VA Health Care: Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care
Released: 2016-04-18T00:00:00

Letter

Background

Enrolling for VHA Health Care Benefits

VHA offers eligible veterans a standard medical benefits package, including primary care. To receive these health care benefits, veterans must first complete VA’s enrollment application—the 1010 EZ—and submit it online, in person, by mail, or by fax to a VA medical center or VA’s Health Eligibility Center. Health Eligibility Center officials query several VA and Department of Defense databases to verify veterans’ eligibility for benefits and share this information with the applicable medical centers. If the Health Eligibility Center cannot make a determination as to veterans’ eligibility, officials notify veterans’ local medical centers to take further action, such as requesting additional documentation of military service records. The Health Eligibility Center sends a letter to each veteran once it has made an eligibility determination with the decision and a description of benefits.

Scheduling Appointments for Newly Enrolled Veterans

Veterans requesting on their enrollment applications that VA contact them to schedule appointments, if eligible, are to be placed on VHA’s New Enrollee Appointment Request (NEAR) list. (See fig.1 for an illustration of how newly enrolling veterans request on their enrollment applications that VA contact them to schedule appointments.) The NEAR list is intended to help VA medical centers track newly enrolled veterans needing appointments. It includes information regarding the medical center at which the veteran wants to be seen, contact information for the veteran, and whether the veteran is waiting to be contacted to schedule an appointment. If a veteran submits an application in person, medical center staff may schedule an appointment for the veteran at that time. Once the appointment is scheduled, the request is considered “filled” and the veteran’s name is removed from the NEAR list.

According to VHA policy, as outlined in its July 2014 interim scheduling guidance, VA medical center staff should contact newly enrolled veterans to schedule appointments within 7 days from the date they were placed on the NEAR list. When contacted by the medical center, which may be by phone or letter, each veteran is scheduled for a 60-minute appointment based on the veteran’s preferred date—the date the veteran wants to be seen. Schedulers negotiate appointment dates with veterans using the preferred date and appointment availability.

In July 2015, VA’s Health Resource Center began implementing a new program called “Welcome to VA.” Under this program, Health Resource Center staff located at central call centers are responsible for contacting each newly enrolled veteran within 5 days of the veteran’s enrollment date. Call center staff are to contact each veteran who submits an enrollment application and is determined eligible for health care, regardless of whether the veteran requests to be contacted on the application, to determine whether the veteran wants to schedule an appointment. To make an appointment, Health Resource Center staff are to provide the veteran with the phone number for his or her preferred VA medical center and connect the veteran with a local scheduler. Health Resource Center officials explained that although this program was running concurrently with the NEAR list process at the time of our review, the program will eventually replace the NEAR list process. When fully implemented, which is expected in spring 2016 according to Health Resource Center officials, medical centers would use a list generated by the Health Resource Center to contact veterans who request appointments.

If VA medical center schedulers attempt to schedule appointments for new patients, including newly enrolled veterans, and no appointments are available within 90 days from when veterans would like to be seen, VHA policy requires that veterans be added to the electronic wait list. As appointments become available, schedulers contact veterans on the electronic wait list to schedule their appointments, at which time they are removed from the wait list.

Scheduling Follow-up Appointments for Veterans

According to VHA policy, providers should document clinically appropriate return-to-clinic dates in the veterans’ medical records at the end of each appointment. Follow-up appointments requested by providers within 90 days of seeing a veteran should be scheduled before the veteran leaves the clinic. Follow-up appointments requested beyond 90 days are to be entered into the VA medical center’s Recall Reminder System. The recall system automatically notifies veterans, of the need to schedule a follow- up appointment. When a veteran receives an appointment reminder, he or she is asked to contact the clinic to make an appointment. Primary care appointments for established patients are generally scheduled for 30 minutes. Schedulers determine the date of each follow-up appointment based on the return-to-clinic date the provider documented in the veteran’s medical record.

