Primary Care in VA

Primer

Management Decision and Research Center

Health Services Research and Development Service

Department of Veterans Affairs

In collaboration with

Foundation for Health Services Research
Primary Care in VA / by Barbara Starfield ... et al.

Boston, Mass. : Management Decision and Research Center;

Washington, D.C. : VA Health Services Research and

Development Service, 1995.

p. cm. 

Includes bibliographical references. Primer.

DNLM: 1. Hospitals, Veterans—organization & administration—

United States. 2. Primary Health Care—organization & administration. 

3. United States. Dept. of Veterans Affairs. Health Services Research 

and Development Service.

W84.2 P952 1995
Primary Care in VA

Barbara Starfield, M.D., M.P.H.

Thomas Parrino, M.D.

Elwood Headley, M.D.

Carol Ashton, M.D., M.P.H.

Purpose of Primer Series: to help bridge the gap among

health services researchers, policymakers, managers and clinicians

in an effort to improve the quality and cost-effectiveness of health

care for veterans. The primer series is part of a larger set of dissemination initiatives developed by the Department of Veterans Affairs’

Management Decision and Research Center in collaboration with the

Foundation for Health Services Research.

Purpose of “Primary Care in VA”: to provide a common framework for conceptualizing, implementing and assessing primary care. Using a question and answer format, the primer provides

an overview of primary care and its appropriate role in a health care

system. The primer is not an exhaustive text on primary care and it

is not a how-to manual. However, a select list of more in-depth reference materials is provided in the text of the primer.

Suggested Audience: VA hospital and health care system

managers working to develop primary care programs — including

administrators, clinical managers and policymakers.

Suggested Uses: ■ individual study, ■ discussion at medical

staff meetings, ■ orientation for primary care planning committees

in VA medical centers and integrated service networks, ■ primary

care training programs designed for specialists unfamiliar with primary care concepts, ■ orientation for medical residents, and 

■ resource document for VA strategic planning.

September 1995

Boston, Massachusetts
Table of Contents

i

Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

What is primary care?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

How does primary care differ from other 

levels of health care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Is primary care the same as ambulatory care? . . . . . . . . . . . . . .3

Is primary care the same as managed care?. . . . . . . . . . . . . . . . 4

What is the status of primary care in VA?. . . . . . . . . . . . . . . . . . 5

What steps are needed to build a VA health 

care system with primary care as the cornerstone?. . . . . . . . . . 5

What are VA medical centers doing locally to attain 

a primary care focus?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

What large-scale efforts are under way to 

achieve a primary care focus in VA?. . . . . . . . . . . . . . . . . . . . . . .11

What additional primary care resources 

are recommended?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Concluding Remarks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Appendix A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Appendix B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Contributors

Barbara Starfield, M.D., M.P.H. Dr. Starfield is a health services

researcher whose work focuses on primary care and on the impact of the

health care system on the health of populations. She has won many

awards for her research contributions to health policy decisions. Dr.

Starfield is University Distinguished Professor, Health Policy and Management Department and Department of Pediatrics, The Johns Hopkins

University.

Thomas A. Parrino, M.D. Dr. Parrino is Assistant Chief of Staff at

Providence VA Medical Center and Professor of Medicine at Brown University. In 1994, Dr. Parrino chaired the Primary Care Working Group of

VA’s National Health Reform Project. Dr. Parrino is President of the

National Association of VA Physician Ambulatory Managers, an organization dedicated to program development in primary and managed care.

Elwood Headley, M.D. Dr. Headley is Chief of Staff at Boston’s VA

Medical Center. Previously he served as Deputy Associate Deputy Chief

Medical Director for Ambulatory Care and Acting Deputy Under Secretary for Health in VA Central Office. Dr. Headley has been involved

actively in planning for managed care, primary care and VA’s shift from

inpatient to outpatient care.

Carol Ashton, M.D., M.P.H. Dr. Ashton is Associate Director of

HSR&D’s Center for Quality of Care and Utilization Studies at Houston

VA Medical Center and Associate Professor at Baylor College of Medicine. Dr. Ashton’s research focuses on hospital utilization, particularly

readmissions, and how VA interacts with other segments of the U.S. medical care system.

Kenneth W. Kizer, M.D., M.P.H. As Under Secretary for Health in the

Department of Veterans Affairs, Dr. Kizer is responsible for managing

the Veterans Health Administration, the nation’s largest integrated

health care system. Among Dr. Kizer’s previous positions are Chairman,

Department of Community and International Health, University of California, Davis; Director, California Department of Health Services; Chairman of the Board, The California Wellness Foundation; and Director,

Health Systems International, Inc. Dr. Kizer’s special areas of interest

include health promotion and primary care.

Acknowledgements. Appreciation is extended to colleagues throughout VA for their thoughtful comments in reviewing an earlier draft of the

primer: Lori Bastian, M.D., Durham VA Medical Center; Joan E. Cummings, M.D., Edward Hines, Jr. VA Hospital (Hines, IL); John R. Feussner, M.D., Durham VA Medical Center; Stephan D. Fihn, M.D., M.P.H.,

Seattle VA Medical Center; Ronald J. Gebhart, M.D., Veterans Health

Administration; Ralph Gigliotti, Chillicothe VA Medical Center (OH);

Stephanie Hoffman, Ph.D., James A. Haley Veteran’s Hospital (Tampa,

FL); Catherine Legg, R.N., Alexandria VA Medical Center (LA); Rivkah

Lindenfeld, R.N., Ph.D., Northport Regional Medical Education Center

(NY); Thomas Meyer, M.D., Denver VA Medical Center; Jerome Olack,

M.D., Fayetteville VA Medical Center (NC); Carole Pillinger, M.D.,

William Jennings Bryan Dorn Veteran’s Hospital (Columbia, SC); Rose

Mary Pries, M.S.P.H., St. Louis VA Medical Center; Arthur Robins, M.D.,

Boston VA Medical Center; and Nathan Trolinger, Oklahoma City VA

Medical Center. Thanks also go to Carolyn Clancy, M.D., Agency for

Health Care Policy and Research. iii
Preface

Since colonial days, the United States has provided some medical

care and other support to persons who suffered as a result of their

serving in the nation’s uniformed services. The veterans health care

system was originally established to treat combat-related injuries

and to help rehabilitate veterans with service-connected disabilities.

Over the years, the system has greatly expanded.

Today, the Veterans Health Administration in the U.S. Department

of Veterans Affairs manages the largest integrated health care delivery system in the United States, providing services to over 40 percent

of the approximately 11 million veterans eligible for care. These services are provided at more than 950 government-owned and operated

facilities, including hospitals, multispecialty clinics, nursing homes,

counseling centers and other access points, as well as through myriad

contractual and sharing arrangements with private health care

providers, other government agencies and more than 100 medical

schools and academic health centers.

