VAPIHCS provides comprehensive health care to eligible veterans who reside in Hawaii and the three U.S. territories in the Pacific— American Samoa, Guam, and the Commonwealth of the Northern Mariana Islands. According to VAPIHCS officials, the geographic distances between the Pacific Islands and the use of multiple sources of health care to provide services to veterans in this region create complex care delivery and coordination challenges for VAPIHCS. VAPIHCS generally provides outpatient primary and mental health care services to the veterans it serves. These services are provided through its ambulatory care clinic, housed at the Spark M. Matsunaga VAMC in Honolulu, Hawaii, on the island of Oahu, and 10 clinics located in other communities across the Pacific Islands. These 10 clinics include 7 in the state of Hawaii on the islands of Oahu (1 clinic); Hawaii (2 clinics); Maui (1 clinic); Lanai (1 clinic); Molokai (1 clinic); and Kauai (1 clinic); 1 in the territory of American Samoa; 1 in the territory of Guam; and 1 in the Commonwealth of the Northern Mariana Islands on the island of Saipan. VAPIHCS provides some outpatient specialty care services through the ambulatory care clinic and through traveling VAPIHCS specialty care providers. Table 2 shows the number of enrolled veterans and the number of veterans that have used outpatient services in fiscal year 2017 at each VAPIHCS facility. According to VAPIHCS officials, VAPIHCS provides most specialty care and inpatient services to veterans at military treatment facilities through joint venture and sharing agreements with DOD or through non-VA providers in the community. In fiscal year 2017, VAPIHCS sent 50,000 referrals outside of VA, mostly to DOD or through the Choice Program. Military treatment facilities. Two military treatment facilities located in the Pacific Islands provide care for veterans through joint venture and sharing agreements with VAPIHCS: TAMC and NHG. According to VAPIHCS’ data, VAPIHCS made more than 8,000 referrals to these facilities in fiscal year 2017. VAPIHCS’ joint venture with TAMC: VAPIHCS’ joint venture agreement with TAMC—1 of 10 joint venture agreements in place between VA and DOD as of December 2017—states that VAPIHCS may refer veterans to TAMC providers for specialty care and inpatient services and, in return, for VAPIHCS to provide services for DOD beneficiaries, such as psychiatric and post-traumatic stress disorder services. VAPIHCS’ sharing agreement with NHG: VAPIHCS’ sharing agreement with NHG—1 of more than 200 active sharing agreements in place between VA and DOD as of December 2017—states that VAPIHCS may refer patients from the Saipan and Guam clinics to NHG for available specialty care, laboratory, emergency care, and inpatient services. NHG is located within a mile of the Guam clinic. Choice Program. VAPIHCS may also refer veterans to a non-VA provider in the community when veterans need care that is not offered by VAPIHCS, or cannot obtain the needed care in a timely manner. In fiscal year 2017, 61 percent of VAPIHCS referrals sent to community providers were through the Choice Program. (See fig. 1 for the breakdown of the number and percent of referrals sent to care outside of VAPIHCS in fiscal year 2017.) Veterans may opt to obtain health care services from a network of community providers through the Choice Program if they meet certain criteria, including: 1. the next available medical appointment with a VHA clinician is more than 30 days from the veteran’s preferred appointment date or the date the veteran’s physician determines he or she should be seen; 2. the veteran lives more than 40 miles driving distance from the nearest VHA facility with a full-time primary care physician; 3. the veteran needs to travel by air, boat, or ferry to the VHA facility that is closest to his or her home; 4. the veteran faces an unusual or excessive burden in travelling to a VHA facility based on geographic challenges, environmental factors, or a medical condition; 5. the veteran’s specific health care needs, including the nature and frequency of care needed, warrants participation in the program; or 6. the veteran lives in a state or territory without a full-service VHA medical facility. As the third-party administrator of the Choice Program for VAPIHCS, TriWest is responsible for establishing networks of community providers, scheduling appointments with community providers for eligible veterans, and paying providers for their services. TriWest has contractual time frames in which to accept and schedule the appointment, or return the referral to VAPIHCS for further action. Our review of 30 medical records of newly enrolled veterans accessing initial primary care services at the American Samoa, Guam, or Maui clinic found some delays in processing of health care benefits enrollment applications and contacting of veterans to schedule appointments. Once contacted, however, most veterans in our sample received initial primary care within VHA’s timeliness goal. These enrollment delays may have contributed to the time taken for veterans to see primary care providers, consistent with findings from our prior work. Enrollment for VA Health Care Benefits To receive VA health care benefits, a veteran may submit an enrollment application by mail, telephone, through VA’s website, or by applying in person at a VA health care facility. Once a veteran submits an application, there are three key steps for processing the application: (1) intake of application, (2) verification of eligibility, and (3) enrollment determination. In fiscal year 2016, most enrollment applications were processed by VA medical center staff. According to Veterans Health Administration policy, staff are required to process applications within 5 business days of receipt. applications within the timeliness goal set in VHA policy. For 27 of the 30 veterans in our sample, VHA staff recorded the date the application was received, which enabled us to assess the timeliness of enrollment processing for these veterans. We found that 22 of these 27 applications were processed within VHA’s required 5 business days, with an average of 1 day for processing. (See table 3.) Five applications were not processed within the 5-day requirement; for four of these veterans, it took an average of 10 days to process the enrollment applications. For the fifth veteran, it took 627 days for VHA to process the application, and for which VAPIHCS staff could not explain the delay. New Enrollee Appointments Veterans can request on their enrollment applications that Department of Veterans Affairs (VA) staff contact them to schedule an initial outpatient appointment. After a veteran’s enrollment application has been processed, VA staff are to initiate the scheduling of appointment requests within 7 days. within 7 days of their eligibility determination as required by VHA policy. We found that 15 of the 30 veterans in our review had contact initiated within 7 days to schedule an appointment, with an average of 4 days. (See table 4.) Fifteen veterans did not have contact initiated within the 7 day requirement; for 14 of these veterans, it took an average of 20 days to initiate contact. For the 15th veteran, it took 183 days to initiate contact. According to clinic staff, gaps in communication between clinic and VAPIHCS staff responsible for veteran enrollment, as well as staffing shortages, may have contributed to delays in contacting newly enrolled veterans. Clinic staff reported differences in how they are notified that a veteran’s enrollment application has been processed and that appointment scheduling should be initiated. In addition, staff from two clinics said there were staffing vacancies for primary care appointment schedulers in their clinics during the time of our medical record sample selection (October 2016 through March 2017), which may have caused delays in contacting veterans. Timeliness of initial primary care services. For the 30 newly enrolled veterans’ medical records we reviewed, we found that, once contacted, 27 veterans received initial primary care services within VHA’s timeliness goal of 30 days of their preferred appointment dates (the date a veteran requests health care services), with an average wait time of 7 days. (See table 4.) Three veterans did not receive initial primary care appointments at the Guam clinic within the 30-day requirement, and waited an average of 62 days. However, as we have previously reported, VHA’s timeliness goal monitors only a portion of the overall time it takes newly enrolled veterans to access primary care, and does not account for the time it takes to process enrollment applications, to notify clinic staff of successful enrollments, or to contact veterans to schedule their appointments. In our March 2016 report, we recommended that VA 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. When accounting for the time to process applications and contact veterans, we found 6 of the 30 veterans in our review waited more than 90 days to see a provider while 9 waited 30 days or less. Our review of a randomly selected sample of 30 medical records for veterans who accessed mental health care services for the first time at one of the selected three clinics found that most veterans received initial mental health care within VHA’s timeliness goal. Although most veterans in our sample received timely initial services, our review found that those veterans needing comprehensive mental health evaluations often experienced delays receiving