Minutes of the Meeting of the



Minutes of the Meeting of the VHA Geriatrics and Gerontology Advisory Committee (GGAC)April 19 & 20, 2016VA Central Office, Room 730Participants:Adrian Atizado (GGAC Member)Marie Bernard, MD (ex officio GGAC member)Jennie Chin-Hansen, MSN (GGAC Member) —by phone Judith Beizer, PhD, PharmD (GGAC Member)Bruce Leff, MD (GGAC Member)Jeffrey Halter, MD (GGAC Member)W. Clyde Marsh (GGAC Member)Nora OBrien-Suric, PhD (GGAC Member)Barbara J. Smith, PhD, MPH (GGAC Member)Richard Veith, MD (GGAC Chair)Janette Warsaw, BSN, MSN (GGAC Member)Kathleen Welsh-Bohmer, PhD (GGAC member)—by phonePresenters:Robert A. McDonald, Secretary for Veterans AffairsJeffrey Moragne, Director, Advisory Committee Management OfficeMaureen McCarthy, MD, Assistant Deputy Under Secretary for Patient Care ServicesNeil Evans, MD, Director, Connected CareGene Migliaccio, DPH, Deputy Chief, Business Office, Community CareRichard Allman, MD, Chief Consultant, Geriatrics and Extended Care (GEC)Tom Edes, MD, Executive Director, GEC OperationsLisa Minor, MSN, Director, Facility-Based Extended Care, GEC OperationsDayna Cooper, MSN, Director, Home and Community –Based Extended Care, GEC OperationsMarianne Shaughnessy, PhD, ARNP, Director, Facility-Based Extended Care, GEC PolicyKimberly Kelley, LCSW, MHSA, Director, Home and Community-Based Extended Care, GEC PolicyStaff:Kenneth Shay, DDS, MS, Director, Geriatric Programs and Designated Federal Officer for GGAC Susan G. Cooley, PhD, Chief of Dementia Initiatives and Chief of Geriatric Research, GEC Policy Marcia Holt-Delaney, Program Analyst, GEC PolicyMarc Bowen, Management Analyst, GEC PolicyJacob Blumenthal, MD (on detail to Geriatric Programs, VACO)Guests:Jennifer Lee, MD, Deputy Under Secretary for Health for Policy and ServicesDeborah W. Dort, MD, Deputy Principal Deputy Under Secretary for HealthKelly J. Kash, CEO, Maine Veterans’ HomeJulie Crockett, American Association of Colleges of Osteopathic MedicineRiva Stidd, Consultant, Atlas ResearchLatrice Vinson, PhD, Health and Aging Policy Fellow, detailed to GEC OfficeNote: In the following text, DISCUSSIONS are indicated in blue; RECOMMENDATIONS in yellow.Summary of Recommendations stemming from this meeting (as highlighted in Minutes, with superscript numbers as shown below)Recommendations for the Secretary of Veterans AffairsExplore means for improving Advisory Committee communication with SecVA (1).Maintain focus on purchased LTC to ensure VA’s broader efforts to increase access does not adversely impact existing purchased extended care options for Veterans (5).Pursue options for building a VHA healthcare workforce with enhanced skills in care of the aging, including scholarships, loan repayment, and mid-career training options (3).Adopt a uniform approach to alignment of GEC programs at VAMC and VISN level (4).Collaborate with GGAC Chair on an editorial submission highlighting VA’s contributions in geriatric care (6).Recommendations for the Offices of Geriatrics and Extended CareExplore collaboration with John A. Hartford Foundation regarding VA-Administration on Community Living joint efforts (2).Publish article on Veteran Demographics in the professional literature (8).Recommendations for GGAC itselfInclude graphs and data in minutes (10).Elect Chair and Vice-chair for 2-year terms (12).Include other Federal Advisory Committee personnel in meetings (7).Include some marketing/communications in each GGAC meeting (11).Identify and capitalize on opportunities for educating Congressional personnel (9).Meeting called to order by Richard C. Veith, MD, 8:30 AM, April 19, 2016Dr. Veith welcomed participants and invited all members to introduce themselves for those on the phone and the members participating for the first time. There were three new members present: Judith Beizer, PhD, Bruce Leff, MD; and Barbara Smith, PhD. Dr. Veith mentioned that he, Dr. Allman, Dr. Edes, and Dr. Shay had convened a conference call with the three new members the previous week, to orient them to VA, VHA, and the Committee, in order to make their first meeting as productive as possible. Dr. Veith also announced that Dr. Sharon Brangman has resigned from GGAC in the face of her growing time commitments that she anticipates will come with the recent award of an Alzheimer’s Disease Center at her institution.Review of minutes of September 29-30, 2015 GGAC meeting (which was conducted by telephone)Dr. Veith ascertained that the minutes had been previously reviewed electronically and all corrections incorporated. Dr. Shay briefly reviewed the action items specified in the minutes and affirmed that all either had been or were in the process of being addressed. Review of AgendaDr. Veith reviewed the proposed agenda. He reviewed the Executive Briefing Summary that had been provided to the Secretary for Veterans