Although the VA was initially slow in responding to the changing

U.S. health care environment, it is now engaged in far-reaching and

innovative changes in American health care. In fact, the veterans

health care system is poised for one of the most profound transformations of any organization in American history.

One of the most important changes under way in the veterans

health care system is the transition from being a bed-based, hospital

inpatient system to one rooted in ambulatory care. Central to this

transformation is a major expansion of VA’s primary care capacity,

i.e., assuring that each and every patient has a designated generalist

physician or physician-led team of caregivers that is responsible for

providing readily accessible, continuous, comprehensive and coordinated care.

This primer on Primary Care in VA is one of a number of efforts by

VA to promote greater understanding and knowledge about primary

care, both within and outside of VA, and to provide a common framework for conceptualizing, implementing and assessing primary care

and its appropriate role in the “new VA.” The primer succinctly

describes many key aspects of primary care, and it provides guidance

for accessing more detailed information about primary care.

I compliment the authors on producing this text and hope that

administrators, physicians, house staff, nurses and many others will

find it a valuable source of information.

Kenneth W. Kizer, M.D., M.P.H.

Under Secretary for Health

Department of Veterans Affairs

v
Introduction

vii

Over the past 50 years, health care delivery in this country has

revolved around the hospital as the hub of activity. This traditional

role of hospitals is now in a state of transition as evidenced by the

growing influence of managed care, the expanded role of primary

care providers, the dramatic shift from inpatient to outpatient services, and the coordination and integration of services across the continuum of care. Within VA these changes have spurred sweeping

transformations in the way health care is delivered to our nation’s

veterans.

Through a series of questions and responses, this primer seeks to

provide a basic understanding of primary care and its relationship to

the larger health care system. After defining the generic concept of

primary care and differentiating it from emergency care, specialty

care, ambulatory care and managed care, the primer examines the

current state of primary care within VA. Other primary care

resources are listed for readers wanting more in-depth information.
What is primary care?

Primary care is the “provision of continuous, comprehensive and

coordinated care to populations undifferentiated by gender, disease

or organ system.”1 Primary care is an approach to organizing care

for individuals and populations. Primary care is more than services

provided in a physician’s office. While many health care providers

deliver services that are considered primary care, providing one or

more specific primary care services does not necessarily constitute a

primary care provider.

Textbook primary care is characterized by four key features that

enhance the effectiveness and efficiency of services and differentiate

it from other levels of health care services. These are: ■ accessible

first-contact care, ■ continuity over time, ■ comprehensiveness, and

■ coordination.2

Accessible first-contact care. Primary care is the patient’s point

of first-contact with the health care system when a need for care is

initially perceived. As the entrypoint into the system, primary care

must be readily accessible to patients. Considerations such as proximity of the primary care delivery site to public transportation, availability of parking, wheelchair compatibility, cultural sensitivity and

convenient office hours are examples of the many important factors

that influence primary care accessibility.

Continuity over time. An ongoing relationship between a patient

and a primary care provider (or team of providers) is the basis for

continuity of care. A patient should receive all non-emergent and

non-referred care, regardless of its nature, from the primary care

provider. In instances when the primary care provider refers a

patient to a specialist, continuity is still maintained. Continuity of

care is achieved when patients receive person-focused, not diseasefocused, care from the same provider over a period of time.

Comprehensiveness. No single primary care provider (or team of

providers) can deliver all the services needed by the population.

Clinical problems that fall outside the scope of primary care practice

should be referred to other levels of service for advice, guidance or

management. A set of criteria for deciding which kinds of problems

should be referred to other providers (specialists) must be developed.

Comprehensiveness of care is achieved when the primary care

provider arranges for the full range of services to meet all but the

uncommon health care needs of the population, i.e., unusual or

unusually complex clinical problems.

Coordination. Care must be coordinated to avoid duplication of

services, to enhance the efficiency of care, to prevent harm that may

result when patients are given conflicting advice or therapies, and to

preclude gaps in care. Coordination of care requires diligence by all

caregivers and is facilitated when all information pertaining to the

patient’s health and health care is integrated and is easily retrievable. This coordination of information is often referred to as information transfer; it should occur regardless of where and under what

circumstances information is generated by providers. Information

transfer is enhanced by: ■ medical records augmented by lists of

presenting problems and prescribed medications, ■ computerized

information systems, and ■ patient-held records.

1

Primary care is the

“provision of continuous, comprehensive and

coordinated care to populations undifferentiated by gender, disease or

organ system.”
How does primary care differ from other levels 

of health care?

In addition to primary care, health care systems provide other levels of care including emergency care and specialty care. These other

types of care can be distinguished from primary care by several

structural and process characteristics, although in practice their

respective boundaries are not always clear-cut.

The table below summarizes how key features of primary care

relate to other levels of care within a health care system. 

KEY FEATURES OF PRIMARY CARE 

LEVEL OF CARE First-Contact Continuity Comprehensiveness Coordination

Primary Care Yes Yes Yes Yes, primary 

care provider 

assumes 

responsibility for 

overall coordination.

Emergency Care Yes No No Emergency care 

provider 

facilitates 

coordination by 

supplying information on 

encounter to 

primary care 

provider.

Specialty Care No Sometimes. No Specialty care 

For patients provider 

with certain facilitates coormedical con- dination by 

ditions, con- supplying 

tinuity might information on 

be a feature encounter to 

of specialty primary care

care. provider. 

For patients 

with certain 

medical conditions, specialty 

care provider 

might assume 

responsibility for 

overall coordination.

Emergency care. Emergency care is required for sudden or unexpected illness or injury that needs immediate medical attention.

Emergency services must be accessible 24 hours a day, seven days a

week, and often involve assisted transportation. 

Unfortunately, emergency care is often used inappropriately by

patients as first-contact care for non-emergent medical needs. In

emergency care, triage functions are critical; personnel must be

trained to quickly recognize the severity of the presenting problem.

Neither continuous nor comprehensive services are features of emergency care. A system for coordination, in which the emergency care

giver passes along pertinent information to the primary care giver,

must be in place.

. . . emergency care is

often used inappropriately by patients as 

first-contact care for

non-emergent medical

needs.

2
Specialty care. Speciality care is of two types. The first type is

consultative care to assist the primary care provider with the diagnosis or initiation or alteration of treatment strategies. For example,

patients whose problems pose diagnostic dilemmas or who have

unclear treatment protocols may be referred for one or two visits to a

specialist to provide the basis for advice to the primary care provider.

The second type is highly specialized care provided to patients with

illnesses that are too uncommon or complex for the primary care

provider to maintain competence in their management. This type of

specialty care is sometimes long term and requires assimilation of

rapidly changing knowledge and developing technology.

First-contact care is not an important attribute of specialty care.