them. Mental Health Care Appointments Veterans can either request mental health care services, or be referred for these services, such as by their primary care providers. Once care is requested for non- emergent mental health care needs, appointments are to be scheduled within 30 days of the referral’s clinically indicated date, or in the absence of a clinically indicated date, the veteran’s preferred date for their first mental health care appointment. In addition to scheduling the initial appointment, veterans are to receive a comprehensive mental health evaluation within 30 days of that initial referral’s clinically indicated date, or in the absence of a clinically indicated date, the veteran’s preferred date for their first mental health care appointment. This comprehensive mental health evaluation occurs during a mental health appointment, and includes a diagnosis and a plan for treatment. While this evaluation does not necessarily have to occur during the first mental health care appointment, it is expected to be completed within the timeliness goals as noted. Timeliness of initial mental health care services. Our review found that 21 of the 30 veterans in our sample who needed mental health care received their initial mental health care appointments within VHA’s timeliness goal of 30 days of their documented clinically indicated dates (the date an appointment is deemed clinically appropriate by the referring provider), or in the absence of clinically indicated dates, their preferred dates. (See table 5.) These 21 veterans were seen by a mental health care provider within an average of 7 days of their clinically indicated date or preferred date. Nine veterans did not receive initial mental health care appointments within VHA’s 30-day timeliness goal, and waited an average of 46 days to receive care from a mental health provider. Timeliness of comprehensive mental health evaluations. Although 21 of 30 veterans in our sample received initial mental health care appointments in a timely manner, our review found that most veterans needing comprehensive mental health evaluations experienced delays receiving them. Of the 30 veterans in our sample, 25 were identified as needing a comprehensive mental health evaluation, and only 9 received that evaluation within VHA’s timeliness goal of 30 days of their clinically indicated date, or in the absence of a clinically indicated date, the veteran’s preferred date. (See table 6.) These 9 veterans received their evaluations within an average of 8 days. For the 16 veterans that did not receive a comprehensive mental health evaluation within the 30-day requirement, it took between 35 and 217 days (an average of 82 days) for 15 veterans to receive an evaluation from the initial referral’s clinically indicated date or veteran’s preferred appointment date. The remaining veteran had not completed an evaluation as of February 2018. The process by which veterans received comprehensive mental health evaluations varied by clinic, and this sometimes resulted in the evaluations being completed outside of VHA’s timeliness goal: American Samoa clinic staff stated that they provide veterans with a hard-copy comprehensive mental health evaluation at the veteran’s first appointment. The veteran is instructed to complete the form at home, and return to the clinic at a later date to discuss with a provider. Staff stated that allowing veterans to fill out the form on their own saves time at the clinic, and allows veterans to be more thorough in their answers. A staff member stated that the comprehensive mental health evaluation is just one piece of the diagnostic interview and that, presumably, the provider obtains sufficient information from the veteran to develop a treatment plan and initiate services for the veteran while waiting for the veteran to complete the form. Guam clinic staff said that they generally complete the comprehensive mental health evaluation during the veteran’s first mental health care appointment, but do sometimes need to schedule a second appointment to complete the entire evaluation. Staff stated that the first priority is to treat and address what is clinically indicated, so they are sometimes delayed in completing all form requirements until a later time. Maui clinic staff stated that they typically schedule the first appointment with a veteran, and if it becomes clear that the veteran needs to continue receiving mental health services, they will schedule a comprehensive mental health evaluation at a future appointment. Follow-Up Appointments After a veteran is seen for an appointment at a Department of Veterans Affairs (VA) facility, the provider is to document in the veteran’s medical record a clinically appropriate specific return date or interval (such as 2, 3, or 6 months), when the provider determines the veteran should return for care. This is also known as the clinically indicated date. The follow-up appointment should then be scheduled within 30 days of the clinically indicated date. Our review of a randomly selected sample of medical records for 30 veterans in the Pacific Islands (15 veterans needing primary care and 15 veterans needing mental health care) who received follow-up appointments found that most of these veterans received care within VHA’s timeliness goal. Specifically, we found that of the 30 veterans, 25 veterans received follow-up care within 30 days of the clinically indicated date determined by each veteran’s provider, in accordance with VHA policy. (See table 7.) This included 10 veterans needing follow-up primary care (who received care an average of 6 days within the veteran’s clinically indicated date), and all 15 veterans needing follow-up mental health care (who received care an average of 3 days within the veteran’s clinically indicated date). The 5 veterans needing follow-up primary care that were not seen within the required 30 days were seen between 109 and 584 days (an average of 299 days) from their clinically indicated dates. Explanations for the length of time it took for these 5 veterans to receive care varied; for example, Guam clinic staff told us that one veteran’s follow-up care was delayed due to clinical and scheduling staffing shortages. We found that VAPIHCS referred 67 of 69 randomly selected specialty care referrals in our sample to non-VA providers in the Choice Program or through DOD within 7 days, in accordance with the timeliness goal set in VHA policy. Specifically, VAPIHCS met this goal for 28 of 30 specialty care referrals sent to Choice Program providers, and all 39 specialty care referrals sent to DOD providers at two military treatment facilities. VAPIHCS staff took an average of 2 days to review and send referrals to VAPIHCS staff responsible for Choice Program referrals, and an average of 1 day to review and send specialty care referrals to TAMC and NHG. VAPIHCS staff responsible for Choice Program referrals also are responsible for uploading the referrals into TriWest’s portal, the Choice Programs’ third-party administrator within VAPIHCS. Although VHA policy applies to referrals sent to in-house providers, a VHA official told us that VHA expects VAMCs to manage non-VA referrals as they would those referred in-house. A VAPIHCS official confirmed that it holds staff to the 7-day requirement found in VHA policy. We found that once specialty care referrals in our review were sent to the Choice Program or one of the two DOD military treatment facilities— TAMC and NHG—the amount of time it took veterans to receive care from these non-VA providers varied, and sometimes was lengthy. Time taken to receive care from a Choice Program provider. Once VAPIHCS staff reviews and uploads each referral into TriWest’s portal, TriWest is required to meet VA’s timeliness requirements for the Choice Program, which specify the amount of time TriWest has to (1) contact the veteran, (2) schedule the appointment, (3) and provide veterans with care. We found that for all 30 referrals in our sample, TriWest first attempted to contact the veteran within the 4 business days required once TriWest received and accepted the referral from VAPIHCS. However, we also found that TriWest did not follow the requirements for mailing letters for 3 of the referrals when it was unable to reach the veterans by phone. If TriWest is unable to reach a veteran after calling a minimum of three times over 4 business days, a letter is to be mailed to the veteran on the 7th business day after receiving the referral notifying them that they have 10 business days from the date of the letter to contact TriWest to schedule an appointment. For these 3 referrals, TriWest mailed a letter, but did not do so until one day later than the required 7th business day after receiving and accepting the referral. We found that after reaching the veteran, TriWest staff scheduled appointments for 17 of the 25 referrals within the 5 business days required for scheduling an appointment after the veteran opts in to the Choice Program. (See table 8.) We found varying reasons that may have delayed the scheduling of an appointment. For example, some records showed that TriWest staff did not begin to call a provider until 4 or more days after they reached the veteran and confirmed they wanted to utilize, or opt in to, the Choice Program to receive care. In addition, some providers required time to review the veteran’s medical record before scheduling the appointment with TriWest. We found that 20 of the 30 veterans referred to Choice Program providers received