Department of Veterans Affairs
	

Office of Inspector General
	

Informational Report
 

Community Based Outpatient
 

Clinic Cyclical Reports
 

Fiscal Year 2012
 

Report No. 11-03653-283 September 20, 2011
	 VA Office of Inspector General
	

Washington, DC 20420
	
To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov(Hotline Information:
 

http://www.va.gov/oig/contacts/hotline.asp)
 
Community Based Outpatient Clinic Cyclical Reports FY 2012
 

Contents
	

Page
	

Executive Summary ..............................................................................................i
 

Purpose 

Appendixes
	

.................................................................................................................1
 

Background ..........................................................................................................1
 

Review Purpose and Objectives .........................................................................1
 

Methodology .........................................................................................................3
 

Topic Review Areas .............................................................................................4
 

Short-Term Fee Basis.................................................................................................. 4
 

Women’s Health .......................................................................................................... 5
 

Diabetes Mellitus-Lower Limb Peripheral Vascular Disease........................................ 6
 

Heart Failure Follow-up ............................................................................................... 7
 

Credentialing and Privileging....................................................................................... 8
 

Environment and Emergency Management................................................................. 8
 

Contract Reviews ............................................................................................................ 9
 

Report Timeline ....................................................................................................9
 

A. OIG Contact and Staff Acknowledgments............................................................ 10
 

B. Report Distribution................................................................................................ 11
 

VA Office of Inspector General 
Community Based Outpatient Clinic Cyclical Reports FY 2012 

Executive Summary
	

As requested in House Report 110-775, to accompany H.R. 6599, Military Construction, 

Veterans Affairs, and Related Agencies Appropriation Bill, fiscal year (FY) 2009, 

the VA Office of Inspector General (OIG) began a systematic review of Veterans 

Health Administration (VHA) community based outpatient clinics (CBOCs) in FY 

2009. The purpose of this report is to describe the review design of the CBOC 

focused topic areas for FY 2012. 

VA Office of Inspector General i 
Community Based Outpatient Clinic Cyclical Reports FY 2012 

DEPARTMENT OF VETERANS AFFAIRS
	

Office of Inspector General
	

Washington, DC 20420
	

SUBJECT:		 Informational Report – Community Based Outpatient Clinic Cyclical 

Reports Fiscal Year 2012 

Purpose 

As requested in House Report 110-775, to accompany H.R. 6599, Military Construction, 

Veterans Affairs, and Related Agencies Appropriation Bill, fiscal year (FY) 2009, the VA 

Office of Inspector General (OIG) began a systematic review of Veterans Health 

Administration (VHA) community based outpatient clinics (CBOCs) in FY 2009. The 

purpose of this report is to describe the review design of the CBOC focused topic areas 

for FY 2012. 

Background 

The Veterans’ Health Care Eligibility Reform Act of 1996 was enacted to equip VA 

with ways to provide veterans with medically needed care in a more equitable and 

cost-effective manner. As a result, VHA expanded the Ambulatory and Primary Care 

Services to include CBOCs located throughout the United States. CBOCs were 

established to provide more convenient access to care for currently enrolled users and 

to improve access opportunities within existing resources for eligible veterans not 

currently served. 

Veterans are required to receive one standard of care at all VHA health care facilities. 

Care at CBOCs needs to be consistent, safe, and of high quality, regardless of model 

(VA staffed or contract). CBOCs are expected to comply with all relevant VA policies 

and procedures, including those related to quality, patient safety, and performance. 

The Office of Healthcare Inspections has conducted reviews at 187 CBOCs, which have 

resulted in 22 published reports as of August 15, 2011. 

