IPT to explore a follow-on program is based on four major decision-makingcriteria: a) the areas of need for rural and highly rural Veterans; b) estimatedadministrative 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 determiningareas of need were evaluated based on the following criteria: 1) improves accessto primary care for Veterans in rural and highly rural areas by reducing Veterandrive times and improving geographic accessibility, and 2) improves wait timesfor Veteran primary care appointments in rural and highly rural areas. The IPT

analyzed and discussed the following options that should be considered by thesecond IPT:



conducted analysis with the GIS to determine the number ofVeterans with a drive time of 60 minutes or more from the nearestVA facility delivering primary care in a rural area or zip code.

c. In addition, the IPT determined VA primary care areas outside the60-minute drive time band where Veterans are enrolled for PrimaryCare, but not necessarily receiving VA services, which is a potentialindicator of inaccessibility to care for rural and highly ruralVeterans.

d. Final determination of need: Veterans who live outside the 60minute drive time band from a VA facility delivering primary carewith wait times for Primary Care that are 30 days or greater. Table

1 (below) features preliminary data on the number of Veteranenrollees living in ZIP codes where the closest facility has a highwait-time—defined as an average wait-time of over 30 days forprimary care appointments for new patients.

e. Consider ORH funding a limited expansion of contracted primarycare services, pending additional research, analysis, and availableresources.

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

VISN

# Enrollees living in ZIPcodes where the

closest facility has ahigh wait-time

# Rural (R) # HighlyRural (HR)

Average HighRural

Wait-Times(in days)*

Average HighHighly RuralWait-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



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.

B. ANALYSIS FOR ESTIMATING ADMINISTRATIVE AND STAFFING COSTS:The IPT recognizes Project ARCH’s improved ability to create access closer tohome and the very important need to maintain the quality and safety of patientcare by staffing a potential follow-on program appropriately. This sectionestimates the administrative and staffing costs and revenues for fully coordinatedcontracted 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 “costneutral” to the facility after 3 years of operation, considering VERA reimbursesthe participating VISN. By increasing the number of new rural and highly ruralVeterans served, VISNs will receive higher reimbursements from VERA, andsome 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 t f i ($600 000)



community. This will increase VERA reimbursements from basic ($2000 perpatient) 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 facility’s number of Veterans servedthrough non-VA care programs. This approach would utilize a programmanagement model similar to PC3. PC3 is supported centrally by the CBO andde-centrally at the VAMC level through NVCC personnel. In addition, fieldassistants are hired to facilitate in communication between the field and CBO—mitigating, resolving, and reporting issues to the Contracting OfficerRepresentatives (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 percentof Medicare rates as a starting point for estimating the cost of care provided inthe areas of need indicated in Section 3A above. The estimation would becompleted in the follow-on IPT.

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

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

6. STAKEHOLDER INVOLVEMENT: VHA’s Office of Rural Health, VHA’s ChiefBusiness Office, Denver Acquisitions and Logistics Center and/or local contractingoffices, VAMCs, non-VA community providers, and members of Congress and Senateare all stakeholders.



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

13. BUDGET OR FINANCIAL CONSIDERATIONS OF THE RECOMMENDEDOPTION: A second IPT will address budget and financial considerations. 14. PUBLIC RELATIONS OR MEDIA CONSIDERATIONS OF THE RECOMMENDEDOPTION: Any communication will be processed through standard VA communicationchannels.

15. CONGRESSIONAL OR OTHER PUBLIC OFFICIAL OR AGENCYCONSIDERATIONS OF THE RECOMMENDED OPTION: Any discussion ofCongressional and/or other public official or agency notification or involvementconsiderations will be processed through standard VA communication channels.

16. IMPLEMENTATION: A second IPT would be formed immediately after authority isgranted from this EDM. CBO would be the lead office. There are no anticipatedobstacles.

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

RECOMMEND OPTION 1 (Contracted Solutions to Provide Primary Care Closer toHome): 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.

VA Title 38 Physician and Dentist Pay Ranges(Base Pay + Market Pay) 10



Effective October 11, 2009Pay 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 Staffand 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.