VHA Wait-Time Measurement

VHA’s July 2014 interim scheduling guidance established an appointment wait-time goal of 30 days for new patients based on the date each appointment was created (referred to as the create date) and 30 days for established patients based on each veteran’s preferred date. In October 2014, in response to the Choice Act, VHA eliminated the wait-time measure based on create date. It instituted a new wait-time goal of providing appointments for new and established patients not more than 30 days from the date that an appointment is deemed clinically appropriate by a VA health care provider, or if no such determination has been made, the veteran’s preferred date.

Oversight of Primary Care Access

VHA, VISNs, and VA medical centers each have responsibilities for developing scheduling and wait-time policies for primary care and for monitoring wait-time measures to ensure medical centers are providing timely access. The VHA Director of Access and Clinical Administration and VHA’s Chief Business Office have responsibilities for oversight of medical centers’ implementation of VHA’s enrollment and scheduling policies, including measuring and monitoring ongoing performance. Each VISN is responsible for overseeing the facilities within its designated region, including the oversight of enrollment, scheduling, and wait lists for eligible veterans. Finally, medical center directors are responsible for ensuring local policies are in place for the timely enrollment of veterans and for the effective operation of their primary care clinics, including affiliated community-based outpatient clinics and ambulatory care centers. In addition, the medical center director is responsible for ensuring that any staff who have access to the appointment scheduling system have completed the required VHA scheduler training.

Not All Newly Enrolled Veterans in Our Review Were Able to Access Primary Care; Others Experienced Wide Variation in the Amount of Time They Waited for Care

Newly Enrolled Veterans Did Not Always Receive Primary Care Appointments Due to Weaknesses in VHA’s Appointment Scheduling Process and Other Factors

Our review of medical records for a sample of veterans at six VA medical centers found several problems in medical centers processing veterans’ requests that VA contact them to schedule appointments, and thus not all newly enrolled veterans were able to access primary care. For the 60 veterans in our review who had requested care, but had not been seen by primary care providers, we found that 29 did not receive appointments due to the following problems in the appointment scheduling process:

Veterans did not appear on NEAR list. We found that although 17 of the 60 veterans in our review requested that VA contact them to schedule appointments, medical center officials said that schedulers did not contact the veterans because they had not appeared on the NEAR list. Medical center officials were not aware that this problem was occurring, and could not definitively tell us why these veterans never appeared on the NEAR list. For 6 of these veterans, VA medical center officials told us that when they reviewed the medical records at our request, they found that these veterans’ requests were likely filled, in error, by a compensation and pension exam. In these cases, officials had no record that these veterans had appeared on the NEAR list that schedulers used to contact veterans. Officials at one medical center explained that they encourage providers to discuss how to make an appointment with veterans at the end of the compensation and pension exam. For the remaining 11 veterans, after reviewing their medical records, officials were unable to determine why the veterans never appeared on the NEAR list.

VA medical center staff did not follow VHA scheduling policy. We found that VA medical centers did not follow VHA policies for contacting newly enrolled veterans for 12 of the 60 veterans in our review. VHA policy states that medical centers should document three attempts to contact each newly enrolled veteran by phone, and if unsuccessful, send the veteran a letter. However, for 5 of the 12 veterans, our review of their medical records revealed no attempts to contact them, and medical center officials could not tell us whether the veterans had been contacted to schedule appointments. Medical centers attempted to contact the other 7 veterans at least once, but did not follow the process to contact them as outlined in VHA policy.

For 24 of the 60 veterans who did not have a primary care appointment, VA medical center officials stated that scheduling staff were either unable to contact them to schedule an appointment or upon contact, the veterans declined care. Officials stated that they were unable to contact 6 veterans either due to incorrect or incomplete contact information in veterans’ enrollment applications, or to veterans not responding to medical centers’ attempts to contact them. In addition, VA medical center officials stated that 18 veterans declined care when contacted by a scheduler. These officials said that in some cases veterans were seeking a VA identification card, for example, and did not want to be seen by a provider at the time.

The remaining 7 of the 60 veterans had appointments scheduled but had not been seen by primary care providers at the time of our review. Four of those veterans had initial appointments they needed to reschedule, which had not yet been rescheduled at the time of our review. The remaining three veterans scheduled their appointments after VHA provided us with a list of veterans who had requested care.