Purpose and Topic Area Review Objectives 

The purpose of the cyclical reviews is to assess whether CBOCs are operated in a 

manner that provides veterans with consistent, safe, high-quality health care in 

accordance with VA policies and procedures. The objectives of the focused reviews for 

this identified review period are: 

VA Office of Inspector General 1 
Community Based Outpatient Clinic Cyclical Reports FY 2012 

1.	 Assess Short-Term Fee Basis authorization and follow-up processes for outpatient 

radiology consults including computerized tomography (CT), magnetic resonance 

imaging (MRI), and positron emission tomography (PET) scan in an effort to ensure 

quality and timeliness of patient care in CBOCs. 

a.	 Determine the parent facility’s compliance with established standards, 

regulations, and policies in regards to the authorization of Short-Term Fee 

Basis consults for CBOCs. 

b.	 Determine whether the parent facility has a local policy or guidelines defining 

how Short-Term Fee Basis consults are handled. 

c.	 Determine if VA providers appropriately ordered and followed up on 

Short-Term Fee Basis outpatient radiology procedures (CT, MRI, and PET 

scan) in a timely manner. 

d.	 Determine if Fee Basis payments to primary care providers are in accordance 

with VA reimbursement policies. 

2.	 Evaluate whether CBOCs comply with selected VHA requirements regarding the 

provision of mammography services for women veterans. 

a.	 Determine whether screening mammograms were offered in a timely manner 

to women veterans receiving care at CBOCs and whether results were 

available in the Computerized Patient Record System using required Breast 

Imaging Reporting and Data System (BI-RADS) code categories. 

b.	 Determine whether ordering providers and patients received notification of 

mammography results within timeframes established by VHA. 

c.	 Determine whether non-VA contract mammography facilities providing 

services for CBOC women veterans maintain required certification. 

d.	 Determine whether VHA facilities have established effective oversight of 

mammography services. 

e.	 Determine whether CBOCs have designated women’s health liaisons who 

collaborate with the parent facility Women Veterans Program Manager to 

ensure coordinated and comprehensive care for women veterans. 

3.	 Evaluate the extent CBOCs have implemented the management of Diabetes 

Mellitus-Lower Limb Peripheral Vascular Disease (DM-LLPVD) in order to prevent 

lower limb amputation. 

a.	 Determine whether facilities have developed a system to identify and track 

patients at risk for lower limb amputations as outlined in VHA Directive 2006­

050.1 

b.	 Determine whether at-risk veterans are screened, identified by risk category, 

and referred for follow-up according to VHA Directive 2006-050. 

c.	 Determine whether facilities document education to DM-LLPVD veterans 

about preventive foot care and footwear as outlined in VA/DoD [Department 

1 VHA Directive 2006-050, Preservation-Amputation Care and Treatment (PACT) Program, September 14, 2006. 

VA Office of Inspector General 2 
Community Based Outpatient Clinic Cyclical Reports FY 2012 

of Defense] Clinical Practice Guideline: Management of Diabetes Mellitus 

(DM) and VHA Handbook 1122.01.2 

d.	 Determine whether employees providing diabetic foot care education meet 

the requirements specified in VHA Handbook 1122.01. 

4.	 Evaluate the continuity of care for enrolled CBOC patients discharged from the 

parent facility in FY 2011 with a primary discharge diagnosis of congestive heart 

failure (HF). 

a.	 Determine if discharge plans were addressed in the primary care setting. 

b.	 Determine if providers communicated the “hand off” of patient care to 

optimize continuity. 

c.	 Determine if primary care clinicians include medication, diet, and daily 

management [symptom and /or trigger] interventions in the treatment plans of 

patients diagnosed with HF. 

d.	 Determine if patients receive timely access to primary care and/or cardiology 

visits. 

5.	 Determine whether CBOC providers are appropriately credentialed and privileged in 

accordance to VHA Handbook 1100.19.3 

6.	 Determine whether CBOCs are in compliance with standards of operations 

according to VHA Handbook 1006.14 in the areas of: 

a.	 Environmental safety. 

b.	 Emergency plan. 

7.	 Determine whether primary care and mental health (MH) services provided at 

contracted CBOCs are in compliance with the contract provisions and VA directives. 

a.	 Review specific contract provisions related to payment for services, invoice 

format, contractor monitoring procedures, traveling veterans, and 

performance-based incentives and penalties. 

b.	 Review the contract to ensure compliance with VA directives. 

c.	 Evaluate the effectiveness of contract oversight provided by the Contracting 

Officer’s Technical Representative (COTR) to ensure compliance with the 

contract. 

d.	 Determine whether the contract, modifications, and extensions have been 

appropriately prepared and processed. 

e.	 Review documentation that supports proper designation of the COTR. 

