The mission of VA is to serve America’s veterans and their dependents. All VA programs are administered through three major administrations— VHA, Veterans Benefits Administration, and the National Cemetery Administration. VA provides medical services to various veteran populations—including an aging veteran population and a growing number of younger veterans returning from the military operations in Afghanistan and Iraq. In general, veterans must enroll in VA health care to receive VA’s medical benefits package—a set of services that includes a full range of hospital and outpatient services, prescription drugs, and long-term care services provided in veterans’ own homes and in other locations in the community. VHA is responsible for overseeing the delivery of care to enrolled veterans, as well as the health care professionals and support staff that deliver that care. VHA is also responsible for managing all VA medical facilities. VA organizes its system of care into regional networks called VISNs. In September 2015, there were 21 VISNs nationwide, but VA is in the process of merging VISNs that will result in 18 VISNs when completed. Each VISN is responsible for coordination and oversight of all administrative and clinical activities within its specified geographic region. Medical services are provided in inpatient/residential medical facilities and outpatient medical facilities, including: Inpatient/residential care medical facilities as of January 2017: VA medical centers: A medical facility that provides at least two types of care, such as, inpatient, outpatient, residential, or institutional extended care. There are 168 VA medical centers. Extended care site (community living center): A medical facility that provides institutional care, such as nursing home beds, for extended periods of time. There are 135 community living centers. Residential care site: A medical facility that provides residential care, such as a domiciliary, for extended periods of time. There are 48 domiciliaries. Outpatient care medical facilities as of October 1, 2016: Community-based outpatient clinics (CBOC): A medical facility that provides primary care and mental health services, and in some cases, specialty services such as cardiology or neurology, in an outpatient setting. There are 737 CBOCs. Health care center: A medical facility that provides the same services as CBOCs, but also ambulatory surgical procedures that may require moderate sedation. There are 22 health care centers. Other outpatient service: A medical facility that provides care to veterans but is not classified as a CBOC or health care center, such as a mobile treatment facility. There are 305 other outpatient services sites. In order to meet the needs of the veterans it serves, VA is authorized to pay for veteran health care services from non-VA providers through both the Non-VA Medical Care Program and clinical contracts. In fiscal year 2015, VA obligated about $10.1 billion to purchase care from non-VA providers. The Non-VA Medical Care Program, including the Choice Program and Patient-Centered Community Care, is referred to as “care in the community” by VA, and allows VA to offer care to veterans in non-VA facilities, such as physicians’ offices and hospitals in the community, and pay for this care using a fee-for-service arrangement. Clinical contracts are used by VA to bring non-VA providers—such as physicians, pharmacists, and nurses—into VA facilities to provide services to veterans. VA works with the VISNs, and medical facilities to manage its real property assets through VA’s capital-planning process. The SCIP process—established in 2010 to assess and identify long-term capital needs—is VA’s main mechanism for planning and prioritizing capital- planning projects, but is affected by the VA’s budgetary resources, which will determine how many projects will be funded. The goal of SCIP is to identify the full capital need to address VA’s service and infrastructure gaps, and to demonstrate that all project requests are centrally reviewed in an equitable and consistent way throughout VA, including across market areas within VA’s health care system given competing capital needs. The SCIP process for that particular fiscal year’s projects begins approximately 23 months before the start of the fiscal year with VA providing a set of guidelines to the VISNs and medical facilities. SCIP uses information from models to identify excesses and deficits in the services at the local level—called “gaps” within VA—and justify capital investments. For example, SCIP uses data from the EHCPM, a model for projecting veteran enrollment, utilization of VA health care, and the associated expenditures VA needs to meet the expected demand for most of the health care services it provides. VA officials at the VISNs and medical facilities play a major role in the capital-planning process. Each VISN has a Capital Asset Manager and a planner who are responsible for coordination and oversight of facility alignment activities, and work with individual facility planners and engineering staff. Annually, planners at the medical facilities develop a 10-year action plan for their respective facilities, which include capital or non-capital