Initial access to specialty care providers is controlled by referrals

from the primary care provider. Thereafter, and by negotiation with

the primary care provider, the patient may contact the specialty care

provider directly for specific health care needs. Generally speaking,

comprehensiveness is not an attribute of specialty care because specialty care, by definition, focuses on a specific medical problem;

highly specialized providers generally lack experience dealing with

the unique challenges of primary care. The specialist contributes to

coordination by communicating relevant information to the primary

care provider.

Is primary care the same as ambulatory care?

Primary care and ambulatory care are not the same. Not all primary care is ambulatory care, and not all ambulatory care is primary

care. To illustrate, a primary care provider’s responsibility for coordination does not end when a patient leaves the ambulatory care setting and is hospitalized. Similarly, a procedure performed by a

specialist in an ambulatory care setting is not considered primary

care, nor is the ongoing ambulatory care of, e.g., complicated cancer,

being managed by a specialist.

The identifying characteristic of ambulatory care is the site in

which it’s delivered. Ambulatory care is care provided in all settings

except hospital inpatient and other institutional settings. Ambulatory care can be delivered in: ■ physician offices, ■ hospital or freestanding outpatient diagnostic and surgical centers, ■ urgent care

centers, ■ outpatient rehabilitation centers, ■ outpatient drug and

alcohol rehabilitation centers, ■ homes, and ■ hospices.

Advances in diagnostic, therapeutic and rehabilitative services due

to technological and pharmaceutical breakthroughs have shifted

many specific health care services from inpatient to ambulatory or

outpatient settings. Payer and consumer-driven factors, such as

cost-containment and convenience, also have influenced the growth

of ambulatory services in recent years. These ambulatory care

trends, both technologically and economically based, are expected to

continue and even accelerate in the years ahead. 

3

Not all primary care is

ambulatory care, and

not all ambulatory care

is primary care.
Is primary care the same as managed care?

Primary care and managed care are not the same. Primary care is

an approach to provide care to patients and managed care is a strategy to finance services. 

Primary care providers are comparable to managed care’s casemanagers in the sense that both coordinate care as well as directly

provide the majority of it. Managed care is not necessarily based on

a primary care model. Managed care often does not place priority on

maintaining continuity of the primary care practitioner over time or

assuring services are sufficiently comprehensive to cover all health

care needs of patients. Moreover, “managed care” is increasingly

used for care of particular types of conditions (such as managed

mental health care), whereas primary care is, by definition, care of

patients regardless of what particular types of problem they have.

The growth of managed care in recent years is largely attributed

to the drive for cost-containment and/or the pursuit of value in

health care. Managed care seeks to create financial incentives for

providers and/or patients to limit unnecessary utilization of services.

Primary care, in contrast, is a concept that is independent of financial incentives, although primary care oriented health care systems

have been shown to cost less than specialty oriented health care systems.3

Managed care is a broad term encompassing a diverse mix of

health plans and systems. Managed care arrangements vary from

highly structured health maintenance organizations (HMOs) to more

loosely structured preferred provider organizations (PPOs) and

point-of-service (POS) plans. By some definitions, even an indemnity plan having a pre-hospital certification requirement that is

designed to ensure appropriate use of hospital care represents a form

of managed care.

A description of the various roles assigned to primary care

providers in three common managed care arrangements follows.

These three arrangements are illustrative examples and are not

intended to depict the seemingly infinite number of permutations of

managed care that exist.

Role of Primary Care Provider in Common Managed Care

Arrangements

■ Health maintenance organizations (HMOs). This highly

structured managed care plan requires formal enrollment with a primary care provider in the network. HMOs include staff models,

group models and independent practice associations. A referral from

the primary care provider is required for all care. If an enrollee

chooses to seek care outside the HMO, he/she typically must bear the

entire cost for the out-of-network care.

■ Preferred provider organizations (PPOs). A PPO is a type of

managed care plan that offers financial incentives to enrollees to

seek care from a designated group of providers — typically physicians, hospitals and labs — that have agreed to furnish services to a

specified population at a reduced charge. In return for the discounted charges, the providers expect to experience growth in the size of

their patient population. Criteria often used by plans in selecting

Primary care and 

managed care are not

the same.

4
providers to participate in a PPO are level of discount, patient satisfaction and cost-effective utilization practices. Enrollees can opt to

obtain care from this select group of providers or can go to providers

not on the PPO list. Formal enrollment with a primary care

provider is not a feature of PPOs and the plan does not require referrals for visits inside or outside the PPO. In this way PPOs resemble

fee-for-service plans. Enrollees pay more out-of-pocket for using a

provider not on the list. 

■ Point-of-service (POS) plans. This recent entry into the managed care world — the POS plan — requires formal enrollment with

a primary care provider, but the enrollment is loosely structured and

subscribers are free to use providers inside or outside of the network

on any given day, or at any point-of-service. POS plans attempt to

balance payers’ demands for cost-containment with enrollees’

demands for freedom of choice of providers. POS plans are sometimes referred to as open-ended HMOs. A referral from the primary

care provider is not required for out-of-network visits but is required

for in-network care. Enrollees pay more out-of-pocket for using a

provider outside the network.

Although managed care may be organized with a solid primary

care infrastructure, managed care arrangements can exist without

being grounded in a primary care model. PPOs are evidence of this.

Similarly, primary care — the provision of accessible, continuous,

comprehensive and coordinated care — certainly can exist in the

absence of managed care. This is evidenced by the many primary

care providers who are not in an HMO or POS plan and are not subject to any financial incentives to limit appropriate utilization, but

do actively manage and coordinate care across the continuum for

their patient population.

What is the status of primary care in VA?

By the end of fiscal year 1996, all VA medical centers will have a

primary care program in place.4

The Veterans Health Administration is working to adapt its delivery system to align VA with the changes occurring in the larger

health care system. The vision for the “new VA” is premised on

putting patients first, increasing primary care access points and integrating VA’s delivery assets to provide a seamless continuum of care.

What steps are needed to build a VA health care system

with primary care as the cornerstone?

In some areas of the country, the building blocks needed to develop a

solid primary care foundation within the VA health care system already

exist. In other areas, VA needs to start from the beginning to build a

primary care infrastructure. 

Seven steps to designing a health care system with primary care as

the cornerstone are: ■ define the population to be served, ■ document

the distribution of health problems within the population, ■ determine

the appropriate mix of providers and services, ■ ensure that patients’

initial visits are to the designated primary care provider, ■ establish

referral protocols and referral networks, ■ develop mechanisms for coordinating care, and ■ create a system for measuring primary care.5

5

Primary care providers

are comparable to a

managed care model’s

“case-managers” in the

sense that they coordinate care as well as

directly provide the

majority of it.
■ Define the population that is to be served and characterize

that population by gender, age and coverage status so that

resources can be allocated efficiently.

Our country’s approximate 26.5 million veterans are a heterogenous

group.6

About four percent of the veteran population is female and their

median age is 45 years. This is significantly lower than the median

age for male veterans which is 57 years. 

