Evaluation of the Lovell Federal Health Care Center Merger Findings, Conclusions, and Recommendations (2012) / Chapter Skim
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4 Initial Results of the Integration Demonstration
4 Initial Results of the Integration Demonstration
Pages 103-144
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From page 103... ...
Lovell Federal Health Care Center (FHCC) had been in operation only for a year and a half when this report was drafted and is still a work in progress.
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From page 104... ...
According to the Lovell FHCC's concept of operations, the planning assumptions supported the more expansive concept of integration. The assumptions included the following: • There is total integration -- a single chain of command exists with single departments.
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From page 105... ...
. Functional Integration Administrative services are combined and integrated to some extent at the Lovell FHCC, although the need to adhere to the different business rules and procedures of the DoD and the VA requires a certain amount of duplication and limits the realization of optimal operating efficiencies.
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From page 106... ...
Physician Integration The clinical task group recommended from the start that Navy active duty and VA physicians be unified through the development of a single set of medical staff bylaws and organization into single departments under a single chief medical executive. It became evident, however, that it made sense to create a separate organization for dental services because of the volume of dental work and the size of the dental staff, which also conforms to the Navy practice of having separate medical and dental commands.
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From page 107... ...
were by veterans at the dental clinic on the west campus; the rest were at the east campus branch health clinics. Although the clinical staffs were not officially combined until October 1, 2010, the chief medical officers of the NCVAMC and the NHCGL were already fully engaged in merging the medical staffs, a goal that they strongly supported.
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From page 108... ...
. Physicians are both active duty servicemembers and VA civilians, and in many cases they treat both VA and DoD beneficiaries.
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From page 109... ...
with the VA dental clinic on the west campus were abandoned when the square footage of the ACC was cut in half. Instead, the Navy dental clinic was moved to the Zachary and Elizabeth Fisher Medical and Dental Clinic on the east campus, which also provides medical care to active duty staff.
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From page 110... ...
. Soon, however, the concept of integrating at least some outpatient services or clinics was adopted, in which both VA and DoD beneficiaries would be treated by either VA or Navy providers, depending on who was available.
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From page 111... ...
Specialty/Clinic NCVAMC NHCGL Audiology 6.09 1.00 Cardiology 1.40 0.95 Dermatology 0.13 1.90 Endocrinology 1.97 Family Practice 6.00 Gastroenterology 3.63 General Surgery 2.11 2.90 Gynecology 1.05 2.00 Immunizations 1.00 Infectious Disease 0.23 Internal Medicine 19.15 5.95 Mental Health Clinic 49.01 11.00 Nephrology 0.70 Neurology 2.64 0.50 Occupational Therapy 0.98 Oncology 0.89 Ophthalmology 1.40 1.00 Optometry 1.88 1.00 Orthopedic 3.15 3.90 Otolaryngology 0.55 1.90 Outpatient Nutrition 2.00 Pediatric 3.89 Physical Therapy 5.95 8.00 Podiatry 1.43 2.00 Primary Care Employee Health 1.00 Pulmonary Disease 2.50 Rheumatology 1.00 Substance Abuse 3.00 Urology 1.10 0.90 Total 109.94 60.79 NOTE: This table pertains to the clinical personnel (e.g., physicians, psychologists, podiatrists, audiologists, nutritionists, and physical and occupational therapists) at the NHCGL's 200H facility who moved to the ambulatory care center on the west campus, not the clinical personnel in the branch health clinics who remained on the east campus (i.e., at Naval Station Great Lakes)
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From page 112... ...
were centralized. These branch health clinics include the USS Red Rover, which screens recruits for medical and dental problems as they arrive and provides immunizations, eyeglasses, and women's health services; the USS Weeden Osborne, which provides dental services to recruits, a large percentage of whom have dental deficiencies; the USS Tranquility, which provides medical services to recruits and active duty members of the Recruit Training Command (RTC)
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From page 113... ...
Some are Navy only, such as the branch health clinics on the east campus that serve only active duty servicemembers. Inpatient mental health, medicine,
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From page 114... ...