Veterans Experienced Wide Variation in the Amount of Time They Waited for Primary Care Due to Limited Appointment Availability and Weaknesses in Scheduling Practices

Based on our review of medical records for a sample of veterans across the six VA medical centers in our review, we found the average number of days between newly enrolled veterans’ initial requests that VA contact them to schedule appointments and the dates the veterans were seen by primary care providers at each medical center ranged from 22 days to 71 days. (See table 1.) Slightly more than half of the 120 veterans in our sample were able to see a provider in less than 30 days; however, veterans’ experiences varied widely, even within the same medical center, and 12 of the 120 veterans in our review waited more than 90 days to see a provider.

We found that two factors generally impacted veterans’ experiences regarding the number of days it took to be seen by primary care providers. First, appointments were not always available when veterans wanted to be seen, which contributed to delays in receiving care. For example, one veteran was contacted within 7 days of being placed on the NEAR list, but no appointment was available until 73 days after the veteran’s preferred appointment date. This veteran was placed on the electronic wait list per VHA policy, and a total of 94 days elapsed before the veteran was seen by a provider. In another example, a veteran wanted to be seen as soon as possible, but no appointment was available for 63 days. Officials at each of the six medical centers in our review told us that they have difficulty keeping up with the demand for primary care appointments for new patients because of shortages in the number of providers, or lack of space due to rapid growth in the demand for these services. Officials at two of the medical centers told us that because of these capacity limitations, they were placing veterans who requested primary care services on an electronic wait list at the time our review.

Second, we found weaknesses in VA medical center scheduling practices may have impacted the amount of time it took for veterans to see primary care providers and contributed to unnecessary delays. Staff at the medical centers in our review did not always contact veterans to schedule an appointment according to VHA policy, which states that attempts to contact newly enrolled veterans to schedule appointments must be made within 7 days of their being added to the NEAR list. Among the 120 veterans included in our review, 37 veterans (31 percent) were not contacted according to VHA policy within 7 days to schedule an appointment, and compliance varied across medical centers. (See table 2.)

We found some medical center processes for contacting newly enrolled veterans to schedule appointments were inconsistent with VHA policy and may have contributed to delays in scheduling newly enrolled veterans:

VA officials at one medical center told us that they send letters to newly enrolled veterans who apply online, which inform the veterans that it is their responsibility to come into the medical center to complete enrollment and schedule appointments. According to VISN officials with oversight of this VA medical center, this practice is not consistent with VHA scheduling policies, and veterans should not be asked to come to medical centers to schedule their appointments. In one case, a veteran enrolled online and requested VA contact him to schedule an appointment, but according to medical center officials, the veteran was not called to schedule an appointment, although a letter was later sent. As a result, officials said he did not receive an appointment until he contacted the medical center to again ask for one 47 days later.

At another medical center, we found that the medical center’s process for contacting newly enrolled veterans involves initial calls to explain their VHA health care benefits. After the initial call, each veteran’s name is sent to a scheduler to contact the veteran to schedule an appointment. Although officials indicated that initial outreach to the veterans in our review often occurred within 7 days of their addition to the NEAR list, these veterans were not always contacted again to schedule appointments within 7 days, in accordance with VHA’s scheduling policy.

Finally, officials at a third medical center told us they added every new enrollee to the electronic wait list even when there were appointments available within 90 days of the veteran’s request. The VA medical center then used the electronic wait list rather than the NEAR list to identify veterans who needed to be contacted to schedule an appointment. For example, a veteran requested VA contact him to schedule an appointment, and was added to the electronic wait list. Rather than contacting the veteran within 7 days of being added to the NEAR list, in accordance with VHA policy, officials contacted the veteran 19 days later to schedule an appointment. Officials told us that they changed their process during our review and are now using the NEAR list to identify newly enrolled veterans who need appointments.