The age range for all veterans is as follows: ❑ 24 percent are under 45

years; ❑ 44 percent are 45 to 64 years; and ❑ 32 percent are 65 years or

older.

Of the 26.5 million veterans, approximately 10.5 million are eligible for health care through VA. Some of the VA eligible veterans

have private health insurance or Medicare coverage. About 30 percent of all veterans have incomes at or below the poverty level and

have no source of health care other than VA. Not all eligible veterans seek and receive care at VA medical centers; about 40 percent of

the nation’s eligible veterans use the VA health care system over a

four-to-five year period — some for all of their care and some for

part of their care.

Recently, one medical center estimated that half of its regular

users rely on VA for primary care, and the other half receive uncoordinated care from multiple VA and non-VA sources. Lack of a clearly

defined and relatively static patient population makes needs assessments difficult, yet all the more important for VA medical centers to

undertake.

■ Document the distribution of health problems in the population to be served.

Some veterans have service-connected conditions requiring highly

specialized services, and some are socio-economically disadvantaged

requiring a full range of medical and social services.

Documentation of all of the health problems of VA eligible veterans in a given service area may be particularly difficult for VA since

many veterans have other sources of health care coverage and may

never receive care from VA, or may use VA sporadically or only for

certain specialized services. As a result, complete patient data on all

VA eligible veterans, needed to document the distribution of health

problems, are not captured in VA databases.

One strategy to help fill this information gap is to solicit selfreported health status data from a representative sample of veterans. One 1992 study of self-reported data found that more than 30

percent of veterans reported having high blood pressure and slightly

more than eight percent reported having diabetes.7

Data on the health problems of the subset of veterans who use the

VA system are more complete and more readily accessible than data

on the entire VA eligible veteran population. This data, however, is

less useful in documenting the distribution of health problems

among veterans. One study of VA patients indicated that of all VA

medical center discharges in fiscal year 1994, the most prevalent diseases were alcohol dependence syndrome (8 percent) and schizophrenic disorders (4 percent).8

■ Based on the distribution of health problems, determine the

appropriate balance between primary and specialty care

providers and determine the mix of services to be offered.

The VA delivery system has traditionally focused on inpatient and

specialty care and, as a result, is not yet appropriately staffed to provide primary care. The largest VA medical centers are dominated by

In some areas of the

country, the building

blocks needed to develop

a solid primary care

foundation within the

VA health care system

already exist. In other

areas, VA needs to start

from the beginning to

build a primary care

infrastructure.

6
specialty staff and the typical specialist-to-generalist ratio is ten-toone. While the ideal specialist-to-generalist ratio needed to care for

the veteran population is not known, most agree that a ten-to-one

ratio is too high. Some analysts recommend a one-to-one ratio for

the general population.

VA managers need to develop programs that ensure an adequate

number of primary care providers — including mid-level practioners

— and need to explore the appropriate balance between primary care

providers and specialists for their population.

One strategy for achieving the appropriate mix of providers combines the use of VA and contract providers. For example, in some

communities it might be cost-effective to provide specialty care on a

contractual basis with non-VA providers, whereas in others it might

be prudent to provide primary care services on a contractual basis.

Another model retrains specialists to become primary care providers.

■ Design the health care system to ensure that all initial 

visits are to the designated primary care provider except in

the case of emergencies.

Due to limited resources and other considerations, VA’s mission does

not include being the sole health care system for all veterans. Most

veterans receive the majority of their care, including primary care,

outside VA. Since primary care planners are charged with designing

a system to ensure that initial patient visits are to the designated

primary care provider, it is, therefore, appropriate to channel

resources to create accessible first-contact care for those VA patients

who do not have a primary care provider outside VA.

To ensure that VA primary care providers are the point of first

contact for non-emergency care for veterans who do not otherwise

have a primary care provider, VA needs to develop its primary care

capacity, educate hospital staff about the primary care model (e.g.,

referral protocols), and ensure that primary care is accessible. To

accomplish the latter, educational outreach is needed to make veterans aware of how they can and should appropriately access care. In

designing the system, attention must be paid to a customer service

perspective, including office reception procedures and telephone protocols. See the chart below.

PRIMARY CARE CUSTOMER SERVICE PERSPECTIVE

Primary care must be responsive to customer needs if it is to be

accessible first-contact care. From the veteran’s perspective,

accessible primary care often means:

❑ I always call the same office number

❑ I always go to the same place

❑ I always work with the same people

❑ I know that my caregiver will follow me in the hospital

❑ I know that my caregiver will be available to talk with me and

my family about my problems when necessary (on the phone or in

person)

7

. . . educational outreach is needed to make

veterans aware of how

they can and should

appropriately access

care.
■ Establish referral protocols and referral networks.

Criteria for deciding which services should be referred to other

providers (specialists) must be developed. Relevant considerations

for some referral protocols include the frequency with which a practitioner treats the particular medical condition and the complexity of

the diagnosis or treatment.

To establish a referral network, creation of a network committee

is recommended. The primary care network should complement

VA’s existing system of specialty care with effective use of community resources. Community health and social service networks should

be established as a part of the primary care continuum of care to sustain the veteran in the community setting, ideally in the patient’s

own home. Veterans have many private and public entitlements separate from VA eligibility, and these services should be considered

when developing networks.

■ Develop a mechanism for coordinating care to ensure that

the designated primary care provider is aware of all visits

made by his or her patients.

Responsibility for coordination of care must reside with a primary

care provider or team of providers. One mechanism to facilitate

coordination is to establish an information system that can be

accessed by providers in the same or different locations. The information system must provide a record on each enrollee, his or her

socio-demographic characteristics, a minimum data set on all clinical

encounters and an identifier that permits linkage of the individual’s

encounter data over time. Without such a system, feedback to clinicians is incomplete and coordination of care is not feasible.

The Decision Support System, an executive information system

currently being phased in throughout VA, will provide some patientspecific information that will enhance coordination of care. More

sophisticated systems are needed, however, to ensure that relevant

patient information is transmitted from VA physicians (when providing specialty care) to non-VA physicians acting in the capacity of a

veteran’s primary care provider.

■ Create a system for measuring primary care.

Primary care providers must be accountable for organizing services

to achieve first-contact care, continuity, comprehensiveness and

coordination. Accountability requires that each of these four characteristics be definable and measurable and that acceptable standards

or benchmarks be developed. This, in turn, requires the collection of

several types of data, including population surveys, providers’

administrative data and clinical information.

At the time a primary care program is first established and routinely thereafter, a system for measuring primary care needs to be

operational. Indicators of how well primary care is being delivered

are critical to guide program development, implementation and

refinement and must be regularly communicated to providers and

managers.

In developing benchmarks, data collection methods and sample

size should be specified to assure comparability over time and across

delivery sites. Two examples of how the four characteristics of primary care can be translated into measurable attributes follow.