114 LOVELL FEDERAL HEALTH CARE CENTER MERGER TABLE 4-2 Clinical Integration Status of the Lovell Federal Health Care Center Directorate Department Division Clinical Section Patient Care Medicine Inpatient Acute/Intensive Care Unit Emergency Medical Specialties Cardiology Dermatology Endocrinology Gastroenterology Hematology/Oncology Infectious Disease Nephrology Neurology Pulmonology Rheumatology Ambulatory Medical Care Primary Care Family Practice Internal Medicine Pediatrics Veterans' Primary Care Special Medical Exams DoD Specialty Exams VA Specialty Exams Surgery Perioperative Anesthesia Operating Room Surgical Subspecialties General Surgery Gynecology/Women's Health Ophthalmology Optometry Orthopedics Otolaryngology Podiatry Urology Mental Health Acute Inpatient Outpatient/Consultation Services Consultation Liaison Mental Health/Life Skills
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From page 115... ...
(VA, DoD, or Both) System VA VA VA West Both Both VistA VA West Both VA VistA DoD VA West Both Both VistA DoD West Both Both VistA VA West Both VA VistA VA West Both VA VistA VA West Both VA VistA VA West Both VA VistA VA West Both VA VistA VA West Both VA VistA VA West Both VA VistA VA West Both VA VistA DoD DoD DoD West DoD Both AHLTA DoD West DoD Both AHLTA DoD West DoD Both AHLTA VA West VA VA VistA DoD DoD West DoD Both AHLTA VA West Both Both VistA VA VA VA West Both VA VistA VA West Both Both VistA DoD DoD West Both Both VistA DoD West Both Both Both VA West Both Both Both DoD West Both Both VistA DoD West Both Both VistA DoD West Both Both VistA VA West Both Both VistA DoD West Both Both VistA VA VA West Both VA VistA DoD VA West Both VA VistA DoD Both Both Both Both continued
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From page 116... ...
116 LOVELL FEDERAL HEALTH CARE CENTER MERGER TABLE 4-2 Continued Directorate Department Division Clinical Section Mental Health Case Management Psychosocial Rehabilitation and Recovery Center Special Programs Homeless Posttraumatic Stress Disorder Substance Abuse Rehabilitation Program/Addiction Treatment Program Vocational Rehabilitation Patient Services Ancillary Services Audiology and Speech Pathology Nutrition and Food Services Pastoral Services Pharmacy Prosthetics Rehabilitation Kinesiotherapy Occupational Therapy Physiatry/Electromyography Physical Therapy Geriatrics and Extended Care Community Living Geriatric Medicine Home and Community-Based Care Diagnostic Services Blood Donor Processing Imaging and Radiation Safety Pathology and Laboratory Education and Training Clinical Education Employee/Military Education Dental Dental Services General Dentistry USS Osborne USS Red Rover Fisher Clinic Dental Prosthetic Care
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From page 117... ...
(VA, DoD, or Both) System VA West VA VA VistA VA West VA VA VistA VA VA West VA VA VistA VA West VA VA VistA DoD West Both Both Both VA West VA VA VistA VA VA VA West Both Both VistA VA West Both VA VistA VA West Both Both VistA DoD West Both Both Both VA West Both VA VistA VA VA West Both VA VistA VA West Both VA VistA VA West Both VA VistA DoD West Both Both VistA VA VA West Both VA VistA VA West Both VA VistA VA West VA VA VistA DoD DoD West Both DoD DBSS VA Both Both Both Both VA Both Both Both VistA/CoPath DoD VA West Both Both NA DoD West NA Both NA DoD DoD VA West VA VA VistA DoD East DoD DoD AHLTA DoD East DoD DoD AHLTA DoD East DoD DoD AHLTA DoD East DoD DoD AHLTA continued
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From page 118... ...
SOURCE: Information provided by the Lovell FHCC to the IOM committee.
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From page 119... ...