Affairs, emphasizing the need for a more effective means for conveying GGAC recommendations to the Secretary1. Dr. Shay pointed out that, in keeping with requests from multiple members, there were a number of scheduled opportunities for open discussion incorporated in the agenda. He also noted that the selection of a new Chair would be essential due to Dr. Veith’s final meeting being in September 2016.Richard Allman, MD (Chief Consultant, GEC)Dr. Allman briefly reviewed his background prior to coming to VA Central Office in his current role, approximately 2 years ago. He had been 27.5 yr at the University of Alabama/Birmingham, where he led the Division in Geriatrics and Palliative Medicine; founded the Birmingham/Atlanta Geriatric Research, Education, and Clinical Center; and Directed the Center for Healthy Aging and the Resource Center for Minority Aging. He noted that he had chosen to come to VA Central Office because he believes VA has the opportunity for defining excellence in geriatric are, and he thanked GGAC for their efforts to support those efforts. He emphasized that many of the programs in GEC are unique to VA for the simple reason that neither Medicare nor other payers include many non-institutional extended care services in their plans.He reviewed the Vision and Mission Statements; the “ABCs of GEC;” and continuum of GEC services. On the Continuum of Care graphic, he pointed out that the programs in a red font represented activities that are currently receiving serious consideration for being reassigned to the newly-forming Office of Community Engagement. He made clear that a strong working relationship between GEC and Community Care will be indispensable to ensure these most vulnerable Veterans—those who require these services—do not experience in a decline in selection, quality or frequency of the services they have grown to expect from VA.Dr. Allman described some noteworthy accomplishments in recent years. Home and Community Based Services (HCBS) have seen an 8.77% increase in the past year. He reminded the group that there has been a pattern of underspending on non-institutional extended care (NIC) that shifted in FY15, when VA overspent in total by nearly $3B (total: not limited to NIC) in its zeal to address adverse media reports reflecting on limitations in Veteran access to care.Dr. Veith: GGAC has noted not only under spending, but enormous variability in spending on NIC, and called this to the attention of SecVA on several occasions. Might some of this derive from the variation in how GEC is organized from site to site? Dr. Allman: that has certainly played a role, but everything has experienced disruption from the rollout of Choice—the program for purchasing care for Veterans who would otherwise either wait an inordinate duration or have to drive an inordinate distance to receive care. He noted that several years ago there was Congressional concern that there was too much variation in size and composition of VISN offices, resulting in a cap on the number of VISN positions. Many geriatrics and palliative care leaders were reassigned and this has made regional consistency in GEC programming elusive. He did note that the GEC offices have prepared a memo for the (acting) Deputy Under Secretary for Health for Operations and Management to send to the VISNs, stressing that it is now a matter of policy (since issuance of the Universal GEC Services Handbook in November 2015) to have GEC leadership at each VISN.Dr. Allman then described some position changes of note since the last GGAC meeting. He reported that Dr. Maureen McCarthy has just recently been appointed Assistant Deputy Under Secretary for Patient Care Services. Furthermore, she has a new boss, the Deputy Under Secretary for Health for Policy and Services, Dr. Jennifer Lee. Dr. Lee had worked in VACO prior to being appointed Deputy Director for the Commonwealth of Virginia’s Department of Health and Human Services—which means that, with her return to VA, she brings familiarity with Medicaid long term care services. Positions within GEC that were vacated with the retirements of Christa Hojlo, PhD, and Nancy Quest, MBA, were recently addressed with the hiring of Marianne Shaughnessy, PhD, ARNP as the new Director for facility-Based GEC Policy (which includes CLCs, State Veterans Homes, and Community Nursing Homes); and Kim Kelley, LCSW, MHSA, as new Director for Home and Community-Based Services, respectively. Mr. Atizado reiterated Dr. Veith’s point about site-specific variation in NIC, with reference to what the site visit team heard in its December visit to Milwaukee—that high-performing networks were being severely disrupted by the introduction of Choice. Dr. Allman noted that Dan Schoeps (Director, Purchased Care in Policy); and Dayna Cooper (Director of Home and Community-Based Care in