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###### Department of Veterans Affairs

# AGENCY:

Department of Veterans Affairs.

# ACTION:

Notice and request for comment.

# SUMMARY:

 The Secretary of Department of Veterans Affairs (VA) is responsible for establishing a procedure for making recommendations in reviewing assets and infrastructure. This notice provides the selection criteria to guide this process in order to meet this this responsibility.

# ADDRESSES:

                         Written comments may be submitted through                         *www.regulations.gov.*                         Comments should indicate that they are submitted in response to “Notice of Intent and request for comments.” During the comment period, comments may also be viewed online through the Federal Docket Management System at                         *www.regulations.gov.*

# DATES:

 Comments must be received on or before May 1, 2021.

# FOR FURTHER INFORMATION CONTACT:

                         Valerie Mattison Brown, Chief Strategy Officer, Veterans Health Administration, Department of Veterans Affairs, 810 Vermont Avenue NW, Washington DC 20420, (202) 461-7100 or                         *VAMissionActSection203@va.gov.*

# SUPPLEMENTARY INFORMATION:

 Section 1703C of 38 U.S.C., as added by Section 203 of the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 requires VA to establish criteria to be used in assessing and making recommendations regarding the modernization or realignment of facilities of the Veterans Health Administration (VHA) under the subtitle Selection Criteria. In 2019, VHA began working with various stakeholders and experts to identify factors to be considered in developing the criteria. VHA solicited feedback from Veterans Service Organizations, Veteran Engagement Boards and a wide range of interdisciplinary VA leaders. Six criteria and associated sub-criteria were developed through these robust engagements. VHA proposes to use these criteria to evaluate potential market opportunities for submission to the Asset and Infrastructure Review Commission.

## Foreword

VA is honored to deliver excellent health care for the more than 9 million Veterans who entrust us with their care and is proud to serve as the backstop to the Nation's health care system. VA was in the midst of a tremendous transformation before the COVID-19 pandemic, working to empower Veterans with more excellent choices while modernizing our systems to enable an optimal experience of care and services. As the impacts of this unprecedented public health challenge have moved across the Nation and the globe, we have continued to demonstrate the strength of our nationwide, integrated system, positioning VA at the leading edge of U.S. health care on behalf of those we serve. We have employed each of our four missions—health care, education, research and emergency response—to lead the Nation forward beside our interagency and strategic partners. Each of these missions will be a vital element of the next step in our transformation journey: Designing the future of VA around the Veterans we serve.

                    VA works each day to serve and honor America's Veterans and seeks to ensure each individual Veteran feels they are cared for uniquely, wherever they are and however they need. As Veteran needs, preferences and demographics shift over the coming decades, decisions about health care delivery and infrastructure need to be made by the Secretary to ensure Veterans can continue to access a sustainable, flexible and high-quality health care system well into the future. In line with our missions, VA proposes the following set of criteria for making decisions on health care improvement, as required by Section 203 of the MISSION Act of 2018. The criteria are designed to keep Veterans' needs at the center of the decision-making process,                           ( print page 7922)                        assuring that each Veteran can receive the care they have earned and deserve.                

## Criteria

                    VA is conducting Market Assessments to design high-performing networks of care to provide high quality, readily accessible cost-effective care through VHA, Federal partners, academic affiliates and other private sector providers. This design provides VA with the ability to plan for the continuing evolution of Veteran health care, incorporating major trends and events in the national and global health ecosystem (                    *e.g.,*                     the COVID-19 pandemic and telehealth). Each assessment will create opportunities to position the VA health care system to increase health equity, enhance Veteran experience, account for social determinants and serve as the coordinator of health care provided by VA. Through thoughtful and constructive engagements with internal and external stakeholders, the following criteria were developed for the evaluation of VHA realignment and modernization opportunities.                

The Secretary will use the criteria to make recommendations to the Asset and Infrastructure Review (AIR) Commission, established by the MISSION Act for the modernization and realignment of VHA facilities and to improve Veteran access to high-quality health care across the country. Recommendations submitted to the AIR Commission will focus on creating Veteran-centric outcomes that retain or improve health care services for Veterans through the most equitable modalities and through services and locations that most benefit those we serve. The recommendations will then go through the AIR Commission review process as outlined in the MISSION Act.

