# Presentation: 149519

## Briefing on Draft National CARES Plan

**Briefing on Draft National CARES Plan**
***August 6, 2003***

## Definitions (Hand out)

**CARES**
**VISNs**
**Critical Access Hospitals**
**Access guidelines**
**Market share**
**Planning Initiatives**
**Small facilities**
**CBOCS**

## Why CARES?

**Need to realign campuses to reflect ****changes in VA healthcare delivery**
**Meet the needs of an aging veteran population **
**Aging infrastructure—average building is over 50 years old**
**Congressional reluctance to provide capital funds without a strategic plan for capital investment **
**GAO report critical of vacant space**

## Scope of CARES

**Condition and functionality of all VHA space was assessed**
**Vacant space was assessed**
**Expected demand for outpatient and acute inpatient  care based upon matching to private sector utilization**
**Realignment of 2 division campuses**
**Facility and service consolidations**
**Future mission of small facilities**

## Facilities Overview

**VA owns 5,044 buildings; 118.5 million sq. ft.**
**Average age of VA buildings is 50.4 years**
**Life cycle replacement at current rate of investment is 155 years**
**162 Medical Centers**
**677 Community-based outpatient clinics**
**137 Nursing home units**
**43 Domiciliaries**

## CARES Process 

**Identified Markets (planning unit)**
**Projected enrollment & utilization for each market & facility by age, gender, priority group**
**Planning Initiatives to address: **
**Capacity (workload)**
**Access (driving time)**
**Efficiency/Quality (vacant space, small facilities, proximity, realignments, & consolidations) **
**Special Disability Programs (SCI & Blind Rehab)**
**VISNs developed Market Plans**
**Review Process (VHA, Independent CARES Commission, Secretary)**

## Collaboration

**VBA: 6 high priority regional benefits office co-locations**
**NCA: 7 high priority future cemetery use   opportunities**
**DoD: 21 high priority collaborations/joint ventures**

## Outreach & Communication

** ****Stakeholder outreach:**
**- Veteran Service Organizations (national, state, and local levels)**
**- Congressional Delegations**
**- Academic Affiliates**
**- Employees**
**- Unions**
** ****Communication vehicles deployed across the ****	****country:**
** ****	****	****- CARES Web Site**
**	****	****- News Releases**
**	****	****- Videos**
**	****	****- Fact Sheets, Brochures, and Posters**

## Reasons for Realignments

**Quality of care: surgical and medical realignments – low volume to high volume sites**
**Improve access by moving services closer to concentration of veterans **
**Inefficient footprint on campus**
**Significant amount of vacant space**
**Potential operational savings**
**Excessive capital costs for renovations of existing campus**
**Enhanced-use leasing for assisted living facility or other compatible uses**

## Expected Results

**Prepare for future demand**
**Increase of >12.1 million clinic stops**
**Reduction of 600 acute hospital beds**
**Private sector contracts to meet peak load demand and access**
**Quality of Care**
**Small facilities: 7 Critical Access Hospitals (CAH)**
**Realignments of medicine and surgery**
**     **

## Expected Results

** ****Access (driving time) to care**
**Improve hospital access from 72% to 84% enrollees meeting guidelines**
**Maintained high level of outpatient access: 74% of enrollees meet guidelines **
**48 high priority CBOCs**
**2 new hospitals (Orlando & Las Vegas)**
**  ****Special populations**
**2 new Blind Rehabilitation Centers**
**4 new Spinal Cord Injury Centers**
**5 expansions of SCI LTC beds**

## Expected Results

**Realignments and consolidations**
**Substantial renovations and some expansions required as consolidations take place**
**3.6 million sq. ft. (minimum) of vacant space eliminated**
**13 potential major campus realignments**
**3 campus foot print realignments**
**7 campuses change to critical access hospitals**
**11 facilities consolidating some services**