8

Primary care must be

responsive to customer

needs if it is to be accessible first-contact care.
■ Coordination could be made measurable by monitoring how well

specialty providers communicate information to primary care

providers. A benchmark or acceptable standard for coordination of

care should be specified, e.g., primary care providers should be notified within 24 hours of all emergency room visits or hospital admissions for patients on their panel.9

■ Accessible first-contact care could be made measurable by monitoring whether patients can reach the primary care provider by

telephone when needed. A benchmark or acceptable standard for

telephone access should be established, e.g., all calls for urgent

problems must be returned within a certain number of hours and

calls for routine queries within a specified timeframe.

When evaluating the accessibility of primary care, measurement

should include some assessment of the entire VA eligible population,

not just those who actually use services. People who have used services are less likely to experience access problems and are more likely to have good interactions with the health care system. Studying

only users may bias the results, making access look more favorable

than is the case. To achieve valid indicators when evaluating accessibility of its primary care systems, VA needs to query a subset of eligible veterans who do not receive care from VA.

A number of other examples of how to measure primary care exist.

A primary care measurement tool — designed to assess how well

each of the four key features of primary care have been attained — is

being tested at The Johns Hopkins University’s medical facilities

and is expected to be available by the end of 1995. One version of

the instrument was developed for telephone interviews of households

in the community, and another was developed for self-administration

by knowledgeable staff in health care facilities. This tool, adapted

for VA use, may provide a means for monitoring the implementation

of VA’s growing primary care orientation.

Other measures that can be used to evaluate the effectiveness of

primary care programs include: ■ tracking primary care sensitive

admissions to hospitals, i.e., monitoring admissions for diagnoses

that likely could have been successfully managed by a primary care

provider, thus obviating the need for hospitalization, and ■ other

outcomes measures.

What are VA medical centers doing locally to attain

a primary care focus?

Anumber of VA medical centers have made primary care a high

priority, despite constraints imposed by veteran eligibility regulations and a disproportionately high staff complement of specialty

providers. The following models — a large portion of which ascribe

to a team approach to care — represent advancements in attaining a

primary care orientation. These are but a few of the many creative

primary care programs within VA.

Examples of VA Medical Center Primary Care Initiatives

■ Physician assistants and nurse practitioners are valuable

assets in assembling a primary care work force. At the Little

Rock and Providence VA Medical Centers, about 75 percent of ongoing care is provided by nurse practitioners in interdisciplinary prac9

Primary care providers

must be accountable for

organizing services to

achieve first-contact

care, continuity, comprehensiveness and coordination.
tice plans. The nurse practitioners assume responsibility for continuity of care once a care plan is established. Physicians act as supervisors and managers, following their panels of patients and

overseeing care rendered by physician assistants and nurse practitioners.

■ Multidisciplinary primary care program is the foundation

of VA medical center’s managed care system. The North

Chicago VA Medical Center instituted a muldisciplinary primary care

program, called PrimeHealth, as the foundation of its managed care

system. All patients have a primary care provider who is responsible

for delivering essential and preventive health care, coordinating all

health care services and serving as the point of access for specialty

care. Each primary care provider has a panel of patients for which

he/she provides continuity in the ambulatory, acute inpatient and

long term care settings. These providers are supported by a team of

professionals (registered nurses, social workers, dietitians, clinical

pharmacists and team secretaries) who also ensure continuity over

time and across clinical settings.

The program is organized around three patient-centered and selfdirected work teams that function as independent small group practices. Customer service is a priority. The teams have clear

responsibilities and accountability, as well as the authority to ensure

that quality care is provided in a timely and cost effective manner.

Performance data is distributed to team providers on a regular basis. 

■ Extended primary care networks help a rural VA medical

center create an integrated primary care program. In the

Amarillo VA Medical Center’s service area, geographic accessibility

was problematic; one in three veterans traveled over one hour each

way to receive VA care and over 5,000 individuals traveled two hours

each way. To reduce travel time to the site of care and improve geographic accessibility, the Amarillo VA Medical Center negotiated a

contractual arrangement with a group of community-based clinics to

care for veterans. The resulting community-based delivery system

integrates care provided in the non-VA clinics with that provided at

the VA medical center.

■ Providers can use data to improve services. The Providence

and Boise VA Medical Centers have initiated programs to evaluate

data relevant to primary care, in particular access and provider

availability data. Current databases also alert primary care

providers when one of their patients is hospitalized and produce routine computerized reports that include information on visits and

visit cancellations. 

■ “Firm systems” provide continuous, coordinated care and

enhance medical education. Firm systems are an organizational

mechanism that integrates the functions of generalists, specialists

and allied health professionals who are responsible for a defined

panel of patients. In a number of VA medical centers, among them

Boise, Sepulveda, Providence and Cleveland, the primary care practice has been subdivided into firms or practice groups, designed to

provide continuity of care between the inpatient and outpatient settings. In one version of the firm model, an interdisciplinary primary

care team delivers most of the care. When a patient of a firm is hospitalized, responsibility for acute care shifts to the appropriate specialist. The primary care team participates in long term treatment

decisions and resumes caring for the patient after discharge.

The Sepulveda VA Medical Center’s Pilot Ambulatory Care and

Education (PACE) project, a more elaborate variant of the firm system, integrates the efforts of generalists and specialists by creating

10

Reminder systems

assure that patients

receive regular preventive care and promote

comprehensive care.
teams that follow patients from the outpatient setting into the hospital and when necessary, to long term care settings. 

■ At rural medical centers, greater use of general internists

enhances inpatient-outpatient continuity. Outstanding examples of integration at smaller VA medical centers include the programs at Grand Junction (Colorado) and Boise. At these medical

centers, general internists provide general medical care to their

patients and provide specialty care as they follow patients into the

hospital. This contrasts with the more traditional practice at larger

VA medical centers, where clinical functions are more narrowly

defined and internists act as consultants and perform technical procedures, while generalists provide primary care services.

■ Reminder systems ensure that patients receive regular

preventive care and promote comprehensive care. Several VA

medical centers have implemented quality improvement plans to

ensure that patients receive regular preventive care such as vaccinations and screening procedures. At the Indianapolis VA Medical

Center, reminder systems have been employed successfully to ensure

that comprehensive primary care is provided. Other ongoing

reminder system efforts in VA include decision support systems for

pharmacy utilization and physician alerts for notification of abnormal radiology results. VA’s Health Services Research and Development Service currently is supporting research to assess the value of

various reminder systems.

■ VA “call centers” facilitate a customer-focused system of

care. VA’s Telephone Liaison Care Programs (TLCP) have the

potential for improving access to providers, reducing unnecessary

clinic visits and decreasing waiting times.10 At Portland, Oregon’s

VA Medical Center, Telephone Linked Care (TLC) provides access to:

1) advice nurses; 2) advice pharmacists; 3) eligibility specialists; and

4) the patient’s primary care nurse. With the TLC program, emergency care visits have decreased 20-25 percent over the last year and

continuity of care and accessibility have improved. The Minneapolis

VA Medical Center has a Telephone Care Communications System

(TCCS) staffed by four nurses, two administrative staff and one

part-time pharmacist to do phone triage. These programs have

decreased the number of walk-in visits and increased access for

patients and family members.