(Base Pay Market Pay)

Pay Table 1 – Clinical Specialty

Allergy and ImmunologyEndocrinologyEndodonticsGeneral Practice – DentistryGeriatricsHospitalistInfectious DiseasesInternal Medicine/Primary Care/

Family PracticeNeurologyPeriodonticsPreventive MedicineProsthodonticsPsychiatryRheumatology

Assignments that do not requirea specific specialty training or certification


Cardio-Thoracic SurgeryInterventional CardiologyInterventional RadiologyNeurosurgeryOrthopedic Surgery


Critical Care (Board Certified)Emergency MedicineGynecologyHematology – OncologyNephrologyPathologyPhysical Medicine & Rehabilitation/

Physiatry/Spinal Cord Injury

Pulmonary


Cardiology (Non-invasive)DermatologyGastroenterologyNuclear MedicineOphthalmologyOral SurgeryOtolaryngology


AnesthesiologyGeneral SurgeryPlastic SurgeryRadiology (Non-invasive) – combinedRadiology and Therapeutic Radiologyfrom 2007 issuanceUrologyVascular 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

0

11



11



Perspective

The NEW ENGLAND JOURNAL of MEDICINE

It has been nearly 20 years since the VeteransHealth Administration (VHA), the subcabinet

agency that oversees the Department of Veterans Af -fairs (VA) health care system, implemented a series

formance standard and placedhigh priority on meeting it in theface of these difficult challenges.

They further compounded the sit-uation by using a severely flawed

Restoring Trust in VA Health CareKenneth W. Kizer, M.D., M.P.H., and Ashish K. Jha, M.D., M.P.H.

12

PERSPECTIVE

VA h it l d ith i ki i i t t lit t i

Restoring trust in VA Health Care



VA hospitals are compared withtop-tier integrated delivery sys-tems, however, their quality ad- vantage diminishes. Some VA hos-pitals excel, but others arestruggling with the basics. ThePhoenix VA Medical Center —ground zero of the wait-timescandal — has mortality ratesfor common conditions that areamong the highest within the VAand higher than those in manyprivate hospitals. Its rates of

catheter-related bloodstream in-fections are nearly three timesthe 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 thereare three main causes: an unfo-cused performance-measurementprogram, increasingly centralizedcontrol of care delivery and as-sociated increased bureaucracy,and increasing organizational in-sularity.

The performance-measurementprogram — a management tool

sion making was a core princi-ple. Day-to-day responsibility forrunning the health care system was largely delegated to the localfacility and regional-network man-agers within the context of clearperformance goals, while cen-tral-office staff focused on set-ting strategic direction and hold-ing the “field” accountable forimproving performance. In recent years, there has been a shift to amore top-down style of manage-

ment, whereby the central officehas oversight of nearly every as-pect of care delivery.4 Concomi-tantly, the VHA’s central-officestaff has grown markedly —from about 800 in the late 1990sto nearly 11,000 in 2012.

Finally, the VA health care

system has become increasinglyinsular and inward-looking. It nowhas little engagement with private-sector health care, and toooften it has declined to make itsperformance data public. For ex-ample, it contributes only a smallproportion of its data to the na-

tional public reporting programfor hospitals, Hospital Compare,

cess to care, mortality rates, in-fection rates, and patient satisfac-tion, is a good start that willimprove with use and would helphold the VA accountable for re-sults.

Second, conceptualizing accessto care in terms of a “continuoushealing relationship,”5 the agencyshould design a new access strat-egy that draws on modern infor-mation and advanced communi-cations technologies to facilitate

caregiver–patient connectivity andthat uses personalized care plansto address patients’ individual ac-cess needs and preferences. Facil-ity-by-facility assessments shoulddetermine whether VA facilitiesare using technology to leveragethe best possible “care delivery

return on investment” and wheth-er personnel are working at thetop of their skills. Perhaps someof the resources supporting thecentral and network office bu-reaucracies could be redirected tobolster the number of caregivers.