8.	 Determine if CBOC procedures regarding traveling veterans are performed in 

accordance with VHA Directive 2007-016.

5 

2 VHA Handbook 1122.01, Podiatric Medical and Surgical Services for Veterans Health Administration Medical
 

Facilities, November 25, 2009.
 3 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008.
 4 VHA Handbook 1006.1, Planning and Activating Community-Based Outpatient Clinics, May 19, 2004.
 5 VHA Handbook 2007-016, Coordinated Care Policy for Traveling Veterans, May 7, 2007.
 

VA Office of Inspector General 3 
Community Based Outpatient Clinic Cyclical Reports FY 2012 

a.	 The facility uses Veterans Health Information Systems and Technology 

Architecture’s [VistA’s] Register Once functionality to register patients who 

are enrolled at other facilities. 

b.	 The facility has a Referral Case Manager to assist the veteran and staff in 

providing care to the traveling veteran at the non-preferred VA medical 

center. 

Methodology 

CBOC inspections consist of four components: (1) CBOC site-specific information 

gathering and review; (2) medical record reviews for determining compliance with VHA 

and The Joint Commission standards and regulations; (3) on-site inspections; and (4) 

CBOC contract review. 

The VISN and Facility Directors will be notified 10–12 weeks prior to the on-site visit of 

the CBOCs selected for review and provided instructions for completing an on-line 

survey and a list of documents needed to conduct the topic area reviews. Through the 

survey we will collect descriptive information of each CBOC, to include the types of 

services provided and types of providers employed at the respective CBOC. 

The requested documents include: (1) parent facility and CBOC local policies and 

standard operating procedures; (2) a list of Primary Care and MH providers; (3) list of 

patients who were approved for fee basis services to receive imaging studies (CT, MRI, 

and PET scan); (4) list of female patients ages 52–69; (5) list of patients cared for in the 

specified CBOC who are 18–70 years of age and have a diagnosis of DM and no 

previous lower limb amputation(s); (6) a list of patients who were discharged from the 

parent medical center with a primary diagnosis of HF; and (7) copies of the CBOC 

contract and modifications for Primary Care Services, invoices, and payment schedules 

covering the 3rd Quarter, FY 2011 for the contracted CBOCs. We request that facility 

managers create a secured SharePoint or shared drive site and place the documents 

there for our review. 

Focused Topic Areas 

Short-Term Fee Basis 

VHA’s Chief Business Office, which is aligned under the Deputy Under Secretary for 

Health for Operations and Management, has primary responsibility for the Fee Program. 

Total annual payments for the Fee Program have grown from approximately $3 billion in 

FY 2008 to approximately $4.4 billion in FY 2010. 

The purpose of the Fee Program is to assist veterans who cannot easily receive care at 

a VA medical center (VAMC). The Program pays the medical care costs of eligible 

veterans who receive care from non-VA providers when the VAMCs are unable to 

provide specific treatments or provide treatment economically because of their 

geographical inaccessibility. This type of care is known as “Fee Basis” and it may 

include dental services, outpatient care, inpatient care, emergency care, and medical 

transportation. All VAMCs can use this program when needed. It is governed by 

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Community Based Outpatient Clinic Cyclical Reports FY 2012 

federal laws containing eligibility criteria and other policies specifying when and why it 

can be used. With the exception of some emergencies, Fee Basis care must be 

authorized prior to veterans receiving the services from non-VA providers. Fee Basis 

care is not an entitlement program or a permanent treatment option. 

Short-Term Fee Basis consults are initiated for examinations or for complete episodes 

of treatment within a designated, concise period of time, usually 60 days. VA providers 

request Short-Term Fee Basis care for veterans by initiating a Fee Basis Consult using 

VA Form10-7079 in the Computerized Patient Record System. Veterans who are 

authorized for Short-Term Fee Basis care may select a qualified physician of their 

choice to render the services required. In the absence of this selection, facility staff will 

arrange for treatment by a qualified physician located within a reasonable distance of 

the veteran's residence. 