care within VHA’s 30-day timeliness goal that VA used to evaluate TriWest’s performance under its contract. TriWest has an overall timeliness goal from VHA to provide veterans care through Choice Program providers, although the way this was calculated changed during our review due to changes in their practice and modifications to the contract. The 20 veterans that received care within the timeliness goal did so within an average of 14 days. The 10 veterans that did not receive care within the 30-day timeliness goal waited between 31 and 126 days (an average of 62 days). Veteran preferences and specific provider tendencies sometimes led to delays in scheduling, causing care to be completed outside VHA’s timeliness goal. For example, our review of TriWest records found that two veterans in Guam noted that they preferred to stay on island for their ophthalmology referrals, rather than flying to Honolulu, and the non-VA Guam orthopedist sometimes took a week or more to review a veteran’s file before scheduling the appointment with TriWest. The 30-day timeliness goal that VA used to evaluate TriWest’s performance captured a portion of the overall amount of time that it took for these veterans to receive care. We found that the number of days from the referral’s creation to the date that veterans received care from Choice Program providers varied by clinic, and ranged from 19 to 239 days, with the average being 75 days. (See table 9.) This range and average includes circumstances outside of TriWest’s control; for example, four veterans in our sample chose to reschedule their appointments for a later date. One veteran from American Samoa was originally scheduled for an appointment within 40 days of the referral’s creation date; however, the veteran chose to reschedule the appointment and, in doing so, it took a total of 166 days for the veteran to be seen. three other veterans experienced delays in care after VAPIHCS initially sent their referrals to TAMC or NHG and later redirected the referrals to the Choice Program. VAPIHCS referred one veteran from Guam for specialty care at NHG. However, when VAPIHCS discovered that NHG could not provide care to the veteran, the veteran’s referral was redirected to the Choice Program 88 days after the referral creation date. This veteran encountered additional delays because of the time it took the Choice Program provider to review medical records before scheduling the appointment. As a result, it took a total of 180 days for the veteran to be seen. Time taken to receive care from a DOD provider. After referring a veteran to a DOD provider, VHA does not have any timeliness goals or requirements in place related to the scheduling of appointments, or when the veteran should receive care. Our review found wide ranges in the time it took for the 39 veterans in our sample to receive care at TAMC and NHG. (See table 10.) TAMC: It took up to 95 days for 29 veterans from the American Samoa, Guam, and Maui clinics referred to TAMC to receive specialty care, with an average of 37 days from the creation of the referral to receiving care. These time frames include some veterans that rescheduled their appointments for later dates. For example, one veteran from Maui did not show up to the originally scheduled appointment (which was scheduled for approximately a month after the referral creation date), and the appointment was rescheduled for two months later. NHG: It took up to 107 days for 10 veterans from the Guam clinic referred to NHG to receive specialty care, with an average of 47 days from the creation of the referral to receiving care. When reviewing VAPIHCS’ referrals to NHG, we found weaknesses with the VAPIHCS’ referral process, including (1) incorrectly canceling referrals, (2) inconsistent guidance describing roles and responsibilities, and (3) untimely referral management. These weaknesses may have contributed to the amount of time it took for veterans to receive care, or resulted in the veteran not receiving care. Military Treatment Facility Referral Process After the Department of Veterans Affairs (VA) Pacific Islands Health Care System (VAPIHCS) staff review a referral and decide care should be rendered at a military treatment facility, there are two different processes for sending the referral to Tripler Army Medical Center (TAMC) or Naval Hospital Guam (NHG). If it is determined that a veteran needs care at TAMC, VAPIHCS staff review and send the referral to TAMC’s VA Referral Center. There, TAMC staff enters the referral information into DOD’s electronic medical record system and completes the appointment scheduling process. If it is determined that a veteran needs care at NHG, VAPIHCS staff review and send the referral to designated staff on Guam who have access to enter the referral directly into NHG’s electronic medical record. After the designated staff on Guam enter the referral into the system, NHG staff are then responsible for scheduling the veteran’s appointment. Some referrals sent to NHG were incorrectly canceled by VAPIHCS staff. Specifically, in addition to the 10 completed referrals we reviewed, we also examined 5 referrals sent to NHG that were subsequently canceled by VAPIHCS staff responsible for referral management, but with no indication of appointments ever being scheduled. The reason for cancelations recorded in the veterans’ medical records was that the referrals had been open for more than 90 days; however, this practice is not in alignment with VHA policy. According to VHA policy confirmed by a VHA official, canceling a referral is an action taken by the receiving service to alert the sending provider that additional information is needed, or to correct an obvious error in the referral; a referral should not be canceled due to the length of time the referral has been open without care being provided. VHA policy also states that canceled referrals older than 90 days are not to be resubmitted by the sending provider; instead, the sending provider must reassess the patient’s needs, as the clinical circumstances may have changed, and create a new referral, as necessary. Based on our review, it is unclear why VAPIHCS staff responsible for referral management were not following VHA policy for canceling referrals, whether it was because they did not understand the policy or for other reasons. Federal internal control standards require management to review processes in a timely manner to ensure that control activities are appropriately designed and implemented. Because our review found that in some cases VAPIHCS staff were not following VHA’s referral policy, it is important for VAPIHCS to determine why staff are not adhering to the policy and take needed steps to ensure compliance. Ultimately, in our review of the veterans’ medical records, we did not find documentation that these veterans received the recommended care included in the canceled referrals. Additionally, we did not find evidence that four of the five referrals had been updated and resubmitted, or that any new referrals had been submitted in their place, which may have delayed needed care; or that the five affected veterans were contacted by VAPIHCS to understand why appointments had not been scheduled. Inconsistent guidance exists describing the roles and responsibilities of VAPIHCS staff involved in the NHG referral process. We identified different VAPIHCS guidance that provided inconsistent descriptions of the referral process with NHG. For example, a VAPIHCS flowchart depicting the referral process states that, after review, the referral is to be sent to a VAPIHCS staff member embedded within NHG to enter the referral information into NHG’s electronic medical record. However, language in the referral itself states that, after review, the referral is sent to Guam clinic staff to enter into NHG’s record. Federal internal control standards call for management to assign responsibility and delegate authority to achieve an agency’s objectives. A VAPIHCS official stated that the embedded member within NHG entering in referrals in NHG’s electronic medical record was an interim fix and that there are plans in place for those responsibilities to be transferred to NHG staff. Specifically, VAPIHCS and NHG officials reported that NHG plans to hire two staff members to manage the referral process, but as of December 2017, these 2 staff members had not yet been hired due to budgetary constraints. Whether or not NHG hires additional staff, it is important for VAPIHCS to clarify and document the roles and responsibilities of their staff for sending, managing, and monitoring referrals to NHG. Without such clarification, there is the risk for confusion about responsibilities for entering referrals into NHG’s electronic medical record, which could potentially create delays in appointment scheduling and veterans’ receiving care. VAPIHCS did not always manage referrals to NHG in a timely way. Our review found instances throughout the NHG referral process where lack of timely referral management by VAPIHCS staff may have contributed to delays in veterans receiving care. VHA policy states that the referral process should include appropriate staff to manage referral notification, disposition, scheduling and completion; and designate staff to run referral reports, which must be reviewed at least weekly to resolve issues. In addition, federal internal control standards state than an organization should establish and operate monitoring activities to determine appropriate corrective actions on a timely