(VA, DoD, or Both) System DoD DoD DoD DoD East DoD DoD AHLTA DoD East DoD Both AHLTA DoD DoD East DoD NA AHLTA DoD East DoD NA AHLTA DoD East DoD NA AHLTA DoD East DoD NA AHLTA DoD DoD DoD East DoD DoD AHLTA DoD East DoD DoD AHLTA DoD East DoD DoD AHLTA DoD East DoD DoD AHLTA DoD East DoD DoD AHLTA DoD East DoD DoD AHLTA DoD DoD East DoD DoD AHLTA DoD East DoD DoD AHLTA DoD East DoD DoD AHLTA DoD East DoD DoD AHLTA DoD East DoD DoD AHLTA VA DoD DoD East Both Both AHLTA DoD East DoD Both AHLTA DoD East DoD Both AHLTA DoD East DoD Both AHLTA DoD West VA Both VistA DoD DoD West DoD Both AHLTA DoD East DoD Both AHLTA
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From page 120... ...
Lack of interoperable EHR systems has significantly hindered the capacity to deliver integrated care, and the workarounds required to integrate patient information have reduced productivity. The lack of a joint or an interoperable EHR system that supports seamless clinical workflow for both VA and DoD beneficiaries is the largest contributor to the Lovell FHCC's inability to operate combined ACCs and to gain the full benefit of an integrated medical staff.
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From page 121... ...
The Lovell FHCC example also shows that there are serious limits on the extent to which such a joint health care center can be unified internally if it has to perform as an MTF for DoD purposes and as a VAMC for VA purposes. This in turn constrains the extent to which the Lovell FHCC can provide coordinated care to patients or increase efficiencies through running one instead of duplicate programs and administrative systems.
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From page 122... ...
Integration Scorecard The 15 benchmark measures are 1. Patient satisfaction measures meet VA and DoD benchmarks 2.
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From page 123... ...
. Most of the performance measures are specific to the VA or to the DoD rather than to the integrated performance of the FHCC, because the main purpose of the performance benchmarks was to address the concerns of the respective departments that the Lovell FHCC experiment might fail badly before the end of the 5-year demonstration period (Interviews)
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From page 124... ...
. OUTCOMES The goals of the Lovell FHCC leadership, taken from the April 2010 EA, are to "improve access, quality, and cost effectiveness of health care delivery for the beneficiaries" of both the DoD and the VA (DoD/VA, 2010, pp.
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From page 125... ...
. Quality of Inpatient Heart Failure Patient Care The Lovell FHCC's ORYX scores for heart failure patients were also 100 percent in all 3 years, with one exception: the percentage of heart failure patients given discharge instructions dipped to 91 percent in 2010 before returning to 100 percent in 2011 (Figure 4-5)
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From page 126... ...
Figure 4-1, color 100 90 80 Percentage of Patients 70 60 2005 2006 50 2007 2008 40 2009 2010 30 2011 20 10 0 Patients with Prior DM Patients DM Patients with DM Patients with AMI with with BP ≤ 140/90 HBA1c > 9 or Retinal Exam LDL-C < 100 Not Done (lower is better) FIGURE 4-2 Selected HEDIS results for the Lovell Federal Health Care Center, 2005–2011 (percentage of patients)
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From page 127... ...
100 90 80 Percentage of Cases 70 60 FY08 50 FY10 40 FY11 30 20 10 0 AM-1 AM-2 AM-5 AM-6 AM-10 FIGURE 4-4 ORYX results for heart attack patients at the Lovell Federal Health Care Center, 2008–2011 (percentage of patients)
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From page 128... ...
HF-1 = percentage of heart failure patients given discharge instructions; HF-2 = percentage of heart failure patients given an evaluation of left ventricular systolic function; HF-3 = percentage of heart failure patients given ace inhibitor or arb for left ventricular systolic dysfunction; HF-4 = percentage of heart failure patients given smoking cessation advice/counseling. SOURCE: Lovell FHCC.
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From page 129... ...
in immunocompetent ICU patient; PN-6b = initial antibiotic selection for CAP immunocompetent non-ICU patient; PN-7 = pneumonia patients assessed and given influenza vaccination. SOURCE: Lovell FHCC.
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From page 130... ...
SCIP = Surgical Care Improvement Project; SCIP-1a = prophylactic antibiotic received within 1 hour prior to surgi Figure 4-7, color cal incision-overall rate; SCIP-2a = prophylactic antibiotic selection for surgical patients-overall rate; SCIP-3a = prophylactic antibiotics discontinued within 24 hours after surgery end time-overall rate; SCIP-6 = surgery patients with appropriate hair removal; SCIP-CARD-2 = surgery patients on beta blocker therapy prior to ad mission who received a beta blocker during the perioperative period; SCIP-VTE-1 = surgery patients with recommended venous thromboembolism prophylaxis ordered; SCIP-VTE-2 = surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery. SOURCE: Lovell FHCC.