Most Veterans in Our Review Accessed Follow-Up Primary Care within the Time Frames Outlined in VHA Policy

Our review found that of 60 veterans who received follow-up primary care, most received care within 30 days of the return-to-clinic date determined by each veteran’s provider, in accordance with VHA’s policy. Our review found that for 51 veterans return-to-clinic dates were applicable and documented in their medical records and 38 of these veterans were seen by providers within 30 days of their return-to-clinic dates. However, the percentage of veterans seen within 30 days of their return-to-clinic dates varied across medical centers in our review. (See table 3.)

We found several reasons why the 13 veterans (out of the 51 for whom return-to-clinic dates were applicable) were not seen for follow-up appointments within 30 days of their return-to-clinic dates: Improperly managed recall reminder process. For 6 of the 13 veterans, VA medical center staff did not properly manage their “recall reminder” process, which notifies veterans that they need to schedule a follow-up appointment, as outlined in VHA policy. Our review of the veterans’ medical records and discussions with medical center officials found that medical center staff did not place 5 veterans on the recall list to receive appointment scheduling reminders as outlined in VHA policy, and thus the veterans were not contacted to schedule their appointments in a timely manner. For the other veteran, one recall notice was sent, and schedulers did not attempt to make contact again, according to medical center officials.

Lack of available appointments or veterans preferred later appointment dates. Four of the 13 veterans were seen more than 30 days beyond the return-to-clinic dates due to the lack of available appointments or based on their preferred dates.

Cancellations and no-shows. For the remaining 3 of the 13 veterans, medical records indicated that appointments were initially scheduled within 30 days of the return-to-clinic dates; however, 2 veterans did not show up for their appointments and the other veteran’s appointment was canceled by the primary care clinic. These veterans were ultimately seen beyond the 30-day time frame.

VHA’s Oversight of Veterans’ Access to Primary Care Is Hindered in Part by Data Weaknesses

VHA Monitors Only a Portion of the Time It Takes Newly Enrolled Veterans to Access Primary Care

A key component of VHA’s oversight of veterans’ access to primary care, particularly for newly enrolled veterans, relies on monitoring appointment wait times. However, VHA monitors only a portion of the overall time it takes newly enrolled veterans to access primary care.

VHA officials said they regularly review data related to access, including data on wait times for primary care. VHA has developed reports to track these data for each VISN and VA medical center. VHA officials indicated that they look for trends in average wait times across medical centers, and also track the percentage of veterans seen within 30 days of their preferred dates or return-to-clinic dates. Officials from all six VISNs and medical centers in our review said they use these reports, and other locally developed reports, to monitor wait times for each of their sites of care to identify any trends. VISN and VA medical center officials said if they find wait times are increasing, they work to identify solutions, which the medical center is then tasked with implementing. For example, officials from two VISNs and medical centers told us that in response to increasing wait times for primary care, actions have been taken to improve patient access, including opening new sites of care and hiring additional providers.

We found, however, that VHA monitors only a portion of the overall time it takes newly enrolled veterans to access primary care, which is inconsistent with federal internal control standards. According to the internal controls for information and communications, information should be recorded and communicated to management and others within the entity who need it to carry out their responsibilities. However, VHA monitors access using veterans’ preferred appointment dates, which are not determined until schedulers make contact with veterans, as the basis for measuring how long it takes veterans to be seen, rather than the dates newly enrolled veterans requested on their enrollment applications that VA contact them to schedule appointments. (See fig. 2.) Therefore, VHA does not account for the time it takes to process enrollment applications, or the time it takes VA medical centers to contact veterans to schedule their appointments. Consequently, data used for monitoring and oversight do not capture veterans’ overall experiences, including the time newly enrolled veterans wait prior to being contacted by a scheduler, which makes it difficult for officials to effectively identify and remedy scheduling problems that arise prior to making contact with veterans.

Our review of medical records for 120 newly enrolled veterans found that, on average, the total amount of time it took to be seen by primary care providers was much longer when measured from the dates veterans initially requested VA contact them to schedule appointments than it was when using appointment wait times calculated using veterans’ preferred dates as the starting point. (See table 4.)