## Timeline

**Draft CARES Plan to CARES Commission****	****8/4**
**Notice in *****Federal Register                             *****8/7**
**	****	****	****	**
**CARES Commission review & hearings****	****8/4-10/4**** **
**Commission Recommends to Secretary****	****11/30**
**Secretary decision                                      ****	****12/30**
**Integrate capital requirement from ****	****	****FY 2004-**
**	****plan into budget    ****	****	****	****	****      future years****	****      ****	****	****	****	****	****	****	****	****	**

## VISN 1

_**Massachusetts**_
**Veteran population: 538,052   Enrollees: 112,878              Market Share: 21%**
** **_**Bedford**_**:**
** ****Realign inpatient care to Brockton; domiciliary to ****	****Northampton; and nursing home care to Manchester, ****	****Brockton, and community nursing homes**
** ****Outpatient services remain at Bedford and will absorb the ****	****Lowell, MA clinic when its lease expires**
** ****Enhanced-use leasing of 184 acres for assisted living ****	****facility and other compatible uses**
_**Boston**_**:**
** ****Study the feasibility of redesigning the Jamaica Plains ****	****campus for operational savings and to maximize the ****	****potential for enhanced-use leasing for assisted living or ****	****other compatible uses**
** ****Retain multi-disciplinary  outpatient clinic**
** ****Cost efficiencies are expected from consolidation to fewer ****	****buildings**
_**Other Massachusetts Proposals**_**:**
** ****In-house expansions at Brockton and West Roxbury**
** ****Leased expansion at Northampton**

_**Rhode Island**_
**Veteran population: 98,787   Enrollees: 22,075              Market Share: 22%**
** ****In-house expansion and improvements at Providence**
** ****Expansion of existing outpatient clinics**
** ****Increase use of community contract services**
_**Maine**_
**Veteran population: 150,809   Enrollees: 36,412              Market Share: 24%**
** ****In-house expansion and improvements at Togus ****	**
** ****Improve access to inpatient and outpatient care through ****	****community contract services**

## VISN 1 (cont’d)

_**New Hampshire**_
**Veteran population: 135,612   Enrollees: 28,248              Market Share: 21%**
** ****In-house expansion and improvements at Manchester **
** ****Expand  outpatient clinics to include mental health**
** ****Improve access to inpatient and outpatient care through ****	****community contract services**
_**Vermont**_
**Veteran population: 61,410   Enrollees: 17,011              Market Share: 28%**
** ****In-house expansion and improvements at White River ****	****Junction**
** ****Expand  outpatient clinics to include mental health**
** ****Improve access to inpatient and outpatient care through****	****community contract services**

_**Connecticut**_
**Veteran population: 297,244   Enrollees: 64,226              Market Share: 22%**
** ****Improve conditions and expansion of existing capacity ****	****using vacant space at West Haven and Newington**
** ****Expand existing outpatient clinics**
** ****Increase use of community contract services**
** ****VARO  will relocate to Newington ****	**

## VISN 2

_**New York (Upstate)**_
**Veteran population: 1,296,431   Enrollees: 430,908              Market Share: 33%**
_**Canandaigua**_**:**** **
**Transfer services to Bath, Batavia, and Syracuse**
** ****Outpatient care will be absorbed by expanding current sites and adding contracted ****	**** or leased outpatient clinics**
** ****Consolidation will result in improved access to care for ****	****veterans**
** ****Explore enhanced-use leasing for assisted living and other compatible uses**
** ****Enhance access to inpatient and outpatient care in Finger Lakes area through ****	****community contract services**
_**Syracuse**_**:**** **
** ****New 30-bed Spinal Care Injury Unit**

## VISN 3

_**New York**_
**Veteran population: 1,296,431   Enrollees: 430,908              Market Share: 33%**
_**Montrose**_**: **
** ****Transfer acute inpatient medicine, psychiatry and ****	****domiciliary services to Castle Point **
** ****Convert campus to outpatient services facility**
** ****Enhanced-use leasing for assisted living and other ****	****compatible uses**
_**Castle Point**_**:**
** ****Retain acute medicine beds, as CAH**
** ****Transfer the Spinal Cord Injury LTC beds  to the Bronx, ****	****but retain SCI outpatient clinic**
_**New York City (Manhattan & Brooklyn)**_**:**** **
** ****Study the feasibility of consolidating inpatient care at ****	****Brooklyn **
** ****Maintain significant outpatient primary and specialty ****	****care presence in Manhattan at the current site or another ****	****appropriate site**
** ****Enhanced-use leasing for assisted living facility and ****	****other compatible uses at  Manhattan**