Operations), are working diligently on the issue. In December they were successful in getting Homemaker/home Health Aide and Veteran Directed Home and Community-Based Services (VDHCBS) added to Choice. Dr. Leff asked about the role of Aging and Disability Resource Centers (ADRC): the John Hartford Foundation has activity underway to enhance non-institutional services through this mechanism; seems like a natural opportunity for fostering more implementation of VDHCBS2. Dr. Shay agreed, and briefly described the Veteran Community Partnerships and their recent intention to work with the Office of Rural Health’s “Cover to Cover” program, which brings together ADRCs/Area Agencies on Aging with VHA and VBA representatives, to expand familiarity with VA and Veterans benefits on the part of the non-VA social support networks. Mr. Marsh asked what was needed to accelerate system-wide implementation of VDHCBS? Is it a matter of funds? Or of staff to administer the programs? Administrative support seems essential for caregiver support activities like respite, adult day care, and home health aides.Secretary of Veterans Affairs, Robert A. McDonaldSecretary McDonald met the committee, and welcomed (and presented certificates to) the three new members. He provided biographical information on himself—he is a West Point graduate and served as an Army Ranger. His father suffered from PTSD; he has multiple relatives in the career military. President Obama sought a Secretary with a different skill set—many in the past have come from the military, but he was interested in someone from the business sector. Mr. McDonald noted that Procter and Gamble, where he spent most of his professional life, is the 20th largest company in the US, with 125,000 employees. If VA were measured on the same yardstick (e.g., annual budget), it would rank as the 6th largest company—and it has 330,000 employees. Recent crises have tempted VA units to withdraw from the public eye—a natural reaction to criticism. But the Secretary is committed to putting the Veteran at the center of VA, forcing all units into the limelight. The Presidential term ends January 2017, so the Secretary has put VA on a fast track. He has visited over 300 sites in his time at the helm. From what he has learned, he has developed a “MyVA” strategy that he briefly reviewed for the committee. He is strongly focusing on the Veteran experience—it is not enough for the experience with VA to be merely adequate: it needs to be memorable and delightful. He noted that the most successful customer-focused companies, e.g., Disneyland, put as much focus on what goes on in front of the customer as what goes on behind the scenes. He noted that in a crisis, a natural reaction is to retreat into rule-based thinking, but this is a mistake. He emphasized the need for principle-based thinking, and cited an example of a Veteran, stuck in his car in a VA parking lot, who was instructed by the VA operator to call 9-1-1 to assist him from his car to the VA entrance. He contrasted that with a mental health clinic nurse who was concerned about a no-show by a patient; on the basis of her relationship with the patient, she convinced law enforcement to break into the Veteran’s home where he was found in critical condition.An important part of MyVA is having employees that feel good about their work. He was criticized during a Congressional hearing for allowing $34M to be spent annually on employee education—but he pointed out that, with 330,000 employees that translated into an average of about $100/employee per year—a completely inadequate investment for keeping employees motivated and current in their fields. Many of the needed changes involve legislative cooperation: budget and hiring authority are among the most critical. Another part of MyVA is to reduce redundancy and the waste it entails. He gave examples of 150 different 1-800 phone numbers, 9 different regional systems (VHA, IT, VBA, NCA, etc.), and seven different means for purchasing care. He spoke of the importance of community partnerships, both because VA can’t do everything, and because of the approximately 15% of Veterans that were NOT honorably discharged, and how VA is not authorized to provide them services. Very promising and productive activities are underway with The Elks (over 800,000 volunteers) and Easter Seals.Dr. Veith raised the issue of communicating effectively, complimenting the Secretary on his meeting with the Advisory Committee chairs last spring but wondering about how to improve the transmission of information from the committee to the Secretary1. The Secretary reiterated his awareness of the demographic imperative regarding the aging of Veterans, and stated his intention to find out from Under Secretary Shulkin what VHA is doing about the aging workforce3, about the provision of non-institutional