basis. One factor that contributed to the lack of timely referral management was that VAPIHCS does not effectively monitor the referrals sent to NHG. First, VAPIHCS staff did not always monitor the availability of services at NHG with the frequency necessary to ensure the timeliness of referral management. NHG is to provide VAPIHCS with a list of available outpatient services no less than quarterly so VAPIHCS can determine if a referral for a specific service can be made to NHG; we confirmed that NHG provided these lists quarterly during our review time frame. However, VAPIHCS staff did not monitor whether services remained available after sending referrals to NHG in a timely manner. For example, one veteran in our review was originally referred to NHG in late November 2016, but it was not until VAPIHCS staff followed up on the referral in early February 2017 that they were informed that NHG could not accommodate the veteran at that time and that they instead should refer the veteran to a non-VA provider. This may have contributed to delay in care for the veteran by more than 2 months. Second, VAPIHCS staff did not ensure that referrals were entered into NHG’s electronic medical record system in a timely manner to begin the appointment scheduling process; under the process agreed to by VAPIHCS and NHG, it is the responsibility of designated VAPIHCS staff to enter referrals into the NHG electronic medical record system. For example, VAPIHCS staff referred one veteran for care to NHG in November 2016. However, it was not until December 2016—one month later—that VAPIHCS staff checked on the status of the referral. Finding no evidence of actions taken to schedule an appointment, staff added a reminder for the embedded VAPIHCS staff member at NHG to enter the referral into NHG’s electronic medical record, to restart the appointment scheduling process. Third, VAPIHCS staff did not always manage referrals to ensure the timely disposition and scheduling of appointments. Among the five canceled referrals that we reviewed, we found VAPIHCS staff noticed appointments had not been scheduled only when they reviewed the referrals months later. For example, of the five referrals VAPIHCS sent to NHG, one referral, sent in mid-November 2016, was canceled in early February 2017 after VAPIHCS staff found no evidence that an appointment had or would be scheduled. another referral was sent in late November 2016. After VAPIHCS staff reviewed the referral and found no evidence that an appointment had or would be scheduled, they noted that the referral was 101 days old and canceled it in late January 2017. VAPIHCS staff referred another veteran to NHG in mid-March 2017. After VAPIHCS staff reviewed the referral and found no evidence that an appointment had or would be scheduled, they noted that the referral was almost 4 months old and canceled it in June 2017. VAPIHCS’ lack of timely referral management was also due to poor communication between VAPIHCS staff and NHG. Federal internal control standards state that an organization should communicate with external bodies to receive the necessary quality information required to achieve the entity’s objectives. A VAPIHCS official stated that VAPIHCS staff do not have the same level of communication with NHG as they do with TAMC, which has its own staff to schedule veteran appointments and communicate that information back to VAPIHCS on a weekly basis, including if they cannot schedule a veteran. Instead, the official stated that VAPIHCS staff have to independently monitor the status of referrals to NHG, or ask the embedded VAPIHCS staff member at NHG to complete referral research for them. In addition, our review of the referral notes for these veterans found no evidence of communication between VAPIHCS staff and NHG staff regarding NHG’s efforts to schedule appointments for veterans before VAPIHCS staff canceled them. Furthermore, we also found no evidence of communication regarding outreach by NHG staff to VAPIHCS staff to discuss any scheduling difficulties, such as being unable to contact a veteran. Because VAPIHCS relies on NHG to provide inpatient and specialty care services for veterans from Guam and the Commonwealth of the Northern Mariana Islands, it is essential that referrals sent to NHG are managed in a timely manner, including verifying the availability of services and ensuring referrals are entered into NHG’s electronic medical record system, as well as communicating with NHG about the status of veterans’ appointments. Without a more robust referral management process, VAPIHCS is unable to ensure that veterans receive needed care in a timely manner, if they receive care at all. We found that VAPIHCS has faced physician recruitment and retention challenges that are both unique to the Pacific Islands, such as the limited number of local physicians from which to recruit, and challenges that are common across VHA, such as the amount of time it takes to hire a new physician. Having an adequate physician workforce is key to ensuring veterans’ timely access to health care. Overall, there were at least 17 physician vacancies out of approximately 100 positions across VAPIHCS as of October 2017, as well as several more vacancies for other types of health care providers, some of which have been unfilled for some time. For example, Guam clinic staff told us that at one point between October 2016 and March 2017, the period of our medical record review, the clinic had 1.8 primary care physician full-time equivalents even though it was authorized for 4. VAPIHCS officials told us they are constantly trying to recruit physicians for their facilities. Recruitment and Retention Challenges Unique to VAPIHCS. Through our review of relevant literature and interviews with VAPIHCS officials, we learned that physician recruitment is challenging for VAPIHCS in the following ways, particularly because of its geographic remoteness: There is one local medical school and limited local providers from which VAPIHCS recruits. The University of Hawaii’s John A. Burns School of Medicine is the only local medical school across Hawaii, Guam, and American Samoa from which VAPIHCS recruits physicians. The islands of American Samoa, Guam, and Hawaii all include counties, facilities, or populations designated as Health Professional Shortage Areas, which indicate health care provider shortages in primary, dental, or mental health care. These designations indicate a limited number of local physicians for VAPIHCS to target in the event of a vacancy. A 2015 University of Hawaii study further highlighted these shortages. It found that the Hawaiian Islands had a deficit of more than 600 physicians, with a projected shortage of between 800 and 1,500 physicians by 2020. This requires VAPIHCS to focus its recruitment efforts on medical schools and physicians located on the mainland United States. Travel options for VAPIHCS staff and their families are limited. Finding physicians that are willing to relocate to such remote locations is difficult, according to VAPIHCS officials. In prior work, we found that other VAMCs experienced challenges recruiting physicians who were reluctant to practice in rural or geographically remote areas. This challenge is likely more pronounced for VAPIHCS, given the location of its clinics. Both American Samoa and Guam are thousands of miles from the mainland United States and travel to and from these islands requires significant time and money. For example, American Samoa only has two direct commercial flights a week (on Mondays and Fridays) and Guam has only a daily direct commercial flight to Honolulu. While the Hawaiian Islands are more accessible to the mainland, they are still geographically isolated relative to the rest of the United States, and face some of the same travel challenges as American Samoa and Guam. Residents face a high cost of living, limited community resources, and trade-offs associated with island living. While other regions of the country face similar challenges, they may be more pronounced living on an island where alternatives are limited. The cost of living in Hawaii is higher than the nationwide average, and VAPIHCS officials told us that the real estate market in Hawaii is extremely expensive. These officials also said that physician candidates have raised concerns about the quality of the public school system in some areas of the islands, which could add a potential expense of sending their children to private schools and thus deter them from accepting employment. Other concerns include, for example, the lack of a veterinarian on American Samoa. According to an official, VAPIHCS lost a candidate who had agreed to relocate to the island until learning of the lack of veterinary services. Technical issues due to locations. One physician in American Samoa told us that it can take almost 1.5 hours to access the web- based program VHA offers for voice-activated dictation of medical notes, and thus, instead, he often uses services offline, although doing so means he has to enter his notes into VA’s medical record at a later time. Guam clinic staff, including physicians, also face unique challenges due to working across the International Date Line from the Spark M. Matsunaga VAMC. Specifically, the Guam clinic information technology system operates off of a server located in Honolulu that is 20 hours, or almost a day, behind Guam. Veterans being treated in Guam are essentially being treated in the “future” according to VA’s server in Honolulu, as the date