Third, we believe the VA needs

to engage more with private-sectorhealth care organizations and the

PERSPECTIVE

ity care to veterans New leader Department of Emergency Medicine Uni Effect of the transformation of the Veterans

Restoring trust in VA Health Care



ity care to veterans. New leader-ship should help them succeed.

The views expressed in this article arethose of the authors and do not necessarilyreflect those of the Department of Veterans

Affairs.Dr. Kizer reports ser ving as Under Secre-tary for Health in the Department of Veter-ans Affairs from 1994 through 1999. Dr. Jha is a staf f physician at the Boston VAHealthcare System.

Disclosure forms provided by the au-thors are available with the full tex t of thisarticle 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 ofNursing — all in Sacramento, CA (K.W.K.);and the Department of Health Policy andManagement, Harvard School of Public

Health; and the Division of General Medi-cine, Brigham and Women’s 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 caresystem. Annu Rev Public Health 2009;30:313-39.

2. Jha AK, Perlin JB, Kizer K W, Dudley RA.

Effect of the transformation of the VeteransAffairs health care system on the quality ofcare. 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-VeteransAffairs settings. Med Care 2011;49:76-88.4. Kizer KW, Kirsh SR. The double edgedsword of performance measurement. J GenIntern Med 2012;27:395-7.5. Institute of Medicine. Crossing the qualitychasm: a new health system for the 21st cen-tury. Washington DC: National AcademyPress, 2001.

DOI: 10.1056/NEJMp1406852

Copyright © 2014 Massachusetts Medical Society.

13



13

14



Attachment A

This document is intended to provide additional detail regarding some of the schedulingprocess changes addressed in the memorandum to which it is attached. This guidanceshould provide assistance to facilities in implementing these changes and will follow theoutline 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

14



1. Definitions

Desired Date (DD): The desired appointment date is the date on which thepatient 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 waittimes 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

https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fSystems+Redesign%2fProspective+Wait+Times&rs:Command=Render











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 theDesired 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



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 DATEDISPLAY 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 wishType 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//



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=======TORDER TEXT SEQUENCE: 2//

FORMAT:

OMIT TEXT:LEADING TEXT:TRAILING TEXT:

START NEW LINE: YES//WORD-WRAP: DON'T WRAP//

Select PROMPT:



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 candocument 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.



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:

Open CPRS, select any patient.

Under the Tools tab select OPTIONS.



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.



Select View, then SAVE

AS DEFAULT VIEW.

5



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



The following method was used by a pilot site to run a report of pending ordersdocumenting 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



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 patient’s 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

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 Dateb. 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



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 callingfrom 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 patient’s /provider’s 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 VA’s scheduler performance in 2005 found desired date

entered correctly only 60% of the time. VHA agreed with the OIG’s 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



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 VHA’s 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 patient’s 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 ongoingperformance.

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:



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 SchedulingProcesses and Procedures.

10. Conducting Scheduler DD audits

Facility External Demand Monitoring/Tracking Accurate Desired Date

Review each scheduler’s 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.

ELECTRONIC WAIT LIST (EWL) - FREQUENTLY ASKED QUESTIONS

15



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 system’s 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 1st and 15th), 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 Center’s view the data in detail as

15


http://vssc.med.va.gov/WaitTime/EWL_List.asp





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 apatient (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 VHA’s 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,




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

provider’s 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 requestmeans 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?




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 month’s, 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 provider’s 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?


htt // k d l / l ? d &M di ID 4833&M C t ID 113

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


Wh b i h h EWL i d f h EWL d h d l d Th















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 bebeneficial 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

D t t f V t Aff i16



Department of Veterans Affairs

Electronic Wait List (EWL) Questions & Answers

To assist you in response to specific query onlynot 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 patientswaiting for an appointment or assignment to a primary care provider or team. It is usedto keep track of new patients who have requested care, but cannot be scheduled within90 days. The EWL is maintained on the VA computer system for use by staff.

Q: How does the EWL Process wo rk?

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

The EWL assists Department of Veterans Affairs (VA) Medical Centers and clinics inmanaging Veterans’ access to outpatient health care. When a new patient requestscare, 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.