_**St. Albans**_**: **
** ****Build new facilities for outpatient, nursing home and    domiciliary care, and demolish existing buildings**
** ****Design the new facilities to maximize the area available for enhanced-use leasing for assisted living or other ****	****compatible uses**
_**Bronx**_**:**
** ****Absorb additional inpatient workload transferred from Castle Point.**
** ****Renovate the current Spinal Cord Injury unit to manage    additional patients from Castle Point**
_**New Jersey**_
**Veteran population: 646,264  Enrollees: 132,685:**
**Market Share: 21%****                                                                                                      **
_**Lyons (NJHCS)**_**:**
** ****Renovate nursing home care unit**
** ****Co-locate Newark VARO**
_**East Orange (NJHCS)**_**:**
** ****Retain SCI/D beds (delay proposed tx to Bronx)**

## VISN 4

_**Pennsylvania**_
**Veteran population: 1,239,157   Enrollees: 289,588              Market Share: 23%**
** **_**Pittsburgh Health Care System**_
** ****Realign services from Highland Drive to University Drive ****	****and Aspinwall with new facilities for psychiatry, mental ****	****health, and related research and administrative services**
** ****Enhanced-use leasing for assisted living facility and other ****	****compatible uses at Highland Drive **
_**Butler**_**:**
** ****Consolidate acute and complex services to Pittsburgh    (also use community contract emergent care)**
** ****Retain nursing home and outpatient services at Butler**
** ****Enhanced-use leasing for assisted living facility and other ****	****compatible uses**
_**Erie**_**:**
** ****Consolidate inpatient surgical services to ****	****Pittsburgh and contract  in local community**
** ****Retain outpatient surgery, acute medicine, nursing home, and outpatient care services**
**	**

_**Altoona**_**:**
** ****Consolidate acute care services to Pittsburgh ****	****and convert critical access hospital as ****	****bed need diminishes approaching 2012**
** ****Retain outpatient and nursing home ****	****care**
_**Other Pennsylvania Proposals**_**:**
** ****Expand outpatient  care services at all 5 ****	****facilities in the eastern market**
** ****Nursing home construction and renovations at ****	****Lebanon and Coatesville**
**SCI Outpatient Clinic at Philadelphia**
_**Delaware**_
**Veteran population: 83,036 Enrollees: 17,667 Market share: 21%**
_**Wilmington**_**:**
**Service consolidations in progress w/ Philadelphia**

## VISN 5

_**Maryland**_
**Veteran population: 506,390   Enrollees: 91,175              Market Share: 19%**
** **_**Perry Point**_**:**
** ****Maintain services, but redesign campus to maximize ****	****enhanced-use potential for assisted living facility and other compatible uses**
_**Other Maryland Proposals**_**:**
** ****New DoD Joint Venture Clinics at Fort Meade and ****	****Fort Detrick**
** ****Expand existing outpatient clinics and include ****	****mental health**
** ****Enhanced-use lease of assisted living facility and ****	****other compatible uses at Fort Howard**

_**District of Columbia**_
**Veteran population: 42,087   Enrollees: 15,855              Market Share: 38%**
** ****In-house expansion at Washington, including ****	****parking**
** ****Expansion of existing outpatient clinics to include ****	****mental health **
** ****New DoD Joint Venture Clinic at Fort Belvoir**
** ****Joint venture with the Armed Forces Retirement ****	****Home for domiciliary program**
** ****Increase use of contract services for outpatient ****	****care**