The amount of time elapsed between when veterans initially requested VA contact them to schedule appointments and when they are seen by providers may be due to veterans’ decisions such as not wanting to schedule appointments immediately, or cancelling and rescheduling initial appointments. However, we found the amount of time between initial requests and when they received care also varied due to factors unaffected by veterans’ decisions, including VA medical centers not contacting veterans in a timely manner, medical centers being unaware of veterans’ requests, and difficulties in processing veterans’ requests that they be contacted to schedule appointments. For example:

One veteran applied for VHA health care benefits in December 2014, which included a request to be contacted for an initial appointment. The VA medical center contacted the veteran to schedule a primary care appointment 43 days later. When making the appointment, the medical center recorded the veteran’s preferred date as March 1, 2015, and the veteran saw a provider on March 3, 2015. Although the medical center’s data showed the veteran waited 2 days to see a provider, the total amount of time that elapsed from the veteran’s request until the veteran was seen was actually 76 days.

For another veteran, the medical record indicated that a request to schedule an appointment was made in October 2014. According to VA medical center officials, the veteran had a compensation and pension exam, and as a result, this veteran was not on the list of those who needed to be contacted to schedule a primary care appointment. Officials told us that the veteran contacted the medical center in January 2015 to schedule an appointment, with a preferred date in January 2015. The veteran had his appointment in February 2015. While the medical center’s data show the veteran waited 13 days to be seen, the total amount of time that elapsed from the veteran’s initial request to schedule an appointment until the veteran was seen was 113 days.

According to VHA officials responsible for monitoring wait times, there are no VHA policies requiring that they measure and monitor the total amount of time that newly enrolled veterans experience while waiting to be seen by a primary care provider. Instead, VHA’s policy is to use data that measure the timeliness of appointments based on veterans’ preferred dates. Although there is no policy requiring that they measure the total time veterans wait to be seen, officials from one VISN told us that they measure this period of time, as it may provide valuable insights into newly enrolled veterans’ experiences in trying to obtain care from VHA. During our discussions with these VISN officials, they expressed concern that monitoring veterans’ wait times using the preferred date is too limited, because it does not capture the full wait times veterans experience.

Since February 2015, officials from this VISN have instructed each of the medical centers they oversee to audit a sample of 30 primary care, specialty care, and mental health appointments for new patients, including newly enrolled veterans, for a total of 90 appointments each month. As part of this audit, medical center officials record the dates veterans initially requested VA contact them to schedule appointments, the dates appointments were created, and the dates veterans were seen by providers. VISN officials use the information to prepare a monthly summary report which tracks a variety of information, including the percentage of appointments for which the veterans’ overall wait was more than 30 days. According to data from the October 2015 audit, 24 percent of veterans waited more than 30 days from their initial request until they were seen by a provider. Officials indicated that by analyzing trends on these and other data, they will be able to identify whether factors such as enrollment issues or problems contacting newly enrolled veterans are impacting overall wait times. Officials indicated that it is time-consuming to perform these audits, and it would be helpful if VHA had a centralized system which would enable them to electronically compile the data.

During our review we also found that under the Health Resource Center’s Welcome to VA program, officials are developing a centralized electronic system to track various dates related to newly enrolled veterans, including the date each veteran applied for VHA health care. Once applications for benefits are approved, staff in the Health Resource Center call centers contact each newly enrolled veteran, and ask if that veteran wants to begin receiving health care at VHA. For veterans that indicated on their applications that they wanted to be contacted to schedule an appointment, their requests are confirmed through these calls, and the dates of the requests on the applications are recorded in the Health Resource Center system, as well as the dates the veterans were contacted. For veterans who did not indicate they wanted to be contacted on their applications, but tell Health Resource Center staff during the calls that they want care, the dates of contact are documented as their initial requests for care. Officials indicated that it is important to begin tracking from the onset of veterans’ requests, because that is when they told VA they needed care. Officials indicated that since July 2015, they have been piloting this Welcome to VA data collection and tracking effort with one VISN, and hope to expand this effort across the VHA system during 2016. They further indicated that they have been coordinating with the VHA office responsible for monitoring access, and hoped their data could be integrated into VHA’s routine monitoring of veterans’ wait times.