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 VA’s official wait list. The

Privacy Act of 1974, 5 U.S.C. § 552a, requires that federal agencies maintaininginformation retrievable by the individual’s name, social security number or other uniqueidentifier publish in the Federal Register notice concerning the system of records inwhich the information is maintained. The EWL is a part of the VHA system of recordsidentified as “Veterans Health Information Systems and Technology Architecture (VistA)Records-VA” (79VA10P2). The purpose of the EWL is to provide a transparent list ofpatients who cannot be scheduled for an appointment within 90 days and are waiting foran 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 bothnew 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 beplaced on the EWL. With minor exceptions, new patients are defined as those whohave 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 patientcannot be accommodated within the 90 days, the facility is required to place thatindividual 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 scheduledappointments. 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

A: If the clinic has no appointments available the appointment request can be placed on



A: If the clinic has no appointments available, the appointment request can be placed onthe 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 outpatientappointments.

Q: What steps can be taken for a provider who does not have capacity toschedule 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 forappointments?

A: Except for medical emergencies or urgent medical needs, Veterans are removed inthis order: Service Connected (SC) 50% and greater, Veterans less than 50% SCrequiring care for a SC disability, followed by first on first off.

Q: How are patients who cancel and reschedule appointments the same dayhandled?

A: Patients who cancel appointments are offered future available appointment slots.

Q: The patient then cancels his appointment for whatever reason and is placedback on EWL. How is wait time calculated?

A: If the patient cancels his appointment, then the wait time is calculated from the dateof 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.

17



Using the Recall Reminder System

RECALL / REMINDER1

G.V. (Sonny) Montgomery VA Medical Center1500 E. Woodrow Wilson Drive

Jackson, MS 39211

601-362-4471

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 tobe 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 toreturn 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 becreated – 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 recalldate the notification letters should be printed.

The letters will provide instructions for the Veteran on how to contact thefacility/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 policythat outlines actions to be taken to make contact, the number of attemptsnecessary 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 clinician’s 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/clinicspecified 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 Veteran’s 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 VeteranEncounter 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

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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. Theuser 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 therecall 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.




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.





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 willbe 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 partof 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 – forinformational purposes – indicating the reason for the appointment. EX: This is a FOLLOW-UPAPPOINTMENT 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 nextscheduled 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 theVeteran. Once the scheduler has edited and/or added Veteran A’s name to Recall Reminder list, theinformation 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 activeRecall 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 Veteran’s 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 – (doesn’t 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 Veteranhas not responded, the scheduler needs to follow local policy that outlines actions to be taken to make contact, the number ofattempts 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 thenotice was sent.

An asterik (*) in front of the reminder sent date indicates the Veteran has been sent two notices and has not yetscheduled an appointment.




16

How to run a Recall List Delinquencies List:

Access #3 Recall List Delinquencies from the RR Menu.




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 haven’t 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.


8



18

Select R for a Range of Clinics, I for an Individual Clinic, and S for Clinic Stop Codes.

EX: In choosing I, we’re 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



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.


20



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.


21



21

To generate a Recall Reminder Deletion Report:

Enter the start and end dates for the time period requested. In this example, it’s 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, we’re 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 theVeteran’s medical record.

Recall Reminder – Schedule Appointments

22



22

Recall Reminder – Working the Way It’s 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.


23



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 predeterminedin the Recall Reminder Removed file. In the example below , this will be the only clinic, and we will notadd 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, we’reselecting the PRIMARY CARE clinic. RECALLPROVIDER,TWO is the attending provider for the clinic. Thiswill be the only clinic, and we will not add/remove the clinic at the Another one (Select/De-Select:)<RET>.


24




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



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.


26

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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, we’re

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>.


27




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 Veteran’s 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



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



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 Veteran’s 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



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.


31



3

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.


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 33




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

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.

Recall Reminder – DON’T TIPS 34



DO NOT edit a PAST Recall Reminder. Instead of editing the reminder, Delete (ifappropriate) 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