## VISN 6

_**West Virginia**_
**Veteran population: 197,943   Enrollees: 72,593              Market Share: 37%**
** **_**Beckley**_**:**
** ****Convert to Critical Access Hospital**
** ****Convert inpatient surgery beds to surgery observation ****	****beds**
** ****Construct a replacement nursing home **
_**Other West Virginia  Proposals**_**:**
** ****In-house expansions at the Martinsburg and Huntington**
** ****Expand nursing home at Clarksburg Medical Center**
** ****Expand existing outpatient clinics**
** ****Increase use of contract services**

_**North Carolina**_
**Veteran population: 785,483   Enrollees: 159,903              Market Share: 20%**
** ****Renovate existing infrastructure and construct new space ****	****to address increasing demand for both inpatient and ****	****outpatient care at Asheville, Durham, Fayetteville, and ****	****Salisbury **
**Establish six additional outpatient clinics**
_**Virginia**_
**Veteran population: 772.295   Enrollees: 142,282              Market Share: 18%**
** ****Renovate existing infrastructure and construct new space ****	****to address increasing demand for both inpatient and ****	****outpatient care at Hampton, Richmond, and Salem **
** ****Establish three additional outpatient clinics**

## VISN 7

_**Alabama**_
**Veteran population: 440,644   Enrollees: 109,372              Market Share: 25%**
** **_**Montgomery**_**:**
** ****Study  feasibility of converting Montgomery to an ****	****outpatient clinic and contracting for inpatient care**
_**Other Alabama Proposals:**_
** ****Establish five additional outpatient clinics **
**Contract for inpatient care at Dothan and Huntsville ****	****	**
**        **_**South Carolina**_
**Veteran population: 417,547   Enrollees: 102,975              Market Share: 25%:**
** ****Contract for inpatient care at Greenville, SC and ****	****Savannah, GA**
** ****Establish five additional outpatient clinics**

_**Georgia**_
**Veteran population: 759,539   Enrollees: 153,144              Market Share: 20%**
_**Augusta**_**:**
**Study feasibility of realigning the two campuses ****	****including feasibility of consolidating services to the****	****Downtown Division or other VA facilities**
** ****Explore enhanced-use lease possibilities at the Uptown ****	****Division for assisted living and other compatible uses**
**Add 20 Spinal Cord Injury beds to the existing unit.**
_**Dublin**_**:**
** ****Reduce the scope of practice for surgery; refer ****	****complex  non-urgent/emergent surgeries to other VAs**
**Contract for urgent, acute, and inpatient surgical care**
** ****Retain acute medicine, nursing home care, domiciliary ****	****and  outpatient services**
** ****Establish two additional outpatient clinics **
_**Other Georgia Proposals:**_
** ****Establish eight additional outpatient clinics**

## VISN 8

_**Florida**_
**Veteran population: 1, 860,576   Enrollees: 457,792              Market Share: 25%**
** **_**Lake City**_**:**
** ****Study feasibility of transferring inpatient surgery beds to ****	****Gainesville ****	**
** ****Study feasibility of transferring acute medicine beds when ****	****proposed new Gainesville bed tower is complete **
**Establish four additional outpatient clinics **
_**Tampa:**_
** ****Add 30 bed wing for Long Term SCI  to existing SCI building **
_**Orlando**_**:**
** ****Build inpatient tower**

_**Other Florida Proposals:**_
** ****Expand community contract services for inpatient ****	****services in the Ft. Myers area**
** ****Expand existing outpatient clinics **
** ****Contract for acute medical care at Jacksonville ****	****Shands**
** ****Establish DoD joint venture at Jacksonville for ****	****inpatient care**
_**Puerto Rico:**_**Veteran population: 144,839 Enrollees: 72,150  Market share: 50%**
** ****Expanding outpatient specialty care through leasing **
**	**
**	**

## VISN 9

_**Kentucky**_
**Veteran population: 375,153   Enrollees: 97,668              Market Share: 26%**
** **_**Lexington**_**:**
** ****Consolidate Leestown outpatient care and nursing home ****	****unit to Cooper Drive**
** ****Enhance-use lease for assisted living and other compatible ****	****uses to improve services for veterans**
_**Other Kentucky Proposals:**_
** ****Expand the Fort Knox outpatient clinic for additional ****	****primary care and outpatient mental health**
** ****Increase use of telemedicine to support specialty care ****	****needs**
** ****Expand existing outpatient clinics to include mental health **
** ****Increase the use of community contract services**

