Tuesday, August 11, 2015

The Madison VA Hospital: Improving Access to Care for America’s Veterans

I received this because I serve on  the Veterans Advisory Board at the Madison, VA. ~Bob

The Madison VA Hospital: Improving Access to Care for America’s Veterans
July 2015

For the past year, improving access to care has been among VA’s top priorities. Six months ago, 2% of our Veterans were waiting more than 30 days for care.  Today, that rate is down to 1.8%.  In response to the unacceptable delays in Veterans receiving medical service, VA developed a strategy that focused on growing capacity in four critical areas:  staffing; space; productivity; and VA Community Care.  The execution of this strategy VA-wide has been data-driven. 

The result of this strategy is that 4,200 more appointments have been scheduled for care with the Madison VA and clinics than in the previous 12 months.  At the same time, 98.2% of appointments are now completed within 30 days of the clinically indicated or Veteran’s preferred date; 93.2% within 14 days; and 88.8% within 7 days. 

Despite all of these improvements, wait times are up for Primary Care from 12 months ago (from 1.61 days to 3.60 days).  Wait times are also up for Specialty Care from 12 months ago (from 1.58 days to 3.87 days). 

Mental Health wait times have decreased from 1.54 days in FY14 to 1.41 days in FY15.  The increases in Primary Care and Specialty Care, along with the increases in appointments scheduled, demonstrate that as the Madison VA improves access to care, Veterans are responding and seeking VA care at higher rates.  While more work remains to be done, the Madison VA has made real progress.

Critical Activities to Improve Access

Executive leadership at the Madison VA has been working with Service Chiefs and Supervisors to implement a variety of strategies in the four critical areas to improve access.  These strategies and their results are reflected

 To date, Madison VA has increased onboard staff by 57 since October 2014, including 6 Physicians and 30 Nurses and Nurse Practitioners.  Madison VA also added 6 scheduling clerks.

 Madison VA added two locum tenens (contract physicians) to Primary Care to increase access until we could fill vacancies.

 Madison VA has hired 37 staff so far using funding from the Choice Act.  Another 21 are in process.

 Madison VA’s employee turnover rate is currently about 8% as compared to the private sector national healthcare average of 18%.

 Madison VA was granted an additional 4 full-time resident positions.

 Madison VA currently has over 20 significant capital improvement projects on-going, including renovation of space for our Women’s Health Clinic, our Pre-Op Clinic, Telephone Care Service, and consolidation of our ICU’s.


 Madison VA extended clinic hours into nights and weekends to leverage limited space and enhance convenience for Veterans.

o Expanded evening and weekend clinic hours for Audiology.

o Expanded our existing weekend Specialty Clinics, e.g., Eye and GI Clinics.

o Providers increased their panel sizes in order to increase access.

 Increased delivery of care by telephone and secure messaging to better use provider time, improve access, and meet Veteran care needs such that they do not have to travel for a scheduled appointment.

o Telehealth Use:  Madison VA Average was 16.2% for FY14 and is 13.9% for FY15.  National Average was 12.7% for FY14 and is 9.5% for FY15. 

o Secure Messaging Utilization:  Madison VA Average was 25.7% for FY14 and 36.5% for FY15, showing a 31.6% increase in Veterans opting into secure messaging.  National Average was 19.3% for FY14 and is 27% for FY15.

 Madison VA optimized Primary Care clinic appointment grids to increase capacity offering more appointment slots to Veterans.

o Added two locum tenens (contract physicians) to Primary Care to increase access untilvacancies could be filled.

o Approved a new Patient Aligned Care Team (PACT) and hired a physician to begin building that team.

o Reviewed Primary Care panels to identify unused capacity.

 Madison VA increased use of telehealth to see more Veterans, reduce or eliminate Veteran travel time, and better leverage provider time.

o Madison VA is on target to exceed the number of Veterans utilizing all areas of telehealth (Home Telehealth, Clinical Video Telehealth and Store and Forward Telehealth) from the previous two years.  Veterans utilizing one of the areas of telehealth to date number 20,837, up from an overall total of users in FY14 of 17,501.

 Increased use of eConsults, improving Veteran access to Specialty Care without an additional appointment and better leveraging Specialty Care provider time.

o Madison VA has remained above VA Averages for the use of eConsults being at 7.7% for FY14 (3,065 Veterans) and is currently at 6.4% (2,603) for FY15 (to date).  National Average for FY14 was at 6.2% and is at 5.1% for FY15.  

 Increased delivery of Mental Health Care by Primary Care providers giving Veterans access to care without requiring additional Specialty Care appointments.

 Deployed a robust Specialty Care productivity tool to evaluate productivity down to the clinic level.

o The penetration rate for Madison Primary Care-Mental Health Integration (PCMHI) is currently at 10.4%.  The National Average is 9.3%.

o PCMHI Encounters have increased from 7.6% in FY14 to 8.2% in FY15.  The National Average increased from 4.2% for FY14 to 4.4% for FY15.

o Madison VA utilizes Relative Value Units (RVU’s) to evaluate productivity.  Madison RVU’s have increased by 9.4% due to better workload capture and an increased number of patients using the Madison VA.