of a health care appointment in Guam is always one day ahead of the server in Honolulu. For example, if a Guam physician sees a patient on Monday at 3:00 pm, it is 7:00 pm on Sunday in Honolulu. As a result, physicians must wait until the next day to retroactively complete clinical notes. Officials also said that physicians are frustrated working in a system that may require multiple days to complete clinical notes, and that this issue has impacted physician recruitment and retention. Guam clinic staff also said that, due to the time change, they only have about 16 business hours per week that the clinic is open that overlap with business hours of VAPIHCS officials working in Honolulu, which limits the amount of time physicians at the Guam clinic can consult with other VAPIHCS physicians or administrators in Honolulu. Recruitment and Retention Challenges across VHA. VAPIHCS has encountered some of the same physician recruitment and retention challenges that we have previously found are common across VHA, although some of these challenges may be compounded by the Pacific Islands’ geographic remoteness. For example: Differences in interpretation of recruiting and hiring policies may have contributed to lengthy recruiting times. In prior work, we found that differences in VAMC officials’ understanding of some of VHA’s recruitment and hiring policies contributed to lengthy recruitment and hiring processes. We also heard differences in policy interpretations during our discussions with VAPIHCS officials for this review. For example, some officials mentioned that a physician vacancy must be posted to USAJobs; however, VHA’s hiring authorities allow facilities to hire physicians for positions without regard to civil service requirements, such as requiring public notice of the vacancy. Some VAPIHCS officials also mentioned having to wait to post a position until after the predecessor had vacated it, while another official correctly noted that the recruitment process to replace a departing physician can begin before the position is vacated. Failure to understand VHA’s hiring authorities and use an expeditious hiring process most suitable for a particular vacancy may contribute to the length of the recruitment process. Lack of interoperable electronic medical record systems between VA and DOD. We have reported for more than a decade that VA and DOD lack interoperable electronic medical record systems that permit the efficient electronic exchange of patient health information. VA and DOD partly addressed the lack of interoperability by utilizing a web-based Joint Legacy Viewer to facilitate information-sharing for VA and DOD patients, including those at VAPIHCS, NHG, and TAMC. The Joint Legacy Viewer provides VAPIHCS physicians with access to clinical notes on a veteran being treated at a military treatment facility. However, VAPIHCS and DOD officials told us that there are challenges using the Joint Legacy Viewer, including the absence of robust information found in electronic medical records, the need for physicians to toggle between multiple applications to obtain a patient’s full history, slow networks, and reduced worker productivity as a result of operating several different systems simultaneously. Retention of physicians may be difficult in an environment where the administrative burdens associated with information technology may take time away from providing patient care. Primary responsibility for physician recruitment and retention rests with each Veterans Affairs medical center (VAMC) While each Veterans Integrated Service Network has a Human Resources office responsible for overseeing the VAMC-level Human Resources offices within its network, individual VAMCs are responsible for managing their employee recruitment and retention programs. The Veterans Health Administration supports VAMCs in recruiting and retaining providers by providing system- wide strategies for their use. VAPIHCS and VHA officials told us they have recruited and retained physicians to the Pacific Islands by promoting attributes of its location and by using VHA strategies, similar to other VAMCs nationwide. Locally, officials told us they have advertised the Pacific Islands’ weather and scenery during their recruitment efforts. Officials also said they promoted VAPIHCS’ unique relationship with DOD through its joint venture with TAMC in Honolulu as an incentive for moving to Hawaii. For example, some VAPIHCS physicians working in Honolulu have the opportunity to work alongside DOD physicians at TAMC—including the ability to consult face-to-face regarding care for a veteran referred to TAMC and provide care to DOD beneficiaries in certain settings. VAPIHCS also used many of the VHA strategies used at VAMCs nationwide to help with its physician recruitment and retention efforts. VAPIHCS officials discussed the use of the following VHA strategies, and noted limitations associated with some of them. Financial incentives. VAPIHCS officials reported that they sometimes used recruitment and retention bonuses and relocation allowances for physicians. For example, in fiscal year 2017, VAPIHCS paid $217,257 in recruitment incentives to three specialty care providers (for an average of $72,419 per physician). VAPIHCS did not offer any other financial incentives that year. Education Debt Reduction Program. Through the Education Debt Reduction Program, VHA reimburses qualifying education loan debt for employees, including physicians, in hard-to-recruit positions. In fiscal year 2017, three primary care physicians in VAPIHCS had applications approved for this program. Each recipient was awarded, on average, $17,000. VAPIHCS officials said the program was generally considered a “great recruiting tool,” but that its success was inconsistent given uncertainties regarding the amount of funding that would be available to the facility in a given year. Funds for the Education Debt Reduction Program, which are centrally managed by VHA’s Healthcare Retention and Recruitment Office, are based on the availability of funds and demand each year. In instances where centralized funding is not available, VAPIHCS and other VAMCs are authorized to use local funds to support program offers, but VAPIHCS officials said they have not used any local funds to support the program in the last 5 years. National Recruitment Program. VHA’s National Healthcare Recruitment Service, a division of VHA’s Workforce Management and Consulting Office, operates the National Recruitment Program, which provides direct physician recruitment services to VAMCs for hard-to- recruit positions by using private-sector recruiting techniques, including representing VHA at medical conferences and screening resumes. As part of VISN 21, VAPIHCS may also use the services of the network’s one dedicated recruiter responsible for serving the nine facilities in the VISN. In the almost 6 years since this recruiter has worked for VISN 21, he reported recruiting seven physicians and one social worker for VAPIHCS, and is in the process of recruiting a nephrologist. The recruiter observed that with recent leadership changes, VAPIHCS officials have been more engaged with his office and the recruiting assistance he can provide. VAPIHCS officials shared these sentiments, echoing their interest in increasing utilization of the VISN recruiter. Rural Health Training and Education Initiative. According to VHA officials, VAPIHCS is one of five facilities to participate in VHA’s Office of Rural Health’s Rural Health Training and Education Initiative to enhance its physician recruitment efforts. This program works with academic affiliates to help place physicians in rural areas and enhance VAMCs’ recruitment efforts and educate trainees about working within a VA rural health environment. According to VAPIHCS officials, 3 out of 16 physicians from this program who are eligible to be hired have taken positions at its clinics, including positions in Guam and Molokai. Enhanced Physician Recruiting and Onboarding Model. In 2015, VHA issued its Enhanced Physician Recruiting and Onboarding Model to standardize interpretation of its recruitment policy, strengthen overall physician recruitment at VAMCs, and shorten hiring processing time. VAMCs were not required to implement the model, and in our prior work, we found that implementation has been limited due to, for example, the lack of resources to implement the recommendation for a dedicated VAMC-based physician recruiter. VAPIHCS officials we spoke with said they were unaware of the Enhanced Physician Recruitment and Onboarding Model, but reported that they use 20 of the 30 best practices listed under the model, when asked about those practices. These best practices include, for example, leveraging increased pay rates when recruiting physicians, engaging with the VISN recruiter for hard-to-fill vacancies, and identifying interview questions and an interview panel before recruitment begins. VAPIHCS officials reported that they do not use other best practices such as utilizing VA’s human resources program for tracking recruitment actions and having a dedicated physician recruiter because they already have an alternate practice in place or a practice does not match their needs, among other reasons. However, officials told us they plan to examine whether there are opportunities to leverage any of these remaining best practices. As noted, in a prior report we recommended that VHA should conduct a comprehensive, system-wide evaluation of the physician recruitment and