improvement projects to address gaps in service identified by the SCIP process. According to VA, these long-range plans allow the department to adapt to changes in demographics, and health care and benefits delivery, while at the same time incorporating infrastructure enhancements. Medical facility officials then develop more detailed business plans for the capital improvement projects that are expected to take place in the first year of the 10-year action plan. These projects are validated, scored, and ranked centrally based on the extent to which they address the annual VA-approved SCIP criteria using the assigned weights. (See fig. 1 for VA’s capital decision-making process for evaluating and funding capital projects.) Another tool available for use by some VISNs and medical facilities is the VAIP Process, which was implemented in fiscal year 2011 as a pilot project. The goal was to identify the best distribution of health care services for veterans, where the services should be located based on the veterans’ locations and referral patterns, and where VA should adapt services, facilities, and health care delivery options to better meet these needs as determined by locations and referral patterns. Data from the VAIP Process are designed to drive the VISNs’ and VA medical facilities’ operational decisions including costs, challenges, and local preferences, but the VAIP Process’s findings can also result in future SCIP projects. The VAIP Process produces a market-level health services delivery plan for the VISN and a facility master plan for each medical facility within the VISN. (See fig. 2 for an overview of the VAIP Process.) After completing a pilot of the program, VA officials began formally implementing the VAIP Process across VISNs and their medical facilities, utilizing multiple contractors. As of January 2017, VA officials told us they had mostly completed the VAIP Process in 6 of the 18 VISNs and had plans to start or complete the remaining VISNs by October 2018. According to officials who oversee the program, the entire cost of the VAIP process is expected to be about $108 million. Over time, VA has recognized the need to modernize its facilities and align its real property portfolio to provide accessible, high-quality, and cost-effective access to services. In addition, VA has been the subject of several assessments focusing on facility alignment, and planning efforts to modernize its facilities. In 1999, VA initiated the CARES process to assess federally owned buildings and land ownership in response to changing veterans’ inpatient and outpatient demand for care. CARES was the first comprehensive, long-range assessment of VA’s health care capital-asset priorities since 1981 and was designed to assess the appropriate function, size, and location of VA facilities. In May 2004, VA issued the CARES Decision report to Congress and other stakeholders. The decision report listed projects and actions that VA planned to take over the next 20 years, as well as the tools and principles that the agency planned to use to align its infrastructure and upgrade its facilities. VA officials told us that the implementation of CARES recommendations was monitored through fiscal year 2010. In July 2011, VA released an implementation and monitoring report on seven areas highlighted in the CARES report. In this report, VA stated that excess space was reduced through mechanisms such as the demolition of vacant buildings and the realignment of underutilized space. VA also reported that since fiscal year 2009, 509,247 square feet of space was disposed. VA officials stated that as of June 2016, some of the CARES recommendations were not fully implemented, and the process was essentially replaced when the SCIP process was implemented in fiscal year 2012. In a more recent effort, the Choice Act required VA to contract with a private entity to conduct an independent assessment of 12 areas of VA’s health care delivery system and management processes, including its facilities in 2014. Among the 12 areas, an assessment of facilities examined VA’s processes for facility planning, funding, maintenance, and construction. The Independent Assessment identified four systemic findings: 1. A disconnect in the alignment of demand, resources, and authorities. 2. Varying bureaucratic operations and processes. 3. Non-integrated variations in clinical and business data and tools. 4. Leaders are not fully empowered due to a lack of clear authority, priorities, and goals. The Choice Act also established the Commission on Care to examine veterans’ access to VA health care and to examine and report on how best to organize VA, locate health resources, and deliver health care to veterans during the next 20 years. The Commission on Care assessed the results of the Independent Assessment as part of its work. The Commission on Care’s report included 18 high-level recommendations, and was submitted to the President on June 30, 2016. For example, the one recommendation in the Commission on Care’s report related to facility management was for the enactment of legislation, which would authorize a process similar to the Base Realignment and Closure process to facilitate facility realignment decisions.