Scheduling Errors Continue to Affect the Reliability of Wait-Time Data, Including for Primary Care

Ongoing problems continue to affect the reliability of wait-time data, including for primary care, used by VHA, VISN, and VA medical center officials for monitoring and oversight. Our previous work in 2012, as well as that of VA and the VA OIG in 2014, has shown that VHA wait-time data are unreliable and prone to errors and interpretation. Among other things, we found in December 2012 that medical centers were not implementing VHA’s scheduling policies in a consistent manner, which led to unreliable wait-time data. Although VHA has taken steps since then to improve the reliability of its wait time data, including ensuring that scheduling staff complete required training, we found VHA schedulers were continuing to make errors in recording veterans’ preferred dates; and thus, data reliability problems continue to hinder effective oversight.

During our review of appointment scheduling for 120 newly enrolled veterans, we found that schedulers in three of the six VA medical centers included in our review had made errors in recording veterans’ preferred dates when making appointments. Specifically, we found 15 appointments for which schedulers had incorrectly revised the preferred dates. In these cases, we recalculated the appointment wait time based on what should have been the correct preferred dates, according to VHA policy, and found the wait-time data contained in the scheduling system were understated. (See table 5.)

We found that schedulers incorrectly revised patients’ preferred dates to later dates, inconsistent with VHA policy, under two scheduling scenarios: 1. Medical center primary care clinics cancelled appointments, and when those appointments were re-scheduled, schedulers did not always maintain the original preferred dates in the system, but updated them to reflect new preferred dates recorded when the appointments were rescheduled. This is not consistent with VHA policy, which indicates that if a clinic cancels an appointment, the original preferred date should be maintained in the system. 2. Preferred dates initially recorded when placing veterans on the electronic wait list were incorrectly revised to later dates when appointments became available and were scheduled. This included revising preferred dates to the same dates of the scheduled appointments. This is also inconsistent with VHA policy, which indicates that the veterans’ preferred dates recorded at the time of entry on the electronic wait list should not be changed. We confirmed our understanding of this policy with officials from one of the VISNs, and discussed these cases with VA medical center officials, who indicated that they would need to provide additional training to schedulers to ensure compliance with VHA’s scheduling policies.

We also found in our review of medical records, that of 120 veterans who saw providers, 65 veterans, or 54 percent, had appointments with a zero- day wait time recorded in the scheduling system. VHA officials indicated that appointments with wait times of zero days are a potential indicator of scheduling errors. Based on our review of medical records for these veterans, 13 of the appointments with zero-day wait times were those that were incorrect due to schedulers revising preferred dates.

In addition, officials from five of the six VA medical centers in our review told us they continue to find through their scheduling audits that schedulers are incorrectly recording preferred dates. Officials from each of the six medical centers explained that they periodically audit scheduled appointments to help ensure schedulers are complying with scheduling policies. Officials from these medical centers indicated a key focus of the audits is to assess whether schedulers are correctly recording the preferred date when making appointments, and that wait times are being calculated correctly. For example, officials from one medical center said they audited nearly 1,200 appointments between January and June 2015, and identified 205 appointments for which schedulers incorrectly recorded the veteran’s preferred date. Officials indicated that based on these results, scheduling supervisors provided training with those schedulers who made the errors.

Since July 2014, VHA has issued a revised interim scheduling directive and numerous individual memos to clarify and update the scheduling policy, but has not yet published a comprehensive policy that incorporates all of these changes. Officials from four of the six VISNs in our review indicated that the way VHA has communicated revised scheduling policies and updates to medical centers has been ineffective and may be contributing to continued scheduling errors. They indicated that high turnover among schedulers and the lack of an updated standardized scheduling policy make it more difficult to train schedulers and to direct these staff to current policy, which increases the likelihood of errors. Federal internal control standards call for management to clearly document, through management directives or administrative policies, significant events or activities—which in this instance would include ensuring that scheduling policies are readily available and easily understood—and that management should use and communicate, both internally and externally, quality information to achieve its objectives. VHA officials acknowledged that they are aware of frustration among medical center staff, and that they have been working over the past 18 months to develop an updated and comprehensive scheduling policy. Officials indicated that their current target is to issue a revised policy some time in 2016.