retention strategies used by VAMCs to determine their overall effectiveness, identify and implement improvements, ensure coordination across VHA offices, and establish an ongoing monitoring process. However, because VAMCs are primarily responsible for managing their own employee recruitment and retention programs and given the unique and ongoing challenges VAPIHCS has experienced with recruiting and retaining physicians, it is also important for VAPIHCS to similarly evaluate whether the strategies it uses are effective. An evaluation conducted by VHA on system-wide recruitment and retention strategies would not preclude the need for VAPIHCS to evaluate the strategies it uses; rather, it would further help identify those specific strategies that are most effective for recruiting and retaining physicians in the Pacific Islands. Federal standards for internal control related to monitoring calls for agencies to perform monitoring activities, including completing evaluations to monitor the design and effectiveness of the operations at a specific time. Agencies are to then evaluate the results of these activities and take corrective actions as needed. Ensuring veterans have timely access to health care services is one of VA’s objectives, which is dependent upon having an adequate number of physicians to provide the care. VAPIHCS officials told us that as of December 2017 they have not conducted any type of evaluation of their current strategies for facilitating physician recruitment and retention due to recent changes in leadership positions. Without evaluating the strategies currently used to determine their effectiveness, or determining if additional strategies offered by VHA might be appropriate, VAPIHCS risks missing the opportunity to target its efforts to those strategies that have the greatest potential to ameliorate long-standing staffing shortages. According to VAPIHCS officials, veterans face challenges accessing health care services on the Pacific Islands due to the lack of certain specialty care providers on many of the islands, the significant travel that is required to obtain these services, and limitations associated with telehealth services. Lack of certain specialty care providers. VAPIHCS officials told us that several Pacific Islands lack certain specialty care services entirely or significantly enough that there may be only one or a few of a certain provider type available to serve all residents, including veterans. Overall, VAPIHCS officials noted that the availability of different types of physicians across the islands is constantly in flux, but said that notable shortages are in gastroenterology, audiology, podiatry, rheumatology, dermatology, and neurology. For example, according to VAPIHCS officials, there is only one dermatologist on Guam practicing at NHG, and there is only one gastroenterologist in the community providing certain services; Kauai has a shortage of oncologists; Maui has a shortage of cardiologists; and American Samoa has a shortage of almost all types of specialty care providers because it only has one hospital—the Lyndon B. Johnson Tropical Medical Center—to provide medical care to its approximate 55,000 residents. VAPIHCS officials said the hospital is lacking many specialty services. According to VA, it does not authorize non-VA care there because the hospital receives funding from other federal agencies to provide medical services. Additionally, the hospital is not accredited for safety and quality. TriWest officials reiterated that there are virtually no specialty providers available on American Samoa for them to contract with; as of July 2017, there was only one Choice Program provider contracted on the island. As a result, essentially all eligible veterans must travel to Hawaii for specialty care services. Significant travel required of veterans. Because many of the islands lack certain specialty providers, VAPIHCS officials said that veterans often must fly elsewhere to obtain care. While travelling such distances helps improve veterans’ access to health care services, it also creates challenges. For example, such travel requires time away from their homes and families, which may be particularly difficult for veterans in poor health. The time and distance required for travel can also be quite significant—for example, veterans from American Samoa, Guam, and the Commonwealth of the Northern Mariana Islands must travel thousands of miles by plane to receive services in Honolulu. A Guam veterans group said that veterans were frustrated with having to fly 8 hours to Hawaii for health care services. In instances where the necessary services are beyond those available in Honolulu, veterans must fly to the mainland United States for care—a flight from Honolulu to California adds about 5 hours. The flight times are even longer for veterans travelling from American Samoa, the Commonwealth of the Northern Mariana Islands, and Guam. Figure 2 illustrates the locations of veterans enrolled in VAPIHCS and the distances and flight times they may need to travel to receive care. According to VAPIHCS data, most VAPIHCS veterans travelling for health care services over the years have received care in Honolulu, although some have had to travel to the mainland United States for subspecialty care or highly specialized care such as organ transplants. Eligible veterans are provided reimbursement for travel-related expenses under VHA’s Beneficiary Travel Program. In fiscal year 2017, VAPIHCS provided beneficiary travel funds to 348 veterans from American Samoa and 92 veterans from Guam to travel to Honolulu for care, for a total of 678 trips. During this same year, 15 veterans traveled to the mainland United States for care. VAPIHCS reported that, overall, 830 VAPIHCS veterans used beneficiary travel benefits to travel to Honolulu or the mainland United States for care that year. This represents approximately 2 percent of the total number of veterans (51,213) who received some type of care through VAPIHCS in fiscal year 2017. Veterans are responsible for paying for travel if they are ineligible for travel benefits and travel is required to receive care. The significant costs associated with travel among the Pacific islands—flights, lodging, meals—could be cost prohibitive for these veterans and, as a result, they may be unable to access VA or non-VA health care services off island. Limitations with telehealth services. Veterans face challenges accessing health care services due to limitations with telehealth services. For example, VAPIHCS officials told us there are limitations with the availability of internet services on the islands of Guam and American Samoa. This could lead to disruptions—or even cancellations—of veterans’ telehealth appointments. For example, VAPIHCS officials shared that damaged cables in the Pacific Ocean due to natural disasters and equipment failure on the part of internet service providers on the islands have led to disrupted and cancelled appointments for veterans. In March 2018, VAPIHCS reported that it had increased bandwidth and purchased new equipment to help support its telehealth efforts. Additionally, the extent to which a veteran can receive telehealth in his or her home versus the local clinic may depend upon the licensure of the provider delivering care. If a veteran is receiving telehealth services while he or she is physically located in a clinic, under federal law, the provider is not required to be licensed in the state in which the facility is located. When the patient is receiving telehealth services at home, however, a state may require that the provider be licensed in the state in which the patient is located. An official said that this is currently hampering VAPIHCS’ telehealth expansion efforts into the home. VAPIHCS has utilized a system of travelling VAPIHCS providers and is working to improve its use of telehealth services to better ensure veterans’ timely access to care, among other strategies, according to VAPIHCS officials. Use of travelling providers. VAPIHCS officials reported that travelling providers enable VAPIHCS to better ensure access for veterans who are not eligible for beneficiary travel, and reduce the travel burden on veterans who are. Furthermore, they noted that it can be more cost effective for VAPIHCS to send a travelling provider to an island on a set schedule than it is to fly veterans to Honolulu for care. These providers also help expand access by providing specialty care that is in short supply or missing entirely in some communities. For example, a VAPIHCS optometrist travels to American Samoa for one week each month, according to officials, because there is no board-certified optometrist on the island. In addition, the travelling providers offer veterans the opportunity to receive specialty care from a VA provider. Officials said they adjust the travelling providers’ schedules to reflect changes in service availability in the local communities. Table 11 illustrates the types of VAPIHCS travelling providers and the frequency with which they visit different clinics, as of December 2017. Increased use of telehealth services. Even though internet service on the Pacific Islands is not always reliable as previously noted, VAPIHCS has been increasing its use of telehealth services to improve veterans’ access to health care services. In fiscal year 2017, VAPIHCS reported that 3,046 VAPIHCS veterans utilized clinic-based telehealth services compared to 1,299 veterans in fiscal year 2011, an increase of more