_**Tennessee**_
**Veteran population: 554,387   Enrollees: 121,323             Market Share: 22%**
** **_**Memphis**_**:**
** ****Add 20 Spinal Cord Injury long-term care beds in the ****	****existing Memphis unit**
_**Nashville & Murfreesboro**_**:**
** ****Consolidate acute medicine at Nashville and retain a ****	****minimum number of medicine beds at Murfreesboro**
_**Other Tennessee Proposals:**_
** ****Expand in-house and contract care for inpatient and ****	****selected specialty care in the Chattanooga and Knoxville ****	****areas**
** ****Increase use of telemedicine to support specialty care ****	****needs**
** ****Expand existing outpatient clinics to include mental health **
** ****Increase the use of community contract services**
** ****Expand National Cemetery capacity at Mountain Home **

## VISN 10

_**Ohio**_
**Veteran population: 1,109,826   Enrollees: 229,519              Market Share: 21%**
** **_**Columbus**_**:**
** ****Build new Ambulatory Specialty Care Center to expand ****	****existing outpatient specialty care **
_**Cleveland:**_
** ****Consolidate Cleveland’s dual division medical center ****	****activities at Wade Park from the Brecksville Division**
** ****Explore possibilities for enhanced-use leasing for assisted ****	****living and other compatible uses at Brecksville**

_**Other Ohio Proposals:**_
** ****Construct new nursing home care unit at ****	****Cleveland-Wade Park, including 20-bed ****	****SCI LTC unit**
** ****Provide additional parking at Cincinnati through ****	****enhanced-use leasing of quarters**
** ****Increase use of contract services for hospital care ****	****in the Columbus and Canton area**
** ****Facility condition improvements at all locations**

## VISN 11

_**Indiana**_
**Veteran population: 575,817   Enrollees: 119,482              Market Share: 21%**
_**Ft. Wayne**_**:**
** ****Transfer acute inpatient medicine and surgery services to ****	****the Indianapolis, Ann Arbor, or Detroit or to community ****	****contracts**
** ****Retain  outpatient care at current site or another suitable location**
** ****Explore enhanced-use lease possibilities for assisted living ****	****or other compatible uses**
_**Illinois**_
**Veteran population: 969,012   Enrollees: 235,398              Market Share: 24%**
_**Danville**_**:**** **
** ****Develop an enhanced-use lease for the nursing home unit ****	****to address space deficiencies**
** ****Demolish 157,555 square feet to reduce vacant space **
_**Other Illinois Proposals**_**:**
** ****Improve inpatient access in Western Illinois through ****	****hospital contracts**

_**Michigan**_
**Veteran population: 884,911   **
**Enrollees: 129,735  Market Share: 15%**
_**Saginaw**_**:**
** ****Transfer inpatient services from to Detroit or Ann ****	****Arbor or to community contracts**
**Retain NHCU and outpatient clinics**
_**Battle Creek**_**:**** **
**Enhanced-use lease for a new mental ****	****health  clinic and a new residential psychiatric and  ****	****rehabilitation “veterans village” owned and ****	****operated by the private sector**

## VISN 15

_**Kansas**_
**Veteran population: 261,627   Enrollees: 61,902              Market Share: 24%**
_**Leavenworth & Topeka**_**:**** **
** ****Continue ongoing realignment**
** ****Consolidate inpatient psychiatry and PTSD services at ****	****Topeka**
** ****Expand intensive outpatient substance treatment capacity ****	****and consolidate nursing home care beds at Leavenworth**
** ****Implement a “surgi-center” and retain acute inpatient ****	****capacity (38 beds) at Leavenworth**
** ****Retain 24/7 emergency services at both campuses**
_**Other Kansas Proposals**_**:**
**	****Expand current primary care sites and community ****	****contracting**