Each criterion begins with a commitment statement, outlining VA's philosophy and commitment to current and future Veterans, followed by the criterion statement, sub-criteria and explanatory statement:

### Veterans' Need for Care & Services (Demand)

*Commitment Statement:*                     VA is committed to providing Veterans the full range of care and services needed and desired throughout their lifetimes, to include preventive, acute and chronic care. These services will be carefully balanced to meet Veterans' needs and preferences. We intend to ensure Veterans receive the personalized care they have earned. We will do this by matching the services and support they may need with our ability to provide those services in a timely manner, through VA's direct care system, through our Community Care Network and through government, academic and strategic partners.                

*Demand Criterion:*                     The recommendation aligns VA's high performing network resources to effectively meet the future health care demand of the Veteran enrollee population.                

*Demand Sub-Criteria:*

The recommendation:

○ Aligns the quality and delivery of care and services with projected Veteran demand across demographics and geography;

○ Retains or improves VA's ability to meet projected demand;

                    ○ Considers health equity (                    *i.e.,*                     demographics);                

                    ○ Reflects consideration of factors underpinning observed utilization patterns (                    *e.g.,*                     rurality and other social determinants of health); and                

○ Incorporates trends in the evolution of U.S. health care.

*When applying the `demand' criterion, VA will consider how a recommendation will impact VA's ability to meet the needs of Veterans in the future. VA will consider what Veterans may need through understanding the services that Veterans have accessed in the past and are projected to need and prefer in the future. VA will also consider how and where Veterans wish to receive services, including in ambulatory settings, hospitals, in the community, through telehealth, and through innovative models and modalities.*

### Accessibility of Care for Veterans (Access)

*Commitment Statement:*                     We intend to provide Veterans with an accessible, whole health experience, with services thoughtfully designed to meet their needs. We will do this by making the services and support Veterans need accessible through locations, models and modalities that most benefit them and match their needs and preferences.                

*Access Criterion:*                     The recommendation maintains or improves Veteran access to care.                

*Access Sub-Criteria:*

The recommendation:

○ Aligns VA points of care and services with projected Veteran need across demographics and geography;

○ Retains or improves Veterans' ability to access VA care;

○ Ensures Veterans are provided a range of health care options and the opportunity to choose care they trust, based on their preferences, throughout their lifetime;

○ Enables VA to serve as the coordinator of each Veteran's health care whether provided within or beyond VA;

                    ○ Considers health equity (                    *i.e.,*                     demographics);                

                    ○ Reflects consideration of factors underpinning observed access patterns (                    *e.g.,*                     rurality and other social determinants of health); and                

○ Incorporates trends in the evolution of U.S. health care.

*When applying the `access' criterion, VA will consider how a recommendation will impact the convenience of care provided to Veterans in the future. Key components of access include the time it takes to receive care and the barriers and accelerators to receiving care, such as distance or availability of technology.*

### Impact on Mission

*Commitment Statement:*                     VA is committed to delivering best-in-class care throughout Veterans' lifetimes. This means positioning the VA health care system at the leading edge of the health care industry in education, research and national emergency preparedness.                

*Impact on Mission Criterion:*                     The recommendation provides for VA's second, third and fourth statutory missions of education, research and emergency preparedness.                

Impact on Mission Sub-Criteria:

The recommendation:

○ Aligns resources to VA's education, research and emergency preparedness missions across demographics and geography;

○ Education: Maintains or augments VA's ability to execute its education mission;

○ Research: Maintains or augments VA's ability to execute its research mission;

○ Emergency Preparedness: Maintains or augments VA's ability to execute its emergency preparedness mission;

                    ○ Considers health equity (                    *i.e.,*                     demographics);                

                    ○ Reflects consideration of factors underpinning observed mission impacts of education, research and emergency preparedness efforts (                    *e.g.,*                     rurality and other social determinants of health; and                

○ Incorporates trends in the evolution of U.S. health care.