care4, about the alignment of GEC programs in VAMCs5, about the GRECCs, and about means for supporting innovative work. Mr. Marsh noted that GGAC has gone to multiple VAMCs and learned valuable information and this was very favorably received. Dr. OBrien-Suric noted that the wonderful geriatrics accomplishments of VA need to be highlighted more—VA is the gold standard in this area but VA itself seems to seldom tout its successes and expertise. The Secretary suggested working with his staff to develop an Opinion-Editorial piece6. Ms. Warsaw asked about training more providers: why would anyone want to pursue geriatrics if they aren’t compensated for their extra training? The Secretary suggested targeting VA scholarships more strategically: this has been very helpful for mental health. Dr. Beizer pointed out the importance of targeting loan forgiveness as well3.Drs. Blumenthal and Shay will complete an initial draft of the proposed Op-Ed piece for the Secretary and Dr. Veith; he will edit and return for submission by COB on Thursday, April 28.Jeff Moragne, Advisory Committee Management Office (ACMO)Mr. Moragne provided biographical information on his background, and then stated his intention to provide information about the Federal Advisory Committee Act. The guidance dates from 1972 legislation that reduced the number of Federal Advisory Committees from about 8,000 to fewer than 1,000. Mr. Moragne mentioned the Committee Members guide, and asked that all members receive copies. He urged members to become familiar with their committee’s Charter.Some of the most important rules include:All activity as a committee must be public. Exceptions are limited to administrative and research discussions.Members cannot testify in their status as Committee members: only regular government employees can do this. Committee members are “Special Government Employees”Membership is limited to 2 terms; if a member subsequently serves on a second committee, their tenure is limited to a single term. An exception to this is Veterans Services Organizations—their representatives to committees are not bound by this.It is helpful for all members to at all times be alert for potential future members.Dr. Veith raised the issue he brought to the Secretary’s attention: how to get recommendations to the attention of the Secretary, without it going through every layer of the bureaucracy1? Going thru the process takes an excessive length of time, and organizational units between the top of the organization and the level advocated for by the Advisory Committee may be playing a role in the delays—and will be indisposed to allow matters that reflect poorly on their operations to reach the Secretary. Mr. Moragne said the concern should be raised as a recommendation in the annual report; but the timing of the response is out of the hands of the ACMO. Dr. Beizer asked how the public learns about FACAs? Mr. Moragne pointed out that announcements appear in the Federal Register; also members are urged to share their awareness of future meetings with stakeholders. Dr. OBrien-Suric wondered if there was any mechanism for the different committees to learn from each other? Mr. Moragne agreed and described how he has urged the Designated Federal Officers to invite each other7—he gave the example of the Homeless, Rural, and Minority Veterans forming a subcommittee to address some shared issues.Kenneth Shay, DDS, MS, Director of Geriatric Programs, GEC: GRECC UpdatesDr. Shay updated GGAC on the progress to date of the Eastern Colorado GRECC. The first year of the three years of funding was made available October 1, 2014. The rollout was complicated by continued construction delays at the site of the new Denver VA Medical Center, including the contractor suing the government in December 2014 to get out of the contract. One unfortunate concession to the time and expense has been that the new CLC on the campus has been dropped. The GRECC has been slated to move into existing University of Colorado (UC) space adjacent to the VA property. A walk-through has sparked floor plan design and move-in is scheduled for July-August 2016. Space for clinical research will be completed in the same time frame; GRECC will control the space but it will be available to non-GRECC investigators as well. The program developed an acceptable Advanced Fellowship Program proposal and a new Fellow will begin July 1.The AO and the three Associate Directors are all on board. Significant delays in Human Resources processes significantly delayed on-boarding staff, but all but 3 positions were filled by the end of the FY2015. The three remaining slots will be filled before the end of FY16.The Research Program, led by Dr. Kohrt, has started off quite strongly. Three of the five Pilot proposals were funded; although this decision was made nearly 12 months