than 134 percent. VAPIHCS launched two new telehealth hubs in June 2017: According to VA officials, VAPIHCS was 1 of 8 VAMCs selected to establish a hub, or center for delivery of teleprimary care from the VAMC to distant clinics within its system. According to VAPIHCS officials, the teleprimary care hub in the Spark M. Matsunaga VAMC is currently providing services to veterans at the Guam clinic and is exploring opportunities to provide teleurgent care in partnership with VAPIHCS’ call center. Officials further noted this would allow telehealth staff to provide veterans with “almost instant access” to health care services and, if successful, help improve veterans’ timely access to care by increasing the number of appointments at the clinics that could be dedicated to more complex concerns. VAPIHCS officials also said that the teleprimary care hub would also be used for long-term coverage for clinics with provider vacancies. Similarly, VAPIHCS was one of 11 VAMCs selected to establish a telemental health hub. According to VAPIHCS officials, this hub is currently serving veterans at the Oahu, Guam, and Molokai clinics and one of the Hawaii clinics (Hilo), with plans to expand services to the Kauai clinic in the future. Overall, officials said that feedback from veterans using these hubs has been “overwhelmingly positive,” as veterans appreciate receiving care from VAPIHCS providers, the privacy afforded by telehealth, and not having to travel for their services. The number of telehealth users in VAPIHCS is likely to continue increasing as a result of these new hubs. While feedback has been positive, VAPIHCS officials said they have experienced some challenges with the launch of these hubs, including the time and date difference between Guam and Honolulu where the staff for both hubs are located. Staff from the hubs had to adjust their schedules to support Guam’s hours given that only 16 business hours per week overlap between the two islands. Having sufficient space in the clinics for telehealth services is another challenge. To address this, one official said they are encouraging veterans to hold video visits with their providers from their homes if clinical exams are not required during their appointments. Improvements to clinical space. Because sufficient examination and treatment space is lacking in many of its clinics, VAPIHCS is in the process of building new or expanding existing clinics to increase the number and type of services available to veterans. According to a VAPIHCS official, as of August 2017, VAPIHCS has plans to replace six of its existing clinics and open one new clinic. These new clinics are expected to be open by fiscal year 2020. For example, the American Samoa clinic will be expanded to include additional space for mental health consultations and group meeting spaces, while the Guam clinic will be expanded to include additional primary and mental health care clinic space. This may help address a concern of the Guam veterans group we spoke with in Guam, who said the clinic was too small and did not offer sufficient patient privacy. According to VAPIHCS officials, VAPIHCS’ new clinic, expected to open in 2020, is to be located on the island of Oahu and will be a multi-specialty outpatient clinic offering many different services, including primary care, mental health, telemedicine, women’s care, dental care, a pain clinic, physical and occupational therapy, prosthetic, laboratory and pathology, pharmacy, and imaging services. Improvements to the beneficiary travel process. VAPIHCS is in the process of updating its process for arranging beneficiary travel, which ultimately could improve veterans’ access to care. Under the old process, officials told us that much of the responsibility for coordinating veterans’ travel fell on nursing and administrative staff, creating stress and reducing the amount of time nurses could spend on providing patient care. As a result, VAPIHCS decided to centralize its beneficiary travel process in the Office of Beneficiary Travel in Honolulu. The goal, according to VAPIHCS officials, is to remove the clinic staff from the process—thereby increasing the amount of time dedicated to their clinical duties—and instead encourage veterans to work directly with the staff in Honolulu to arrange their travel. As of September 2017, VAPIHCS was still in the process of implementing this new process. VAPIHCS also created a task force to improve the process for arranging travel for American Samoa veterans needing care off-island. As a result of their efforts, VAPIHCS officials reported in December 2017 that they had managed to reduce the time clinic staff in American Samoa dedicated each day to addressing travel issues from an average of 408 minutes to 64 minutes. Communicating with veterans about VA and Non-VA services. VAPIHCS uses a variety of mechanisms to communicate with veterans about access to VA and non-VA health care services. Veterans are introduced to these services through New Veteran Orientations that are offered at some of the clinics. VAPIHCS also gives newly enrolled veterans handbooks that are specific to the clinics where they enrolled. VAPIHCS also communicates with veterans through town hall meetings, health forums, its Facebook page, television and radio shows, and community events. For example, staff from the American Samoa clinic told us that they partner with a local television station to host a 30-minute monthly segment to educate veterans about available VA services. VAPIHCS officials reported they had planned to conduct approximately 170 outreach events, spanning 9 islands and targeting about 6,000 veterans, for fiscal year 2017. VAPIHCS officials told us that they try to provide culturally appropriate communications with veterans of the different Pacific Islands. For example, they said they are planning to translate materials into Samoan for veterans from American Samoa. They also recognize that many veterans prefer face-to-face interactions with VA officials rather than receiving information electronically; for example, the Hawaiian tradition known as “talk story” focuses on informal conversations and sharing information with friends in the community. VAPIHCS has generally provided primary and mental health care within VHA’s timeliness goals for most veterans reviewed, but there are weaknesses in the referral process for specialty care services. Because most specialty care services are provided to veterans outside of VA through DOD providers or through non-VA providers in the community, it is crucial that VAPIHCS improve its management of these referrals to ensure adherence to VHA policy. Without improvements to adherence to VHA policy in the referral process, inconsistent guidance on roles and responsibilities, and lack of timeliness of referral management, these weaknesses are likely to persist, and may add to the amount of time it takes for some veterans to receive care, or may result in some veterans not receiving care at all. In addition, maintaining an adequate clinical workforce to meet the health care needs of veterans is necessary to ensuring veterans’ timely access to care. Doing so is particularly important for VAPIHCS given the unique challenges it faces in recruiting and retaining physicians in the geographically remote Pacific Islands. It is therefore critical that VAPIHCS identify and use the most effective recruitment and retention strategies offered by VHA. However, VAPIHCS has not evaluated the strategies that it has used to determine if they are the most optimal or if other available strategies would be more effective. Without completing such an evaluation, VAPIHCS does not know if it is optimizing its resources to improve its hiring efforts and ameliorate long-standing physician shortages. We are making the following four recommendations to VA: 1. The Secretary of VA should ensure that VAPIHCS review its referral process for referrals to DOD providers, including referral cancellation, to determine why VHA policy is not being adhered to and make changes as needed. (Recommendation 1) 2. The Secretary of VA should ensure that VAPIHCS clarify guidance to clearly define and document roles and responsibilities for VAPIHCS staff involved in the referral process with NHG. (Recommendation 2) 3. The Secretary of VA should ensure that VAPIHCS improves the monitoring of referrals and communication with NHG to ensure the timely management of referrals to NHG, including verifying the availability of services for veterans; ensuring referrals are entered into NHG’s electronic medical record system; and obtaining information about the status of scheduling appointments for veterans. (Recommendation 3) 4. The Secretary of VA should ensure that VAPIHCS evaluates the effectiveness of strategies it currently uses to promote physician recruitment and retention, including how the strategies could be improved. The plan should also include an assessment of whether additional strategies currently offered by VHA would be beneficial. (Recommendation 4) We provided a draft of this report to VA and DOD for review and comment. VA provided written comments, which are reproduced in appendix I. In addition, both VA and DOD provided technical comments, which we have incorporated as appropriate. In its written comments, VA concurred with three of our four recommendations and provided information on its plans to address them. VA partly concurred with our recommendation for VAPIHCS to improve the monitoring of referrals and communication with NHG to