For a list of contacts who can provide more details about these VA

medical center primary care initiatives, see Appendix A. Other

examples are described in VA’s Primary Care Resource Guide.11

A

What large-scale efforts are under way to achieve

a primary care focus in VA?

number of large-scale primary care projects have been completed

or are under way throughout VA. Examples of large-scale efforts

include VA’s Primary Care Directive, the VA National Primary Care

Training Program, the Primary Care Education Initiative, the new

Chicago Area Network, Women Veterans Comprehensive Health Programs and the Ambulatory Care Education Project.

11
Examples of Large-scale Primary Care Initiatives

■ Primary Care Directive. VA issued a directive (10-94-100) to

establish guidelines and provide direction for the implementation of

primary care in VA. This effort is to facilitate a shift from the provision of episodic care to delivery of a coordinated continuum of care

emphasizing primary care within referral networks. VA medical centers are mandated to implement primary care by the end of fiscal

year 1996. The VA Office of Ambulatory Care is charged with overseeing this effort.

■ National Primary Care Training Program. The National 

Primary Care Training Program is an example of coordinated interdisciplinary training initiated by VA’s Offices of Ambulatory Care, Academic Affairs, Nursing and Social Work. No longer operational, the

training program brought together interdisciplinary teams from across

the country and reviewed innovative primary care models from VA and

the private sector. Trainees developed primary care action plans to

improve primary care delivery in their respective medical centers and

provided progress reports on subsequent accomplishments at their

medical centers.

■ Primary Care Education Initiative. To assist VA medical centers in organizing their delivery of care around the principles of primary care, VA’s Office of Academic Affairs established the Primary

Care Education Initiative (PRIME) in 1993. The goals of the educational intervention is to better prepare residents in internal medicine, family medicine and preventive medicine, administrative and

management trainees, and affiliated health professionals to deliver

care under this new paradigm. Applications were invited from VA

medical centers that had pre-established programs for delivering primary care, and were interested in adding trainee education to their

primary care program. In July 1994, 49 participating facilities began

receiving trainee salary support for additional medical residents and

associated health trainees. In July 1995, 20 additional facilities initiated primary care education programs. The 69 programs in place for

academic year 1995-96 provide support for 375 medical residents and

almost 750 associated health trainees.

■ Chicago Area Network. In 1994, the Chicago Area Network

was established to design a health care delivery system that would

enhance services to veterans while minimizing the inefficiencies of

operating four VA hospitals in close geographic proximity. Integrating certain functions of the four area VA medical centers promises to

reduce duplication of services and eliminate unproductive competition. The network’s operating assumptions are that: (1) all patients

are identified with physician providers rather than medical centers;

(2) primary care sites are entrypoints into the network; and (3) network facilities are integrated systems for planning, construction,

transportation and information management. 

■ Women Veterans Comprehensive Health Programs. VA has

always provided medical treatment to women but not always with

the sensitivity, physical accommodation and equipment necessary to

ensure comprehensive care. The Women Veterans Health Program

Act of 1992 authorized new and expanded services for women veterans, including eight Women Veterans Comprehensive Health Care

Centers. Four of these centers — Chicago, the Southeast Pennsylvania Network, San Francisco and Tampa — use the primary care

provider approach, with primary care practitioners coordinating

patients’ specialty care needs.

12

Integrating certain

functions of the four 

VA medical centers

promises to reduce

duplication of services

and eliminate unproductive competition.
■ Ambulatory Care Education. The Ambulatory Care Education

(ACE) initiative has been successful in fostering the development of

primary care in what has historically been referred to as VA’s Western Region. The product of a planning process that began in 1988,

ACE’s cooperative management and committee structure’s have

enabled significant progress toward improving medical care and

medical education in practice settings outside the hospital. An ongoing process of program development in education, management, infomatics, research and development, nursing and operations, and

managed care has resulted. For example:

❑ Support for educational programs was obtained through Stanford’s Faculty Development Program and made available to all participating medical centers;

❑ The research and development component of the ACE initiative

developed a grant process that involves peer review of applications

and dissemination of information gathered through the projects; and

❑ A comprehensive consultative service was established to provide

advice on improving care delivery and education.

ACE now includes 13 states, 15 medical schools and 36 VA medical

centers.

For a list of contacts who can provide more detail on these largescale VA initiatives, see Appendix B.

What additional primary care resources 

are recommended?

For more in-depth information about primary care and its role in

health care delivery, the following resources may be helpful:

■ Department of Veterans Affairs, National Center for Cost Containment, Primary Care Resource Guide. August 1995.

■ Department of Veterans Affairs, Veterans Health Administration,

Guidance for the Implementation of Primary Care in Veterans Health

Administration, VHA Directive 10-94-100. October 6, 1994.

■ Department of Veterans Affairs, Health Services Research and

Development Service (in conjunction with the Foundation for Health

Services Research), “The Firm System: An Organizational Concept

for Improving Access and Continuity of Care.” Forum. November

1993.

■ Kongstvedt, P.R. The Managed Health Care Handbook. Second

Edition. Gaithersburg, MD. Aspen Publishers. 1993.

■ Noble, J. Primary Care. Boston: Little Brown. 1980.

■ Parrino, T.A. “A White Paper: Models for Medical Care.” (Proceedings from 1993 National Association of VA Physician Ambulatory Managers Meeting, Arlington, VA.)

13
■ Smith, S. “The Impact of an Ambulatory Care Firm System on

Quality and Continuity of Care.” Medical Care. 1995;33:221-6.

■ Starfield, B. “Measuring the Attainment of Primary Care.” Journal of Medical Education. 1979;54:361-9.

■ Starfield, B. Primary Care: Concept, Evaluation and Policy. New

York: Oxford University Press. 1992.

■ Starfield, B., D. Simborg, C. Johns, and S. Horn. “Coordination of

Care and Its Relationship to Continuity and Medical Records.” Medical Care. 1977;15:929-38.

14
Concluding Remarks

15

Redirecting and 

restructuring resources

to support primary care

within VA presents a

remarkable opportunity

not only to improve the

delivery of care for 

veterans, but also to

work with medical

schools in reorganizing

training.

To achieve coordinated and integrated systems of care requires

reworking VA’s hospital-based system into a flexible health care system that is responsive to veterans’ needs across the continuum of

care. The transformation of the VA health care delivery system

requires a solid foundation of primary care in which the primary care

provider and VA are accountable for the accessibility, continuity, comprehensiveness and coordination of care to veterans.

