# Presentation: 643887

## C

- ARES

**Capital Asset Realignment for Enhanced Services**

**Department of Veterans Affairs****Veterans Health Administration**

**VSO Planning Initiatives Briefing**
**November 21, 2002**

## Outline of Presentation

**CARES Enrollment & Utilization Projections**
**Planning Initiative Identification Process**
**Planning Initiative Results**
**Market Area Examples**

## Fiscal Year Enrollment Forecasts by Priority Groups

- Enrollment (in millions)

## Fiscal Year Market Share Forecasts by Priority Groups

**% Market Share**

## 157% Washington, V5

- 170% E. Southern, V16

- 150% Far North, V1

- 136% East Southern, V16

- -17% Northern, V9

- -63% Puerto Rico, V8

- -70% Central Illinois, V11

- -65% South Valley, V21

## Nursing Home Policy

** ****Large NHC demand in VA LTC model - add 17,000 beds system-wide by 2022**
** ****Review model**
** ****Decision to not have Nursing Home PIs**
** ****However, Market Plans can:**
**Convert acute beds**
**Rebuild **
**Renovations**
**Use vacant space**

## 192% Valley-Coastal Bend, V17

- 136% Long Island, V3

- 256% Valley-Coastal Bend, V17

- -69% Finger Lakes, V2

- -40% wyoming, V19

- -9%, Western, V2

## Outpatient Mental Health

**The demand model projects a number of markets with reductions in forecasted outpatient mental health visits.**
**NCPO is working to understand the dynamics of the model that contributed to this result.**
**As such, decision was made to not include outpatient mental health, negative workload GAPS, as Planning Initiatives**

## Domiciliary Policy

**Forecasting model results in the redistribution of DOM beds from existing DOMs to other areas without DOMs.**
**Since this occurred without a policy review, it is inappropriate to select DOM PIs from these forecasts.**
**However, DOMs may be included in Market Plans to reuse vacant space or as a result of realignments (especially when homelessness or residential rehab is the focus of Dom bed use).**

## Planning Initiative Selection Process

## Goal of PI Review Process

**   ****To **_**identify PIs**_** that will improve the capacity to provide high quality & accessible services to veterans through the allocation of capital resources and eliminating vacant space.**

## Participants

**DOD, Navy, Army, Air Force**
**NCA**
**VBA**
**Special Populations****	****TBI****	****Blind Rehab****	****SCI**
**Mental Health**
**	****VISN Reps, Clinicians, VSSC, NCPO**

## Teams 

** ****Planning Initiative Selection Teams (10)**
_**Multi Disciplinary Teams**_
**NCPO/VSSC Leadership**
**VA Representatives from each Impacted VISN**
**Clinicians **
**VA Representatives from Outside Impacted VISNs **
**All teams used same Process & Thresholds **
**Teams apply Criteria, Judgment & Rationale to the Process**
**NCPO Review & Standardization Team Reviewed Output**
**Special Disability Groups - Review Team**

## Selecting Access Gaps

_**Primary Care**_** **
**Less than **70% of enrollees** within **30 minutes**  **_**and**_
**At least **11,000 enrollees **are outside **30 minutes** driving time from Primary Care**
_**Acute Inpatient Care**_
**Less than **65%** within **60 minutes** driving time **_**and**_
**At least **12,000 enrollees** are outside                     **60 Minutes** drive time from nearest hospital**

## Selecting Access Gaps

**Tertiary Hospital Care**
**Less than **65% of enrollees** are within **4 Hours** driving time; **_**and**_
**At least **12,000 enrollees** are outside **4 Hours** Driving Time of a Tertiary Hospital**

## Selection Thresholds

**Demand Gaps**** **
**Note: (No negative gaps addressed by PI Teams for outpatient mental  health) **
**Significance: Gap = or ****> ± ****25% **
**Volume: **
**Inpatient: ****> ±**** 20 beds **
**	****  ****Outpatient:  **** ****> ± ****26,000 PC and Geriatric ****                       **** ****> ± ****30,000 Specialty visits****                        > + 16,000 Mental Health**
**Proximity of acute and tertiary: 60 and 120 miles**** **
**Small Facility Planning Initiatives - **
**Must have forecast 40 beds or less in both 2012 and 2022**