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From page 131... ...
In 2011, TRICARE users gave the Lovell FHCC more favorable ratings on access questions and less favorable ratings on other questions concerning physician-patient communication and quality of health care and health care providers, compared with all Navy users of TRICARE (Figure 4-8)
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From page 132... ...
80 70 60 50 How well doctors communicate 40 Getting care quickly Getting needed care 30 20 10 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 FIGURE 4-9 TRICARE patient ratings of access to care and physician-patient communication at the Lovell Federal Health Care Center, 2003–2011 (100-point scale)
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From page 133... ...
. Lovell Federal Health Care Center The FHCC tracks and reports patient satisfaction by normalizing the DoD and the VA scores around the overall average score for BUMED and VISN 12, respectively, and using a 5-point scale.
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From page 134... ...
SOURCES: Lovell FHCC and VA, 2011. Figure 4-11, color 70 60 Patient Satisfaction Score 50 40 FHCC Actual Score 30 FHCC Benchmark VHA Average Score 20 10 0 FY 2009 FY 2010 FY 2011 FIGURE 4-12 Department of Veterans Affairs inpatient satisfaction scores, fiscal years 2009–2011.
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From page 135... ...
TABLE 4-4 Veterans Administration Patient Satisfaction Scale for the Lovell Federal Health Care Center Score Basis 5 (Excellent) More than 5 percent above the VISN average 4 (Very Good)
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From page 136... ...
. Mission Readiness of Navy Staff, Recruits, and "A" School Students The impact of the FHCC integration on the operational readiness of active duty personnel was of paramount concern to the Navy.
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From page 137... ...
Job Satisfaction Leadership Cohesion Work Group Cohesion 2012 Work Group Effectiveness 2011 Trust in Organization Organizational Commitment 0 1 2 3 4 5 Staff Workplace Effectiveness Score FIGURE 4-15 Average ratings of organizational effectiveness of the Lovell Federal Health Care Center by its active duty and civilian staff in 2011 and 2012. NOTE: Respondents to an annual survey of the organizational climate at the Lovell Federal Health Care Center administered by the Defense Equal Opportunity Management Figure 4-15, color to give their perception of certain organizational Institute were asked features on a 5-point scale rate in which a higher number is better; e.g., a 4 means greater job satisfaction than a 3.
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From page 138... ...
Recruits in Temporary Holding Units for Medical Reasons After They Graduate Enlisted recruits who graduate from boot camp but are medically unable to transfer are assigned to temporary holding units. It is the responsibility of the MTF, in this case the Lovell FHCC, to provide the care needed to keep this rate as low as possible.
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From page 139... ...
SOURCE: Lovell FHCC. Figure 4-16, color Medically Indeterminate Status An active duty servicemember can be fully medically ready, partially medically ready, or not medically ready, or his or her medical readiness can be indeterminate.
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From page 140... ...
Training and Research The creation of the FHCC has generated opportunities for improved training and research that are not yet exploited but are in the plans of the Lovell FHCC and its affiliated medical school, the Rosalind Franklin University of Medicine and Science. These were discussed in the presentations to the committee at its September 2011 meeting in North Chicago and in an earlier site visit to the university by the committee staff.
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From page 141... ...
Many VA providers have faculty appointments, and the university has now appointed Navy clinicians as faculty. Research Opportunities According to the integration performance benchmark, the amount of research funding at the Lovell FHCC is larger than it was leading up to
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From page 142... ...
Presentation to the IOM Commit tee on Evaluation of the Lovell Federal Health Care Center Merger by Dr. Sarah Fouse and CDR Bridgette Faber, associate director and assistant director, Patient Services Di rectorate, Lovell FHCC, North Chicago, IL, June 29.
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From page 143... ...
2002. The Department of Veterans Affairs and the Department of Defense report on health care resource sharing, FY 2002.
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