 In line with the national initiative to reduce “no-shows” and late appointment cancellations, Madison VA has reduced its “no-show” rates in all areas:

o No Show Rate All-FY14 was at 11%, and is at 9.7% in FY15.  National Average for FY14 was at 13.4%, and is at 13.1% for FY15.

o No Show Rate Mental Health-FY14 was at 18.7% and is at 18% in FY15.  National Average for FY14 was at 18.5%, and is at 18.6% for FY15.

o Cancelled by Clinic Rate-FY14 was at 9.9% and is at 9.6% in FY15.  National Average for FY14 was at 8.1%, and is at 8.8% for FY15.  Madison is working to improve in this area.

 Increased clinical and administrative support staff in Specialty Care clinics to improve the productivity of Specialty Care providers.

o Began several new Rheumatology clinics in order to reduce the number of Veterans on the EWL for Rheumatology (which is now at zero).

o Added specialists, e.g., Orthopedics and Dermatology.

o Approved an additional 6 scheduling clerks.

VA Community Care:

 Expanded the use of care in the community through VA’s Accelerating Access to Care Initiative.

o Under the Choice Program to expand Veteran options for care in the community, Madison has had 799 Choice Authorizations and 682 Choice Appointments.

Improving Access Results

Hard work focused on critical activities is not enough.  Veterans and taxpayers expect to see actual improvement in access to care outcomes.  Highlights include:

 Madison VA completed 4,200 more appointments through the third quarter of FY15 as compared to the

third quarter of FY14.

 Madison VA’s completion percentages for FY15 are: 

 Madison VA’s Average Wait Time for completed appointments:

o 98.2% within 30 days.

o 93.2% within 14 days.

o 88.8% within 7 days.

o Primary Care is 3.60 days.

o Specialty Care is 3.87 days.

o Mental Health Care is 1.41 days.

 From FY14 to FY15 there was an increase in Relative Value Units (RVUs), a standard measure of clinical output, of 9.4% (as of March 27, 2015).

Madison VA completed appointments during extended hours increased by 19.6% during FY14, substantially reducing our appointment backlog.  Madison has completed 2,326 appointments during extended hours through FY15 Qtr3.

 Madison VA currently has no new Veterans waiting for appointments on the New Enrollee Appointment

Request (NEAR) list.

 Madison VA currently has no Veterans on the Electronic Wait List (EWL).

 Nearly a third of Veterans receive care virtually, up from 18% just two years ago, improving access and convenience.

Secure messaging (private e-mails with clinicians)

 Madison VA Secure Messaging was at 18.7% for FY13, 25.7% for FY14 and is

Store and Forward Telehealth (e.g., sending photos of skin lesion to clinician)

 Madison VA Store and Forward Telehealth was at 4.3% for FY13, 3.8% for FY14 and is

Clinical Video Telehealth (speaking with clinician by video)

 Madison VA Clinical Video Telehealth was at 10.3% for FY13, 11.5% for FY14 and is at  currently at 36.5% for FY15 (to date), exceeding the previous two years. at 3.4% for FY15 (to date).  We are on target to meet or exceed the previous two years. 9.9% for FY15 (to date).  We are on target to meet or exceed the previous two years.

Home Telehealth (speaking with provider by video from home)

 Madison VA Home Telehealth was at 2.1% for FY13, 1.8% for FY14 and is at 1.4% for

eConsults (clinicians receive expert advice by e-mail to expedite best decision for patient)

 Madison VA eConsults was at 5.6% for FY13, 7.7% for FY14 and is at 6.4% for FY15 FY15 (to date).  We are on target to meet or exceed the previous two years. (to date).  We are on target to meet or exceed the previous two years.

Veteran Response to Improving Access to Care

As VA has improved access to care, Veterans have responded by seeking more care though VA.

 Madison VA has increased the number of appointments by 4,200 from FY14 to FY15 to date. 

 The number of Veterans using the Madison VA for care has grown about 2.3% per year in the past (FY13 to FY14).  Growth for this fiscal year is reflected in the fact that we had 32,199 users for FY14 compared to the current number of users for FY15 (through May 2015) of 30,343, with 4 months remaining of the current fiscal year. 

 On average, 201 Veterans began using Madison VA for care each month this fiscal year, up from 154 per month in the prior year, a 30.5% increase.

 More Veterans are not only coming to Madison VA for care, they are also using Madison VA for more care. Total appointments scheduled are up 6.2% over the last 12 months.

 More Veterans are coming to Madison VA for their care even though 72% have Medicare, Medicaid, Tricare, or private insurance.  Veterans are coming to VA for care because they want to.

 Based on current patient satisfaction data, 73% of our Veterans would recommend the Madison VA to others, compared to a national average of 66%.  Also, 70% of our Veterans rate the Madison VA as excellent or outstanding compared to a national average of 64%.  Approximately 85% of our Veterans offered Choice elected to receive their care from the Madison VA, compared to a national average of 47%.

Looking Ahead

While access has improved, Veterans are telling us they want and expect more. 

 The Madison VA and its stakeholders must recognize that as we continue to improve access to care, Veterans will continue to respond by coming to VA for more of their care.  If the 30 day standard in Choice is the requirement to which VA manages, then our experience over the last year makes clear that more flexibility and, ultimately more resources, are required to provide Veterans the care they deserve.

 The Madison VA will continue to focus on the key drivers of staffing, space, productivity, and VA Community Care, with particular emphasis on improving the Choice program and increasing Choice utilization. 

 In addition, the Madison VA has launched a sustained effort to deliver care to Veterans waiting the longest for an appointment. 

 Major enhancements to the scheduling system will be rolled out later this year as work continues on a comprehensive longer-term solution.

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