To help VA medical centers and VISNs identify scheduling problems, in January 2015, VHA implemented its scheduling trigger tool, which is designed to provide medical center and VISN officials with an early warning that scheduling problems may be occurring. According to VHA officials, the tool uses statistical analysis software to review appointment data from all medical centers in order to detect potential erroneous scheduling practices, including those that deviate from VHA policies. For example, it assesses whether medical center schedulers are accurately documenting patients’ preferred dates and whether they are using the electronic wait list correctly for new patients. The tool assesses each medical center’s scheduling performance and automatically alerts medical center and VISN leadership if a medical center is performing in the bottom 20 percent. According to VHA officials, use of the tool has prompted many requests for assistance, and they have provided additional scheduler training.

VHA and Medical Centers Have Implemented Efforts Aimed at Improving Veterans’ Timely Access to Primary Care VHA Has Implemented System-Wide Efforts Designed to Offer Veterans More Timely Access to Primary Care

VHA has implemented two system-wide efforts designed to offer veterans more timely access to primary care: the Veterans Choice Program, created through the Choice Act; and an initiative to increase primary-care hours.

VA Medical Centers Have Implemented Local Efforts to Improve Veterans’ Access to Timely Primary Care

In addition to the VHA-wide initiatives aimed at improving access, officials from the VA medical centers in our review also reported implementing several local efforts to improve veterans’ timely access to primary care appointments. (See table 6.)

Specifically, officials from all six medical centers reported reconfiguring or expanding clinic space. For example, officials at two medical centers stated that they are reconfiguring their primary care clinic’s space to accommodate additional providers and other staff without having to lease additional space. Officials from another medical center told us they were expanding clinic space by opening several additional community-based outpatient clinics by entering into emergency lease agreements in addition to beginning the construction of new clinic space.

Further, officials from five medical centers in our review reported hiring additional providers or creating additional positions. For example, officials at one medical center stated that since 2013 they have hired 20 new full- time providers and 18.5 full-time equivalent nurses. Additionally, they have also created a new position—a “gap” provider who is a doctor, nurse practitioner, or nurse—that allows flexibility to cover short-term leave such as sick or annual leave or longer-term leave such as the gap between one provider leaving and a new provider coming on board. In practice, the medical center shifts gap providers from one location to another as needed, enabling the medical center to minimize backlogs that may arise due to staffing shortages and unanticipated provider absences. Currently, this medical center has seven gap providers in primary care. Similarly, two other medical centers reported using flexible providers who work across several clinic locations to improve access to primary care for veterans.

Finally, officials from three of the medical centers included in our review reported developing technological solutions to improve access to timely primary care appointments. These solutions included increasing the use of telehealth and secure messaging to improve the convenience and availability of primary care appointments. For example, officials from one of the medical centers in our review said providers are using secure messaging to communicate with patients and reduce the need for in- person encounters, which they said helps free up appointments for other patients.

Conclusions

Providing our nation’s veterans with timely access to primary care is a critical responsibility of VHA. As primary care services are often the entry point to the VA health care system for newly enrolled veterans, the ability to access primary care and establish a relationship with a VHA provider can be instrumental in the ongoing management of a veteran’s overall health care needs. Although VHA has processes for identifying those veterans who have requested VA contact them to schedule appointments, our review of a sample of newly enrolled veterans revealed that VA medical centers did not always provide that care until several months after veterans initially indicated interest in obtaining it, if at all. In several cases, newly enrolled veterans were never contacted to schedule appointments, due to medical center staff failing to comply with VHA policies for scheduling such appointments or medical center staff being unaware of veterans’ requests. In the absence of consistent adherence by medical center staff to VHA scheduling processes and policies, veterans may continue to experience delays in accessing care.