ensure the timely management of referrals to NHG. For this recommendation, VA agreed that it should improve its monitoring of referrals by verifying the availability of services at NHG for veterans and obtaining the status of their appointments to be scheduled, and noted that VAPIHCS is developing a standard operating procedure that includes, among other things, monitoring referrals weekly to resolve issues. However, VA did not agree with ensuring referrals are entered into NHG’s electronic medical record system as part of its monitoring efforts and stated that it does not have the authority to do so. During our review, we found that designated VAPIHCS staff on Guam have access to, and are responsible for entering referrals directly into, NHG’s electronic medical record. Only after VAPIHCS staff enter referrals directly into NHG’s electronic medical record did NHG staff assume responsibility for scheduling veterans’ appointments. We confirmed this practice through interviews with VAPIHCS and DOD staff and through our review of a sample of referrals sent to NHG, which showed that VAPIHCS staff had entered the referrals. Furthermore, the sharing agreement between VAPIHCS and NHG documented the arrangement for VAPIHCS staff to be granted access to NHG’s electronic medical record. As long as VAPIHCS staff continue to be responsible for entering referrals into NHG’s electronic medical record system, we believe that it is also their responsibility to monitor the status of these referrals, including ensuring that referrals are entered correctly and timely. Because VAPIHCS relies on NHG to provide inpatient and specialty care services for veterans from Guam and the Commonwealth of the Northern Mariana Islands, it is important for VAPIHCS to monitor the entire referral management process to ensure that veterans receive needed care in a timely manner. We are sending copies of this report to the appropriate congressional committees and the Secretaries of Veterans Affairs and Defense. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staffs 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 II. In addition to the contact named above, Ann Tynan, Assistant Director, Kaitlin Coffey (Analyst in Charge), Kate Tussey, Jennie Apter, and Jackie Hamilton made key contributions to this report. Also contributing were Emily Binek, Muriel Brown, Natalie Hagy, Alexis MacDonald, and Brienne Tierney. Veterans Health Administration: Better Data and Evaluation Could Help Improve Physician Staffing, Recruitment, and Retention Strategies, GAO-18-124. Washington, D.C.: October 19, 2017. VA Health Care: Opportunities Exist for Improving Implementation and Oversight of Enrollment Processes for Veterans, GAO-17-709. Washington, D.C.: September 5, 2017. VA Health Care: Improvements Needed in Data and Monitoring of Clinical Productivity and Efficiency, GAO-17-480. Washington, D.C.: May 24, 2017. Veterans Health Care: Preliminary Observations on Veterans’ Access to Choice Program Care, GAO-17-397T. Washington, D.C.: March 7, 2017. Veterans Health Administration: Management Attention Is Needed to Address Systemic, Long-standing Human Capital Challenges, GAO-17-30. Washington, D.C., December 23, 2016. Veterans Health Care: Improvements Needed in Operationalizing Strategic Goals and Objectives, GAO-17-50. Washington, D.C.: October 21, 2016. Veterans Health Administration: Personnel Data Show Losses Increased for Clinical Occupations from Fiscal Year 2011 through 2015, Driven by Voluntary Resignations and Retirements, GAO-16-666R. Washington, D.C.: July 29, 2016. VA Health Care: Actions Needed to Improve Newly Enrolled Veterans’ Access to Primary Care, GAO-16-328. Washington, D.C.: March 18, 2016. VA Mental Health: Clearer Guidance on Access Policies and Wait-Time Data Needed, GAO-16-24. Washington, D.C.: October 28, 2015. VA Primary Care: Improved Oversight Needed to Better Ensure Timely Access and Efficient Delivery of Care. GAO-16-83. Washington, D.C.: October 8, 2015. VA Health Care: Oversight Improvements Needed for Nurse Recruitment and Retention Initiatives, GAO-15-794. Washington, D.C.: September 30, 2015. VA Health Care: Actions Needed to Ensure Adequate and Qualified Nurse Staffing, GAO-15-61. Washington, D.C.: October 16, 2014. VA Health Care: Management and Oversight of Consult Process Need Improvement to Help Ensure Veterans Receive Timely Outpatient Specialty Care, GAO-14-808. Washington, D.C.: September 30, 2014. VA Health Care: Reliability of Reported Outpatient Medical Appointment Wait Times and Scheduling Oversight Need Improvement, GAO-13-130. Washington, D.C.: December 21, 2012. VA and DOD Health Care: Department-Level Actions Needed to Assess Collaboration Performance, Address Barriers, and Identify Opportunities, GAO-12-992. Washington, D.C.: September 28, 2012. Veterans’ Health Care: Service Delivery for Veterans on Guam and the Commonwealth of the Northern Mariana Islands, GAO/HEHS-99-14. Washington, D.C.: November 4, 1998. Veterans’ Benefits: Availability of Benefits in American Samoa, GAO/HRD-93-16. Washington, D.C.: November 18, 1992.

Summary: Veterans' access to timely health care at VA medical facilities has been a long-standing problem identified by GAO and VA's Office of Inspector General. The remote nature of the Pacific Islands creates some unique challenges for VAPIHCS, which may affect its ability to provide the approximately 50,000 veterans it serves in American Samoa, Guam, Hawaii, and the Commonwealth of the Northern Mariana Islands with timely access to primary, mental health, and specialty care. House Report 114–497 included a provision for GAO to review VHA's efforts to provide timely access to health care within VAPIHCS. Among other things, this report examines: the extent to which the VAPIHCS veterans received (1) timely primary and mental health care, and (2) timely specialty care; and (3) any challenges VAPIHCS faced in recruiting and retaining physicians, and strategies to resolve them. GAO reviewed relevant policy documents and a randomly selected, non-generalizable sample of 164 medical records, and interviewed VHA, VAPIHCS, and DOD officials. For the sample of veterans' medical records that GAO reviewed, most veterans received primary and mental health care from the Department of Veterans Affairs (VA) Pacific Islands Health Care System (VAPIHCS) within timeliness goals set by VA's Veterans Health Administration (VHA). However, GAO also found that some of these veterans experienced delays related to the processing of their enrollment applications, contacting them to schedule appointments, and completing comprehensive mental health evaluations. These delays were similar to some GAO had identified in previous work pertaining to veterans' access to care nationwide. For the sample of veterans' medical records that GAO reviewed, VAPIHCS referred nearly all specialty care to non-VA providers within VHA's timeliness goal, but the time taken to provide care was variable and sometimes lengthy. Specifically, VAPIHCS sent specialty care referrals to the Veterans Choice Program (Choice Program)—for veterans that GAO reviewed, the number of days to receive care from the Choice Program was, on average, 75 days. Department of Defense (DOD) military treatment facilities—for veterans that GAO reviewed, the number of days to receive care from the two DOD facilities for which VAPIHCS has agreements was, on average, 37 days from one facility and 47 days from the other. GAO identified weaknesses in VAPIHCS' management of its referral process for sending veterans for specialty care services at one of the two military treatment facilities. GAO found VAPIHCS did not always manage referrals to the military treatment facility in a timely way and there was inconsistent guidance describing the roles and responsibilities of the VAPIHCS staff involved in the process. These weaknesses may have contributed to the amount of time it took for veterans to receive specialty care services. GAO also found that VAPIHCS faces challenges recruiting and retaining physicians. As of October 2017, 17 of approximately 100 VAPIHCS physician positions were vacant, as were several other types of health care providers. Some of the challenges VAPIHCS faced are unique to the Pacific Islands, such as the availability of only one local medical school from which to recruit, along with travel burdens and a high cost of living that may discourage physicians from relocating there. Other challenges were similar to those GAO has previously identified as faced by VA medical centers across the country, such as differences in interpretation of hiring and recruiting policies. VAPIHCS officials said they use several strategies to help recruit and retain physicians, including VHA strategies used by other VA medical centers such as financial incentives and an educational debt reduction program. Although they described limits to the success of some of these strategies, they have not evaluated their effectiveness. Without completing an evaluation of its strategies, VAPIHCS may not be optimizing its resources to improve its hiring efforts and may continue to struggle with physician shortages. GAO makes four recommendations, including that VAPIHCS improve monitoring of referrals to one DOD facility and evaluate the effectiveness of physician recruitment and retention strategies. VA concurred with three recommendations and partially concurred with the fourth. GAO maintains that monitoring referrals to the DOD facility is needed, as discussed in the report.