_**Missouri**_
**Veteran population: 579,815   Enrollees: 129,144              Market Share: 22%**
_**Poplar Bluff**_**:**
** ****Retain as Critical Access Hospital**
_**Other Missouri Proposals**_**:**** **
**Expand current facilities and community contracts**

## VISN 16

_**Mississippi**_
**Veteran population: 247,253   Enrollees: 74,468              Market Share: 30%**
_**Gulfport & Biloxi**_**:**** **
** ****Transfer all Gulfport health care services to Biloxi or ****	****Keesler Air Force Base**
**Enhanced-use leasing for assisted living facility and other compatible uses at Gulfport**
** ****Renovate Biloxi nursing home**
** ****Establish 36-bed Blind Rehabilitation Center at Biloxi**
_**Oklahoma**_
**Veteran population: 369,975   Enrollees: 91,399              Market Share: 25%**
_**Muskogee**_**:**
** ****Study the feasibility of expanding psychiatry**
** ****Retain acute medicine beds and outpatient care**
** ****Maintain outpatient surgery and transfer or contract ****	****inpatient surgery beds **
_**Other Oklahoma Proposals**_**:**
** ****Expand capacity for inpatient care through renovation ****	****projects at Oklahoma City**
_**Houston, TX & vicinity:**_
**Expand capacity for outpatient care through CBOCs**

_**Arkansas**_
**Veteran population: 278,907   Enrollees: 91,015              Market Share: 33%**
_**Little Rock**_**:**** **
** ****Establish a new 30-bed Spinal Cord Injury Unit **
** ****Expand capacity for inpatient medicine and psychiatry ****	****through renovation projects**
_**Louisiana**_
**Veteran population: 384,809   Enrollees: 99,247              Market Share: 26%**
** ****Establish three new outpatient clinics **
**Address nursing home space deficiencies through ****	****renovation projects at Shreveport and Alexandria**
_**Pensacola & FL panhandle**_**:**
** ****Develop a joint venture with the Pensacola Naval Hospital ****	****to relocate the VA output clinic & expand inpatient services **
** ****Expand the Panama outpatient clinic**
** ****Develop sharing agreements with the Eglin and Tyndall Air ****	****Forces Bases to cover a broad range of services**

## VISN 17

_**Texas**_
**Veteran population: 1,723,299   Enrollees: 407,528              Market Share: 24%**
_**Kerrville**_**:**** **
** ****Consolidate acute inpatient care to San Antonio when ****	****proposed inpatient construction is complete (in the interim, ****	****operate as a Critical Access Hospital)**
** ****Retain nursing home and outpatient services**
** ****Explore assisted living **
_**Marlin**_**: **
** ****Establish new multi-specialty outpatient clinic in the area**

_**Waco**_**:**
** ****Transfer inpatient services to Temple**
** ****Lease 27 inpatient psychiatry beds in Austin and contract ****	****for nursing home care**
** ****Provide outpatient care at a new clinic between Waco and ****	****Marlin**
_**Other Texas Proposals:**_
** ****Improve access to specialty and hospital services in ****	****Austin, Harlingen, and Corpus Christi through new clinics ****	****and contracts**
** ****Improve service at San Antonio and Dallas through new ****	****construction and transferring high demand specialty care ****	****to larger clinics**

## VISN 18

_**Texas**_
**Veteran population: 1,723,299   Enrollees: 407,528              Market Share: 24%**
_**Big Spring**_**:**** **
** ****Convert to a CAH**
**Study the feasibility of transferring acute inpatient, ****	****outpatient specialty, nursing home, and mental health care ****	****to the Odessa/Midland area**
** ****Close inpatient surgery and use community contract care**
** ****Expand outpatient clinic to a multi-specialty ****	****outpatient clinic in Odessa/Midland area**
_**Other Texas Proposals:**_
** ****Expand joint venture with DoD, William Beaumont AMC at El Paso **
_**New Mexico**_
**Veteran population: 188,653   Enrollees: 52,598              Market Share: 28%**
** ****Enhance access to hospital, emergency, mental health, and ****	****psychiatry care through contracts at Roswell and other ****	****locations in New Mexico**