Redirecting and restructuring resources to support primary care

within VA presents a remarkable opportunity not only to improve

the delivery of care for veterans, but also to work with medical

schools in reorganizing training for medical students, residents and

fellows. Progress made in primary care medical education also has

implications for advanced training in the medical and surgical subspecialties. New methods are necessary to prepare trainees for their

roles as consultants and team members. Much more needs to be

done to integrate the training of specialists and subspecialists into a

comprehensive model for care.

As VA builds its primary care capacity and refines its delivery system, managers and policymakers at local, regional and national levels need solid data on how to use staff and other resources to best

meet the continuum of veterans’ health care needs. Health services

research can play an integral part in reshaping the VA health care

system. Research can inform VA decisionmakers about primary care

and under what circumstances various primary care models work in

an effort to improve access, quality and cost-effectiveness of care to

the nation’s veterans.
References

17

1. Kimball, H., and P. Young. “A Statement on the Generalist Physician from the American Boards of Family Practice and Internal Medicine.” Journal of the American Medical Association. 1994;

271:315-6.

2. Starfield, B. Primary Care: Concept, Evaluation, and Policy.

New York: Oxford University Press. 1992.

3. Starfield, B. “Is Primary Care Essential?” Lancet. 1994; 344:

1129-33.

4. Department of Veterans Affairs, Veterans Health Administration,

Guidance for the Implementation of Primary Care in Veterans Health

Administration. VHA Directive 10-94-100. October 6, 1994.

5. Adapted from Starfield, B. Primary Care: Concept, Evaluation,

and Policy. New York: Oxford University Press. 1992.

6. Department of Veterans Affairs. Annual Report of the Secretary of

Veterans Affairs, Fiscal Year 1994. Washington, DC. March 1995.

7. Department of Veterans Affairs. National Survey of Veterans.

Washington, DC: U.S. Government Printing Office. April 1995:35.

8. Petersen, N.J. “The Most Prevalent Diseases for Patients Discharged from VA Medical Centers, FY 94.” Technical Report: HCQCUS-95-03, Houston Center for Quality of Care and Utilization

Studies. 1995.

9. Parrino, T.A. “White Paper: Models for Primary Care.” (Proceedings from 1993 National Association of VA Physician Ambulatory Managers Meeting, Arlington, VA.) Submitted for publication.

10. Department of Veterans Affairs, Veterans Health Administration, Telephone Liaison Care Program (TLCP). VHA Directive 10-

94-022. October 1994.

11. Department of Veterans Affairs, National Center for Cost Containment, Primary Care Resource Guide. August 1995.
19

Appendix A

Contacts for more information about local VA medical center primary care initiatives described on pages 9-11:

Use of physician Cynthia Joe, M.D., Acting Associate Chief of Staff for Ambulatory Care

assistants and nurse (11C), John L. McClellan VA Medical Center, 4300 West 7th Street, Little

practitioners: Rock, AR 72205-5484, FTS (700) 742-1202, Com (501) 660-2022, 

Fax (501) 671-2529

Thomas A. Parrino, M.D., Assistant Chief of Staff (11), Providence VA

Medical Center, 830 Chalkstone Avenue, Providence, RI 02908-4799, 

FTS (700) 838-3483, Com (401)457-3045, Fax (401) 457-3363

Cheryl Fitzgerald, R.N., N.P., Operations Manager for Primary Care (11B),

Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI

02908-4799, FTS (700) 838-3483, Com (401) 457-3045, Fax (401) 457-3363

Multidisciplinary Carter Mechner, M.D., Chief of Staff (11), North Chicago VA Medical Center,

primary care program: 3001 Green Bay Road, North Chicago, IL 60064, FTS (700) 384-3701, Com

(708) 578-3701, Fax (708) 578-3737

James Tuchschmidt, M.D., Chief, Medical Service & Director, Managed Care,

(111), North Chicago VA Medical Center, 3001 Green Bay Road, North Chicago, IL 60064, FTS (700) 384-3879, Com (708) 578-3879, Fax (708) 578-3863

Community-based Gerald Holman, M.D., Chief of Staff (11), Amarillo VA Medical Center,

primary care network: 6010 Amarillo Boulevard West, Amarillo, TX 79106, FTS (700) 735-7711, Com

(806) 354-7803, Fax (806) 354-7860

Use of data to improve David Lee, M.D., Chief of Staff (11), Boise VA Medical Center, 500 West

primary care: Fort Street, Boise, ID 83702-4598, FTS (700) 554-7201, Com (208) 338-7201,

Fax (208) 338-7257

Scott Smith, M.D., Chief of Internal Medicine (111), Boise VA Medical

Center, 500 West Fort Street, Boise, ID 83702-4598, FTS (700) 554-7220, Com

(208) 338-7220, Fax (208) 338-7219

Thomas A. Parrino, M.D., Assistant Chief of Staff (11), Providence VA

Medical Center, 830 Chalkstone Avenue, Providence, RI 02908-4799, 

FTS (700) 838-3483, Com (401)457-3045, Fax (401) 457-3363

Cheryl Fitzgerald, R.N., N.P., Operations Manager for Primary Care (11B),

Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI

02908-4799, FTS (700) 838-3483, Com (401) 457-3045, Fax (401) 457-3363

Firm systems: Alan Robbins, M.D., Chief of Staff (11), Charleston VA Medical Center, 

109 Bee Street, Charleston, SC 29403-5799, FTS (700) 259-7202, Com 

(803) 577-5011 ext. 7202, Fax (803) 937-6100 (formerly with Sepulveda VA

Medical Center’s Firm system)

Dennis Cope, M.D., Associate Chief of Staff (11), Charleston VA Medical

Center, 109 Bee Street, Charleston, SC 29403-5799, FTS (700) 259-7304, Com

(803) 577-5011 ext. 7457, Fax (803) 937-6100 (formerly with Sepulveda VA

Medical Center’s Firm system)
John Aucott, M.D., Chief, General Internal Medicine and Director,

VA Firm System 111(W), Cleveland VA Medical Center, 10701 East

Boulevard, Cleveland, OH 44106, FTS (700) 290-3800, Com (216) 791-3800

ext. 4816, Fax (216)231-3289

Thomas A. Parrino, M.D., Assistant Chief of Staff (11), Providence VA

Medical Center, 830 Chalkstone Avenue, Providence, RI 02908-4799, 

FTS (700) 838-3483, Com (401)457-3045, Fax (401) 457-3363

Cheryl Fitzgerald, R.N., N.P., Operations Manager for Primary Care (11B),

Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI

02908-4799, FTS (700) 838-3483, Com (401) 457-3045, Fax (401) 457-3363

David Lee, M.D., Chief of Staff (11), Boise VA Medical Center, 500 West

Fort Street, Boise, ID 83702-4598, FTS (700) 554-7201, Com (208) 338-7201,

Fax (208) 338-7257

Scott Smith, M.D., Chief of Internal Medicine (111), Boise VA Medical

Center, 500 West Fort Street, Boise, ID 83702-4598, FTS (700) 554-7220, Com

(208) 338-7220, Fax (208) 338-7219

PACE project: Alan Robbins, M.D., Chief of Staff (11), Charleston VA Medical Center, 