## Selection Thresholds: Demand Gaps: Number: 3 or 4 ( per VISN)

**Strong trend: Meet 25% and absolute volume gaps in 2012 and 2022 and are same trend forecast **
**Moderate trend: Meets criteria in one  year but not the other: Team choice**
**Peaks at 2012 but decrease in 2022 : Team choice**
**High volumes but below 25%**

## Planning Initiative Selection Process

**Collaborative Issues**
**EU**
**VBA**
**NCA**
**DOD**

## Results from the Planning Initiative Review Process

## Collaborations

** ****EUSE:  18 Opportunities**** **
** ****NCA:    12  Opportunities**
** ****VBA:    13  Opportunities**
** ****DoD:    59 Opportunities (included all VISNs)**

## Number Of Access Planning Initiatives

**  ****15 of the 20 VISNs have Access PIs**
**  ****There were 33 Hospitals in 15 VISNs with Access Gaps**
** ****There were 29 Primary Care Access Gaps in the 15 VISNs**

## Number of Demand Planning Initiatives: CARES Categories

| CARES Categories | Number of Planning Initiatives > + or - 25% Gap |
| --- | --- |
| Medicine | 37 |
| Surgery | 8 |
| Psychiatry | 38 |
| Primary Care | 58 |
| Specialty Care | 71 |
| Mental Health | 14 |
| Total | 226 |

## FY2022 Projected Gaps in Beds for Inpatient CARES Categories

| CARES Categories | Number of Net Beds Impacted |
| --- | --- |
| Medicine | 85 |
| Surgery | -550 |
| Psychiatry | -510 |
| Totals | -975 |

## FY2022 Projected Gaps in Clinic Stops for Outpatient CARES Categories

| CARES Categories | Number of Clinic Stops Impacted |
| --- | --- |
| Primary Care | + 3,747,240 |
| Specialty Care | + 8,635,296 |
| Mental Health | + 300,000 |
| Totals | + 12,382,536 |

## Small Facilities Planning Initiative: Beds 2012 and 2022(20 identified)

**Castle Point   14 10**
** ****Wilmington   39 30**
** ****Altoona         18 13**
** ****Butler              9   7**
** ****Erie                13  9**
** ****Beckley         15 11**

**Ft Wayne         14 11**
**Saginaw          21 16**
**Poplar Bluff    15 11**
**Muskogee       36 27**
**Kerrville          15 11**
**Prescott          25 18**

-        BEDS
- FY12    FY22

-        BEDS
- FY12    FY22

## Small Facilities Planning Initiative (cont’d)

** ****Big Spring    31  31**
** ****Cheyenne     15  12**
** ****Grand Junc. 22  16**
**Sioux Falls     40 28**
** **

**Des Moines    32 21**
**Knoxville        28 30**
**St. Cloud        33 24**
**Hot Springs   32 23**

-        BEDS
- FY12    FY22

-        BEDS
- FY12    FY22

## Proximity Planning Groups

**WestRox/Brockton****Providence**
**Brooklyn/NY****Bronx/NY/Brklyn****E.Orange/NY/Brk****Bronx/Brooklyn**
**Highland Dr. ****UD/Aspinwall**
**Phila/Wilminton**

**Balt/Wash DC**
**Augusta/Columbia**
**   ****Columbia/Charlstn**
**Tampa/BayPines**
**    ****Miami/WPB?**
**Nashville/Murf**
**Lex/Louis/Cincin**

## Proximity Planning Groups

**Louisville/Cincin/**** Indianapolis**
**Cincinnati/Dayton**
**Detroit/Ann Arbor**
**KsCity/Leavnworh**
**Gulfcoast HCS: Biloxi/Gulfport**

**Palo Alto/San Fran**
**Long Bch/LosAng**
**Loma Linda/LosAng**
**Loma Lind/SanDieg**
**Long Bch/San Dieg **

## Special Disability Populations

**SDP Team at PI Selection Process**** **
** ****Reviewed all PIs and made comments **** sent to specific VISNs**** **
**Developed advisory comments on including SDP in Market Plans for all VISNs**** **
**Working with CARES model and alternative models to develop PIs for mid January for VISNs**