_**Arizona**_
**Veteran population: 564,386   Enrollees: 126,320              Market Share: 22%**
_**Prescott**_**:**_** **_
** ****Retain acute beds & increase inpatient and specialty care ****	**
_**Phoenix & Tucson**_**: **
** ****Expand capacity for medicine and psychiatry services**
_**Other Arizona Proposals**_**:**
** ****Enhance access to specialty services by expanding ****	****services at existing clinics and through community ****	****contracts**

## VISN 19

_**Wyoming**_
**Veteran population: 57,550   Enrollees: 19,598              Market Share: 34%**
_**Cheyenne**_**:**** **
** ****Retain acute beds, but convert to Critical Access Hospital **
** ****Transfer some inpatient services to Denver or contract**
_**Colorado**_
**Veteran population: 441,490   Enrollees: 75,651              Market Share: 17%**
_**Denver**_**:**_** **_
** ****Build a replacement hospital on the Fitzsimmons campus **
** ****Build a 30-bed Spinal Cord Injury Center in ****	****replacement facility**
** ****Build a nursing home**
** ****Demolish old facility and explore enhanced-use lease ****	****opportunities for assisted living and other compatible uses**
_**Grand Junction**_**:**_** **_
** ****Convert to a Critical Access Hospital**

_**Montana**_
**Veteran population: 107,092   Enrollees: 30,559              Market Share: 29%**
** ****Expand in-house outpatient care at Fort Harrison ****	**
** ****Expand existing outpatient clinics**
** ****Improve access to hospital care through increased ****	****community contracts**
_**Utah**_
**Veteran population: 160,339   Enrollees: 33,171              Market Share: 21%**
** ****In-house expansion at the Salt Lake City**
** ****Expand existing outpatient clinics**

## VISN 20

_**Washington State**_
**Veteran population: 657,653   Enrollees: 117,679              Market Share: 18%**
** **_**Vancouver**_
** ****Study feasibility of**_** **_**contracting for nursing home and ****	****relocating outpatient services to another location **
** ****Explore enhanced-use lease possibilities for assisted living ****	****or other compatible uses**
_**Walla Walla**_**:**
** ****Contract for acute medical care and psychiatry**
** ****Relocate nursing home care to Spokane and/or contract**
** ****Retain outpatient care**
** ****Explore enhanced-use lease possibilities for assisted living ****	****or other compatible uses**
_**Alaska**_
**Veteran population: 69,216   Enrollees: 20,511              Market Share: 23%**
** ****Establish new ambulatory care clinic in Anchorage**
** ****Increase community contract services**
** ****Co-locate a VARO**
** ****Pursue DoD collaborations **

_**Oregon**_
**Veteran population: 381,616   Enrollees: 84,257             Market Share: 22%**
_**White City**_**:**
** ****Study feasibility of realigning domiciliary to other VA ****	****facilities**
** ****Maintain outpatients services on White City campus or ****	****other appropriate site**
** ****Explore enhanced use- lease possibilities for assisted ****	****living or other compatible uses**
_**Idaho**_
**Veteran population: 136,932   Enrollees: 32,134             Market Share: 23%**
** ****In-house expansion at Boise Medical Center**
** ****Expand the outpatient clinic**
** ****Increase use of community contract services for outpatient ****	****care**
** ****DoD collaboration with Mountain Home Air Force Base**

## VISN 21

_**California**_
**Veteran population: 2,460,890   Enrollees: 491,402            ****	**** **
**Market Share: 20%**
_**Livermore**_**:**** **
**Consolidate two thirds of NHCU beds to Menlo Park; remaining beds to be ****	****contracted locally**
**Expand outpatient care at San Joaquin and in the East Bay**
_**San Francisco & Palo Alto**_**:**
**Consolidate selected administrative and clinical services between San Francisco and Palo Alto**
_**Other (VISN 21) California Proposals**_**:**
** ****Seismic improvements at  Palo Alto, San Francisco, & Fresno.**
** ****Enhanced-use lease project for assisted living at Menlo Park**
** ****Enhanced-use lease project for Eye Institute at Palo Alto**
** ****Enhanced-use lease project for research with UCSF **