We will evaluate if VA providers appropriately ordered and followed up on Short-Term 

Fee Basis consults for outpatient radiology procedures (CT, MRI, and PET scan). We 

will request the facility’s local policies for Short-Term Fee Basis care. We will also 

review the medical records of 50 randomly selected patients, unless fewer patients are 

available, to evaluate if the facility followed applicable VHA policies.6 We will evaluate 

the Fee Basis payments for timeliness and correct amount. 

Women’s Health 

Breast cancer is the second most common type of cancer among American women, 

with approximately 207,000 new cases reported each year.7 Timely screening, 

diagnosis, notification, interdisciplinary treatment planning, and treatment are essential 

to early detection, appropriate management, and optimal patient outcomes. Screening 

by mammography (an x-ray of the breast) has been shown to reduce mortality by 

20–30 percent among women age 40 and older. 

We will review the medical records of 30 randomly selected female patients between 

52 and 69 years of age who had mammograms, unless fewer patients are available, to 

determine compliance with selected VHA policies. 

VHA policy outlines specific requirements that must be met by facilities that perform 

mammography services for women veterans.8 When mammography services are 

obtained through contracts or sharing agreements, the VHA facility must ensure the 

provider is certified by the U.S. Food and Drug Administration (FDA) or a State that has 

been approved by FDA under 21 C.F.R. 900.21 to certify mammography facilities. 

Furthermore, when the services are outsourced, VHA requires that the site performing 

the mammogram communicate the results directly to the veteran when follow up 

treatment or care is not recommended. 9 

6 Manual M-1, Part I, Chapter 18, Outpatient Care – Fee, July 20, 1995.
 7 American Cancer Society, Cancer Facts & Figures 2009.
 8 VHA Handbook 1330.01, Healthcare Services for Women Veterans, May 21, 2010.
 9 VHA Handbook 1105.03, Mammography Program Policies and Guidance, April 28, 2011
 

VA Office of Inspector General 5 
Community Based Outpatient Clinic Cyclical Reports FY 2012 

Additionally, the CBOC and/or parent facility and contract mammography provider must 

have procedures to identify patients with breast implants and to ensure proper care for 

these patients prior to mammography. The CBOC must have assurance of timely result 

notification to ordering providers, as well as processes to ensure patients receive results 

with appropriate follow-up as needed. VHA requires oversight of the tracking and 

timeliness of follow-up of findings from breast cancer screening as a responsibility of the 

quality management team, in collaboration with the Women Veterans Program 

Manager, diagnostic services, and Primary Care Service. CBOCs and independent 

clinics must also designate a women’s health clinical liaison to coordinate women’s 

issues with the parent facility. 

We will evaluate whether: (1) women veterans receiving care at CBOCs had a 

screening mammogram done at least every 2 years, (2) results were available in the 

patient’s medical record which included the BI-RADS code category, (3) ordering 

providers and patients received notification of the results, (4) non-VA mammography 

facilities maintained required certification, (5) parent facilities established effective 

oversight of mammography services, and (6) the CBOCs designated a women’s health 

liaison. 

DM-LLPVD 

The Center for Disease Control and Prevention (CDC) estimates that 25.8 million 

people in the United States, or 8.3 percent of the population, suffer from DM. The CDC 

further estimates that approximately 15 percent of individuals with diabetes will develop 

foot ulcers and that 15 to 20 percent of these ulcers will result in lower extremity 

amputations. 

Diabetes is the leading cause of non-traumatic lower-limb amputations, resulting in 

60 percent of all non-traumatic lower-limb amputations. It has been estimated, 

however, that 85 percent of diabetic foot amputations could be prevented through 

education of health professionals and patients regarding proper foot care and 

prevention of diabetic foot ulcers. 

The VHA established its Preservation-Amputation Care and Treatment (PACT) Program 

in 1993 to prevent and treat lower extremity complications that can lead to amputation. 

An important component of this program is the screening of at-risk populations, 

including veterans with diabetes. 

The VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus 

represents a compendium of best practices for medical providers in the treatment of 

DM. It includes the provisions that clinicians should perform and document patient 

education for preventive foot care and address patient self-management and education. 

It is vital that veterans diagnosed with such conditions as DM-LLPVD receive annual 

screenings and foot care education in accordance with VHA Directives and Clinical 

Practice Guidelines. A clear goal is early intervention with younger veterans so that 

they do not join the estimated 90 percent of veterans over the age of 65 who suffer from 

VA Office of Inspector General 6 
Community Based Outpatient Clinic Cyclical Reports FY 2012 

some type of painful foot condition, severe enough to limit ambulation. The ability to 

walk has a profound influence on the veteran’s physical and psychological condition and 

quality of life. 

We will evaluate the extent VHA CBOCs have implemented the management of DMLLPVD in order to prevent lower limb amputation. We will request the facility’s local 

policies related to the PACT Program and the screening, education, and program 

monitoring of DM-LLPVD. We will also review the medical records of 30 randomly 

selected patients, unless fewer are available, to evaluate if the facility followed 

applicable VHA/DoD Guidelines10 and VHA policies.11 

HF Follow-up 

About 5.7 million people in the United States have HF, and it results in about 300,000 

deaths each year. HF is more common in people who are 65 years old or older, African 

Americans, and people who are overweight. Additionally, men have a higher rate of HF 

than women. The most common signs and symptoms of HF include shortness of breath 

or trouble breathing; fatigue; and swelling in the ankles, feet, legs, abdomen, and veins 

in the neck. Fluid buildup from HF also causes weight gain, frequent urination, and a 

cough that is worse at night and when lying down. 

About 550,000 new HF cases are diagnosed each year. The prevalence of HF 

increases with age, with nearly 5 percent of patients seen at VAMCs having a primary 

diagnosis of HF. According to a recent report from the American Heart Association, 80 

percent of men and 70 percent of women with a diagnosis of HF, who are less than 65 

years of age, will die within 8 years. In addition, the 1-year mortality rate was reported 

as 20 percent. Hospitalizations for HF have increased, accounting for 6.5 million 

hospital days annually. HF was also reported to be the main reason for 12 to 15 million 

clinic visits each year. The VA provides care for over 212,000 veterans with HF, with 

nearly 24,500 of these patients being hospitalized during a 12-month period during FYs 

2010 and 2011 with a primary diagnosis of HF.12 The leading causes of HF are 

diseases that damage the heart, to include coronary artery disease, high blood 

pressure, and diabetes.13 

Treatment for HF depends on the type and stage (or severity) of the condition. 

Treatments usually include lifestyle changes, medicines, and ongoing care. 

Management of HF includes recommendations to follow a heart healthy diet, proper 

fluid intake, weight loss (if indicated), physical activity (as indicated), smoking cessation, 

and getting adequate rest. Successful management is also dependent on following a 

prescribed medication regimen. Additionally, patients must be educated to recognize 

signs and symptoms and to initiate contact with their practitioner when necessary. 

10 VA/DoD Clinical Practice Guideline, Management of Diabetes Mellitus (DM), August 2010.
 11 VHA Directive 2006-050, Preservation-Amputation Care and Treatment (PACT) Program, September 14, 2006
 12 Statistics from VHA Support Services Center, accessed July 11, 2011.
 13 National Heart Lung and Blood Institute, Diseases and Conditions Index, U.S. Department of Health and Human
 

Services, National Institute of Health.
 

VA Office of Inspector General 7 
Community Based Outpatient Clinic Cyclical Reports FY 2012 

Lastly, patients should be encouraged to keep all medical appointments, including visits 

to their practitioner and appointments for tests.14 

We will evaluate the continuity of care for enrolled CBOC patients discharged from the 

parent facility with a primary discharge diagnosis of HF. We will review the medical 

records of 30 randomly selected patients, unless fewer patients are available, to 

determine if patients receive timely access to primary care after hospitalization 

discharge. 