To help oversee veterans’ access to primary care, officials at VHA’s central office, medical centers, and VISNs rely on measuring, monitoring, and evaluating the amount of time it takes veterans to be seen by a provider. The data currently being used to evaluate newly enrolled veterans’ access to primary care, however, are limited because they do not account for the entire amount of time between veterans’ initial requests to be contacted for appointments and being seen by primary care providers. This is because the method VHA uses to measure the appointment wait times for newly enrolled veterans does not begin at the point at which veterans initially request that VA contact them to schedule appointments when applying for VHA health care, but rather begins when VA medical center staff contact veterans and record the veterans’ preferred dates. Consequently, data used for monitoring and oversight do not capture the time newly enrolled veterans wait prior to being contacted by a scheduler, making it difficult for officials to effectively identify and remedy scheduling problems that arise prior to making contact with veterans. Recognizing limitations in monitoring and oversight of access data based on veterans’ preferred dates, some system-wide and local efforts are being developed and implemented to broaden data collection and oversight of newly enrolled veterans’ access to primary care; such efforts could have applicability across the entire VHA system.

Ongoing scheduling problems continue to affect the reliability of wait-time data, including for primary care. Our previous work has shown that VHA wait-time data are unreliable due, in part, to medical centers not implementing VHA’s scheduling policies consistently. VHA central office officials have responded to scheduling problems throughout the VHA system by issuing several individual memorandums to clarify scheduling policies. However, VHA’s piecemeal approach in implementing these policies may not be fully effective in providing schedulers with the comprehensive guidance they need to consistently adhere to scheduling policies or providing the reliable data officials need for monitoring access to primary care. Our review of medical records for a sample of veterans found that scheduling errors continue, diminishing the reliability of data officials use for monitoring the timeliness of appointments by understating the amount of time veterans actually wait to see providers. Officials at several of the VA medical centers also continue to uncover scheduling errors through audits, and VISN officials attribute the errors, in part, to the lack of an updated comprehensive scheduling policy. While VHA central office officials are working on finalizing an updated scheduling policy, they currently have no definitive issuance date. Until a comprehensive scheduling policy is finalized, disseminated, and consistently followed by schedulers, the likelihood for scheduling errors will persist.

Recommendations for Executive Action

We recommend that the Secretary of Veterans Affairs direct the Under Secretary for Health to take the following three actions: (1) Review VHA’s processes for identifying and documenting newly enrolled veterans requesting appointments, revise as appropriate to ensure that all veterans requesting appointments are contacted in a timely manner to schedule them, and institute an oversight mechanism to ensure VA medical centers are appropriately implementing the processes. (2) Monitor the full amount of time newly enrolled veterans wait to be seen by primary care providers, starting with the date veterans request they be contacted to schedule appointments. This could be accomplished, for example, by building on the data collection efforts currently being implemented under the “Welcome to VA” program. (3) Finalize and disseminate a comprehensive national scheduling directive, which consolidates memoranda and guidance disseminated since July 2014 on changes to scheduling processes and procedures, and provide VA medical center staff appropriate training and support to fully and correctly implement the directive.

Agency Comments

We provided VA with a draft of this report for its review and comment. VA provided written comments, which are reprinted in appendix II. In its written comments, VA concurred with all three of the report’s recommendations, and identified actions it is taking to implement them.

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If you or your staff have any questions about this report, please contact me at (202) 512-7114 or at draperd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix III.

Appendix I: Prior GAO Recommendations Related to Oversight of Veterans’ Access to Primary and Specialty Care

Our prior work has found weaknesses in the Department of Veterans Affairs’ (VA) Veterans Health Administration’s (VHA) ability to effectively oversee timely access to health care for veterans. Specifically, we found that VHA did not have adequate data and oversight mechanisms in place to ensure veterans receive timely primary and specialty care, including mental health care. Since 2012, we have issued several reports and made recommendations to help ensure VHA has effective policies and reliable data to carry out its oversight. See table 7 for our previous recommendations and the status of their implementation.

Appendix II: Comments from the Department of Veterans Affairs

Appendix III: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the contact named above, Janina Austin, Assistant Director; Jennie F. Apter; Emily Binek; David Lichtenfeld; Vikki L. Porter; Brienne Tierney; Ann Tynan; and Emily Wilson made key contributions to this report.