## VISN 21(cont’d)

_**Hawaii**_
**Veteran Population: 117,887    Enrollees:  24,391    Market Share:  21%**
**Impact of CARES on Hawaii:**
_**Hawaii**_
*******	****Enhanced access to hospital, tertiary and specialty care through expanded Joint Venture with Tripler AFB.**
*******	****Primary Care space will increase by more than 150%.**
*******	****Access to Residential Rehabilitation services will improve through new lease for 12,500 sq. ft. of additional space.**
*******	****Expansion of research facilities at Honolulu.**
*******	****$7.8 million in proposed construction and renovation projects.**
*******	****No services or facilities in Hawaii are proposed to be curtailed or downsized.**

## VISN 22

_**California**_
**Veteran population: 2,460,890   **
**Enrollees: 491,402            Market Share: 20%**
_**Los Angeles**_**:**
** ****New construction at West Los Angeles to ****	****consolidate all care and accommodate the co-****	****location of VARO**
** ****Construct replacement nursing home at West ****	****Los Angeles**
** ****Make North campus available for a state nursing ****	****home, national cemetery or other enhanced uses**
_**Long Beach**_**:**
** ****Establish new 24-bed Blind Rehabilitation Center**
** ****Convert 30 SCI beds to LTC SCI beds **
_**Other California Proposals**_**:**
** ****Seismic improvements at West L.A., Long Beach, ****	****and San Diego**
**Demolish buildings at Sepulveda to maximize enhanced use potential**

_**Nevada**_
**Veteran population: 240,375   Enrollees:  63,012         Market Share: 26%**
_**Las Vegas**_**:**
**Construct new hospital in Las Vegas to ****	****incorporate current plans for a multi-****	****specialty outpatient clinic**
** ****Establish a new nursing home**
_**Other Nevada Proposals**_**:**
** ****Expand inpatient tertiary care at Reno ****	****Medical Center**
** ****Expand use of local contracts**

## VISN 23

_**Minnesota**_
**Veteran population: 454,385   Enrollees: 90,858               Market Share: 20%**
** **_**Minneapolis**_**:**
** ****Build 30-bed Spinal Cord Injury unit**
_**St. Cloud**_**:**
** ****Relocate acute medicine to Minneapolis and contract in the ****	****local community for inpatient care**
** ****Psychiatry, nursing home, domiciliary and outpatient care ****	****would remain in St. Cloud**
_**South Dakota**_
**Veteran population: 78,384   Enrollees: 31,296                Market Share: 40%**
_**VA Black Hills Health Care System**_**:**
** ****Hot Springs converts to a critical access hospital**

_**Iowa**_
**Veteran population: 285,812   Enrollees: 73,026  Market Share: 26%**
_**Knoxville**_**:**
** ****Transfer inpatient, acute, long-term, and domiciliary ****	****care ****	****to Des Moines**
** ****Outpatient Clinic remains in Knoxville**
_**North Dakota**_
**Veteran population: 60,018   Enrollees: 20,452  Market Share: 34%**
** ****Increase specialty care**
** ****Increase access through increased community ****	****contracts**

## VISN 23 (cont’d.)

_**Western Wisconsin**_
**Veteran population: 503, 056   Enrollees: 102,833           **
**Market Share: 20%**
** ****Establish one new outpatient clinic**
** ****Increase use of community contract hospital services**
_**Nebraska**_
**Veteran population: 169,898   Enrollees: 46,861              **
**Market Share: 29%**
** ****In-house expansion at the Omaha Medical Center**
** ****Renovate Omaha ICU**
** ****Renovate NHCU**
** ****Increase use of community contracts for outpatient services**

## “You cannot escape the responsibility of tomorrow by evading it today.” 

**Abraham Lincoln**
**Visit CARES at:  http://www.va.gov/CARES**