Credentialing and Privileging 

All VHA health care professionals who are permitted by law and the facility to provide 

patient care services independently must be credentialed and privileged. The 

credentialing and privileging (C&P) process is used by medical centers to ensure that 

clinical providers have the appropriate professional licenses and other qualifications to 

practice in a health care setting and that they practice within the scopes of their licenses 

and competencies. 

We will conduct an overall review to assess whether the medical center’s C&P process 

complies with VHA policy.15 We will review providers’ (maximum of five) C&P folders 

(electronic and paper). We will review the privileges granted and scopes of practice 

approved by the parent facility to ensure they were appropriate for services rendered at 

the assigned CBOC. During our review of providers’ folders, we will review servicespecific criteria to ensure that ongoing professional practitioner evaluations have been 

developed and approved that outline the minimum competency criteria for privileges 

with documented evidence of sufficient performance data to meet current requirements. 

We will also review all providers placed on focused professional practitioner evaluations 

for initial and new privileges or for performance issues. 

Environment and Emergency Management 

Environment of care is crucial to achieving a safe patient care environment, reducing 

infection control risks and improving patient care outcomes. CBOCs must be 

maintained in a state of cleanliness that fully meets all VHA, Occupational Safety and 

Health Administration, and The Joint Commission standards. We will conduct 

environment of care rounds at each CBOC to ensure that they adhere to Americans 

with Disabilities Act, National Fire Protection Association regulations, patient safety, and 

infection control guidelines. 

We will review each CBOC’s local emergency management policy and interview 

employees to ensure there is a plan in place to address patients who experience a 

medical or psychological emergency such as heart attack, hypoglycemic events, 

suicidal, or homicidal ideations. We will also ensure that staff are aware and can 

articulate the steps of handling a medical or psychological emergency. 

14 National Heart Lung and Blood Institute. 15 VHA Handbook 1100.19. 

VA Office of Inspector General 8 
Community Based Outpatient Clinic Cyclical Reports FY 2012 

Contract Review 

Approximately 18 percent of all CBOCs are contract. CBOC contracts are administered 

and monitored by the parent facility. A COTR is delegated to provide oversight of the 

contractor providing care at the CBOC. 

We will review invoices and supporting documentation to determine accuracy of 

calculations, rates charged, and the number of enrollees or visits. We will interview VA 

and contractor personnel to gain an understanding of the invoice validation process and 

learn about any contractual and/or performance related matters. We will also perform 

inquiries of the CBOC MH providers, VA MH Chief, and/or COTRs to determine if 

MH services are provided by the contractor or VA and the types of MH services 

being provided. 

VHA has established guidelines to assist veterans that require health care while 

traveling away from home. We will review continuum of care for these traveling 

veterans to ensure compliance with VHA Directive 2007-016, Coordination of Care for 

Traveling Veterans at contract sites. A traveling veteran should not be assigned to a 

provider panel at the visiting facility. Assignment to a provider panel could inflate the 

panel size and could lead to increased costs for contracted facilities. 

Report Timeline 

A report will be issued approximately 90 days after the on-site inspection of the CBOC. 

The report will cover the inspection of three to eight CBOCs, which are usually two 

CBOCs per parent facility. Each report will cover our findings of the objectives 

described in this report. The first report will be issued in December 2011 (CBOCs 

visited in October 2011). 

At the end of the fiscal year, we will aggregate the data and issue a report. The FY 

2012 report is projected to address 95 inspections conducted during the months of 

October 2011 through September 2012. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 9 
Community Based Outpatient Clinic Cyclical Reports FY 2012 

Appendix A 

OIG Contact and Staff Acknowledgments 

OIG Contact	 For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720. 

Acknowledgments	 Marisa Casado, RN, MSA 

Nancy Albaladejo, RN, MSA 

Stephanie Hills, RN, MSN 

Zhana Johnson, CPA 

Sami O’Neill, MA 

Jennifer Reed, RN, BSN 

Thomas Seluzicki, CPA, CFA 

Marilyn Stones, BS 

VA Office of Inspector General 10 
Community Based Outpatient Clinic Cyclical Reports FY 2012 

Appendix B 

Report Distribution
	

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Veterans Integrated Service Network Directors (1–23) 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 11