*The `impact on mission' criterion allows VA to consider how a recommendation will impact our ability to execute our statutory missions of education, research and emergency preparedness in support of Veterans and the nation.*      ( print page 7923)    

### Providing the Highest Quality Whole Health Care (Quality)

*Commitment Statement:*                     VA is committed to providing Veterans with a high-quality, whole health care system that delivers an excellent experience of care and optimal health outcomes. VA will deliver the same high quality, evidence-based standards of care regardless of where, or by which modality, their care is received.                

*Quality Criterion:*                     The recommendation considers the quality and delivery of health care services available to Veterans, including the experience, safety and appropriateness of care.                

*Quality Sub-Criteria:*

The recommendation:

○ Ensures the highest possible quality of care across demographics and geography;

○ Promotes recruitment of top clinical and non-clinical talent;

○ Maintains or enhances Veteran experience;

                    ○ Considers health equity (                    *i.e.,*                     demographics);                

                    ○ Reflects consideration of factors underpinning observed quality patterns (                    *e.g.,*                     rurality and other social determinants of health); and                

○ Incorporates trends in the evolution of U.S. health care.

*When applying the `quality' criterion, VA will consider how a recommendation will impact the quality of care for Veterans. Quality in health care is measured through metrics and ratings assessed by federal and commercial health care entities. VA will consider the care needs and preferences of Veterans in order to provide optimal experience, safety, and outcomes.*

### Effective Use of Resources for Veteran Care (Cost Effectiveness)

*Commitment Statement:*                     VA is committed to optimizing our health care system through the effective use and sharing of resources, including staffing, space, infrastructure and funding, with the goal of providing Veterans with the best health care and outcomes. We will actively and mindfully manage our resources, allowing us to provide services and support that effectively match Veterans' needs and preferences while putting their health and empowerment at the center of system design.                

*Cost Effectiveness Criterion:*                     The recommendation provides a cost-effective means by which to provide Veterans with modern health care.                

*Cost Effectiveness Sub-Criteria:*

The recommendation:

○ Reflects stewardship of taxpayer dollars by optimizing investments and resources for Veterans;

○ Recognizes potential savings or efficiencies that may free resources for more impactful investment for Veterans;

○ Considers the value of Veteran and employee experience, innovation, and other intangible elements of value;

                    ○ Considers health equity (                    *i.e.,*                     demographics);                

                    ○ Reflects consideration of factors underpinning observed cost patterns (                    *e.g.,*                     rurality and other social determinants of health); and                

○ Incorporates trends in the evolution of U.S. health care.

*When applying the `cost effectiveness' criterion, VA will consider whether a recommendation optimizes funding for Veteran care.*

### Ensuring a Safe Environment of Care (Sustainability)

*Commitment Statement:*                     VA is committed to providing Veterans a safe and welcoming environment of care. Our goal is for Veterans to feel safe physically, mentally, socially and emotionally when in our care. We commit to providing standard and complementary types of care for our unique Veteran population in an equitable and inclusive environment. We will do this by ensuring points of care are modern and inviting, with an expert workforce and care options designed to meet them where they are in their health journey.                

*Sustainability Criterion:*                     The recommendation creates a sustainable health care delivery system for Veterans.                

*Sustainability Sub-Criteria:*

The recommendation:

○ Aligns investment in care and services with Veteran need across demographics and geography;

○ Reflects stewardship of taxpayer dollars by creating a sustainable infrastructure system for Veterans;

○ Enables recruitment and retention of top clinical and non-clinical talent;

                    ○ Considers health equity (                    *i.e.,*                     demographics);                

                    ○ Reflects consideration of factors underpinning observed access patterns (                    *e.g.,*                     rurality and other social determinants of health); and                

○ Incorporates trends in the evolution of U.S. health care.

*When applying the `sustainability' criterion, VA will consider how a recommendation impacts our ability to offer Veterans a welcoming and safe care environment that meets modern health care standards and ensures sustainability for future generations of Veterans.*

#### Signing Authority

Dat P. Tran, Acting Secretary of Veterans Affairs, approved this document on January 26, 2021, and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs.

Jeffrey M. Martin,

Assistant Director, Office of Regulation Policy & Management, Office of the Secretary, Department of Veterans Affairs.

[FR Doc. 2021-02138 Filed 2-1-21; 8:45 am]

BILLING CODE 8320-01-P