## Special Disability Populations

**Mental Health group working with NCPO and contractor on CARES model**** **
**Long run is improving CARES model for next CARES or Strategic Planning Cycle **** **
**Concerned over use of CARES data outside of CARES process (advisory information and memo to VISNs)**

## CARES Planning forSpecial Disability Programs

**The unique nature of VA’s Special Disability Programs (SDPs) creates challenges in applying the CARES planning model to them.**
**SDP leaders are active participants in the CARES Planning Initiative (PI) Selection process.**
**PIs developed with the SDP representatives will be incorporated into the Market Plans as soon as available.**
**Legislative mandates for capacity will be maintained and enhanced (whenever there is data to support increased demand).**

## Special Disability Forecasting - Caveats

**VA’s Special Disability Programs (SDPs) provide services for which there are no comparable private sector benchmarks.**
**For some programs, current constraints on utilization may affect the predicted future demand. **
**The CARES model is designed for macro-level planning and is not ideally suited to planning for small program needs.  **
**Thus, modifications of the projection models will be developed and caution is urged in using CARES projections for these programs.**
**General comments follow for each SDP.**

## VISN-Level General IssuesSpecial Disability Programs

- _Blind Rehab:_ **Consider space planning for outpat blind rehab programs (i.e., VISORS, VICTORS, low vision clinics, BROS, & VIST) & restoration of inpat capacity for comprehensive blind rehab centers. **
- _SCI:_ **Maintenance of acute care capacity at SCI Ctr. sites. Specific issues for VISNs 3, 16, 19, 21-23.**

## VISN-Level General IssuesSpecial Disability Programs

_**Dom/Homelessness**_: **Nationally, 44%********(1996-2001) in homeless veterans treated in VA Domiciliary Care for Homeless Veterans (DCHV) and other VA Specialized Programs. Consider involvement of community service providers, EUL, VA Grt/per diem, and other federal funding (e.g., HUD). Outcome studies document successful outcomes: 59% housed and 54% are employed at discharge. **
_**Dom/General**_: **Existing or planned State Veteran Home Domiciliaries should be taken into account in PIs.  Forecasting methodology is based upon national average use rates, which increased beds for VISNs with low use currently and decreased beds for VISN with large numbers of beds:  model assumptions & projections should be re-examined. **

## VISN-Level General IssuesSpecial Disability Programs

- Traumatic Brain Injury (TBI):  **If excess space, consider continuum of service delivery models to address the unique environmental needs of TBI pts.  E.g., coma care, comprehensive inpatient rehab, post-acute care (such as outpatient, home care, voc rehab), community re-entry (transitional living), alternative long term care (LTC) settings (such as assisted living), specialized LTC (such as persistent vegetative) and respite care.  Primary consideration should be given to:**
**Transitional Living for TBI**
**Community Re-entry**
**Independent Living **
**Long Term Care Alternate Living Settings for TBI**
**Neurobehavioral Care **
**Assisted Living**** **

## VISN-Level General IssuesSpecial Disability Programs

- Mental Health (SCMI, PTSD, SA)
**Primary Care/CBOCs –Primary care PI's should include MH services in space planning. **
**SCMI – Mental health leadership at both national and local levels should be included in efforts to address potential reductions in capacity. MH pt population ******** 4%/yr (FY96-FY00) & 6% in FY01.  Forecasting models will be refined to address questions raised by current projections.**
**PTSD – population has increased 58% ******** (FY96-01).  A PTSD demand model to maintain current capacity and accommodate future growth will be developed.**
**Substance Abuse (SA) – an marked decline in the availability of SA services will be addressed through the revised MH demand model.**

## Summary and Conclusions

**Planning Initiative Identification Process has been completed.**
***Next Steps:***
**Market Plan Development by VISN level with assistance of VSSC and National CARES Office**
** ****Participation of VSOs in VISN Planning**
**USH Review of DRAFT National CARES Plan**
**CARES Commission Review and Public Comment**
**Secretary’s review and decision**