109 Bee Street, Charleston, SC 29403-5799, FTS (700) 259-7202, Com 

(803) 577-5011 ext. 7202, Fax (803) 937-6100

Dennis Cope, M.D., Associate Chief of Staff (11), Charleston VA Medical

Center, 109 Bee Street, Charleston, SC 29403-5799, FTS (700) 259-7304, Com

(803) 577-5011 ext. 7457, Fax (803) 937-6100

Greater use of general William Berryman, M.D., Chief of Staff (11), Grand Junction VA Medical

internists: Center, 2121 North Avenue, Grand Junction, CO 81501, FTS (700) 322-0261,

Com (303) 242-0731, Fax (303) 244-1303

David Lee, M.D., Chief of Staff (11), Boise VA Medical Center, 500 West

Fort Street, Boise, ID 83702-4598, FTS (700) 554-7201, Com (208) 338-7201,

Fax (208) 338-7257

Scott Smith, M.D., Chief of Internal Medicine (111), Boise VA Medical

Center, 500 West Fort Street, Boise, ID 83702-4598, FTS (700) 554-7220, Com

(208) 338-7220, Fax (208) 338-7219

Preventive care William Tierney, M.D., HSR&D Service (11H), Richard L. Roudebush VA

reminder systems: Medical Center, 1481 West Tenth Street, Indianapolis, IN 46202, 

FTS (700) 332-2206, Com (317)635-7401 ext. 2887, Fax (317) 269-6392

Dan Berlowitz, M.D., M.P.H., Associate Director, Center for Aging Veterans

(152), Edith Nourse Rogers Veterans Hospital, 200 Springs Road, Building 70,

Bedford, MA 01730, FTS (700) 687-2962, Com (617) 687-2962, Fax (617) 275-

6855

Stephen Fihn, M.D., M.P.H., Director, Northwest Center for Outcomes 

Research (152), VA Medical Center, 1660 South Columbian Way, Seattle, WA 

98108, FTS (700) 396-2420, Com (206) 764-2420, Fax (206) 764-2935

Telephone Liaison Traci Fox, R.N., M.S., Ambulatory Care Nursing Supervisor (118-P), or Lisa

Care Programs: Cochran, Ambulatory Care Hospital Based Clinic Manager (11C-OPC), Portland VA Medical Center, 3710 Southwest U.S. Veterans Hospital Road, P.O.

Box 1034, Portland, OR 97207, FTS (700) 424-7300, Com (503) 273-5300, 

Fax (503) 293-2963

Jana Conlin, R.N., Nurse Manager for Telephone Communication Systems

(118), Minneapolis VAMC, One Veterans Drive, Minneapolis, MN 55417, 

FTS (700) 780-1694, Com (612) 725-1694, Fax (612) 725-2196

20
Appendix B

Contacts for more information about VA’s large-scale primary care initiatives described on pages 11-13:

Primary Care Ronald J. Gebhart, M.D., Deputy Associate Deputy Chief Medical Director for AmbuDirective: latory Care (112), VA Central Office, 810 Vermont Avenue, N.W., Washington, DC

20420, FTS (700) 565-7242, Com (202) 565-7242, Fax (202) 565-4153

National Primary Care Ronald J. Gebhart, M.D., Deputy Associate Deputy Chief Medical Director for

Training Program: Ambulatory Care (112), VA Central Office, 810 Vermont Avenue, N.W.,

Washington, DC 20420, FTS (700) 565-7242, Com (202) 565-7242, Fax (202) 565-4153

Elwood Headley, M.D., Chief of Staff (11), Boston VA Medical Center, 150

South Huntington Avenue, Boston, MA 02130, FTS (700) 839-4000, Com (617) 232-

9500 ext. 5276, Fax (617) 278-4549

Rose Mary Pries, M.S.P.H., CHES, National Coordinator for Patient Education

(14B-JB), St. Louis VA Medical Center, 915 North Grand Boulevard, St.

Louis, MO 63016, FTS (700) 278-4100, Com (314) 894-6534, Fax (314) 894-6573

Rivkah Lindenfeld, R.N., Ph.D, Director, Regional Medical Education Center

(141-D), VA Medical Center, 79 Middleville Road, Northport, NY 11768, 

FTS (700) 663-4400, Com (516) 261-4400 ext. 2900, Fax (516) 754-7996

Primary Care Elizabeth M. Short, M.D., Associate Chief Medical Director for Academic

Education Initiative: Affairs (14), VA Central Office, 810 Vermont Avenue, N.W., Washington, DC

20420, FTS (700) 656-7091, Com (202) 565-7091, Fax (202) 565-7522

Gloria Holland, Ph.D., Special Assistant to the Associate Chief Medical Director for

Academic Affairs (14C), Office of Academic Affairs, Department of Veterans

Affairs, 801 I Street, N.W., Washington, DC 20420, FTS (700) 656-7525, Com (202)

565-7525, Fax (202)565-7522

Chicago Area Network: Joan Cummings, M.D., Director, Edward Hines, Jr. VA Hospital (00), 5th

Avenue and Roosevelt Road, Hines, IL 60141, FTS (700) 381-2500, Com (708) 343-

7200 ext. 5639, Fax (708) 381-2506

Women Veterans Susan Mather, M.D., Associate Chief Medical Director for Public Health and

Comprehensive Health Environmental Hazards (116), Department of Veterans Affairs, 801 I Street,

Program: N.W., Washington, DC 20420, FTS (700) 656-4182, Com (202) 565-4182, 

Fax (202) 565-7572

Ambulatory Care David Lee, M.D., Chief of Staff (11), Boise VA Medical Center, 500 West Fort

Education: Street, Boise, ID 83702-4598, FTS (700) 554-7201, Com (208) 338-7201, 

Fax (208) 338-7257 

David Nardone, M.D., Associate Chief of Staff for Ambulatory Care (11C),

Portland VA Medical Center, 3710 Southwest U.S. Veterans Hospital Road, P.O.

Box 1034, Portland, OR 97207, FTS (700) 424-7300, Com (503) 721-7897, 

Fax (503) 721-7942

Alan Robbins, M.D., Chief of Staff (11), Charleston VA Medical Center, 109

Bee Street, Charleston, SC 29403-5799, FTS (700) 259-7202, Com (803) 577-5011 ext.

7202, Fax (803)937-6100

Dennis Cope, M.D., Associate Chief of Staff (11), Charleston VA Medical

Center, 109 Bee Street, Charleston, SC 29403-5799, FTS (700) 259-7304, 

Com (803) 577-5011 ext. 7457, Fax (803) 937-6100

21
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