ago, only recently have the resources been provided. GRECC Investigators have also put in several Letters Of Intent for Merit proposals, received one Merit and one CDA-II; and publications and presentations have and will continue to be produced. The GRECC is participating in a University-wide research consortium that should trigger additional opportunities.The Education program, led by Dr. Robbins, is on-boarding the Advanced Fellow. Five associated health trainees (2 each in Social Work and Pharmacy; and one in Psychology) are in place, with plans to reach the full complement of 10 trainees in FY 17. They are collaborating with Albany to offer a SCAN-ECHO program in Palliative Care; 14 different VISNs are represented among their learners. They have initiated an Administrative Medicine Issues seminar to develop program improvement skills in their trainees. Dr. Nearing, the evaluation lead, has introduced a multidimensional assessment approach that provides continuous improvement strategies.The Clinical program, led by Dr. Bray-Hall, seems to be struggling in comparison with its FY 15 progress. Much of this is attributable to the 6-month delay in Office of Rural Health funding that was expected to support the new ALS-HBPC home care program. Other resources were then tapped to keep the rollout on schedule—but then the Acquisitions process for obtaining the computer tablets needed in the model was also delayed. Two details that Dr. Bray-Hall undertook for her own professional development also probably contributed to delays. In FY15, she served as Acting Chief Medical Officer for VISN 19. For the months of February and March of FY16, she is serving as the Acting Chief of Staff at Muskogee, Oklahoma. This second opportunity has given her the opportunity to initiate the ALS program in Oklahoma.Dr. Shay then reported on past and upcoming site visits. Greater Los Angeles GRECC was assessed in March 2015, with the main findings, as they had been in 2005 and 2010, being that the site has maintained over 5 vacancies despite repeated promises to fill the positions without delay; and that despite the proximity of a top-tier academic School of Nursing, there is relatively little presence of nursing in the various GRECC-related programs. The site has been in turmoil from leadership turnover since the site visit in March 2015 so the response to the site visit, which was due in October 2015, has not been received. A new Chief of Staff was named a few weeks back and Dr. Shay has already communicated with him the need for a response before the end of May.Madison was visited—both its GRECC and its GEC programs—in December 2015. The GRECC is in excellent shape although the VERA support for the station has been severely reduced through adherence to Office of Research Oversight restrictions. Despite the absence of a Research Foundation through which VA could administer NIH grant funds, the University of Wisconsin has been an engaged, generous, and approachable partner on many VA efforts. The GRECC leaders are all young and dynamic so succession planning is not a concern. There are new Associate Directors in Research (Sterling Johnson, PhD) and in Clinical (Amy Kind, MD, PhD). The assessment of the clinical GEC programs reflected admirable impact of GRECC within the medical center, with many of the staff from a range of disciplines having received training through GRECC. Following the Madison visit, the team went to Milwaukee VAMC, 70 miles east, to conduct the first of their “non-GRECC” GEC program assessments. In Milwaukee they were treated to a tour of the new Green Houses—3 home-size, supervised living spaces designed for 12 LTC patients in each, staffed with “Universal Workers” (“shahbazim”) who combine skills of nurse aide, food aide, pharm tech, and rehab aide. It was in Milwaukee as well that emphatic dissatisfaction with the Choice program was raised. Specifically, there is grave concern that the agencies with which the site has built excellent working relationships will be less willing to work on behalf of Veterans, given the delays in reimbursement and the lower rates for service.The site visit to Durham is approaching May 31-June 1, with the afternoon of 6/1 devoted to traveling to and touring Salisbury, NC. The Durham GRECC is a well-established and stable program, a dynamic director who is also ACOS/GEC, and a strong relationship with the affiliate, Duke University. Little is known at present about Salisbury.A site visit to the Pittsburgh GRECC is scheduled for June 21-22. It was originally scheduled for 2015 but the VAMC Director, Chief of Staff, and VISN Director were all in acting roles. Pittsburgh is a GRECC affiliated with a Department of Neurology rather than Medicine. There is relatively sparse presence of Geriatric Medicine from the University of Pittsburgh within VA. The GRECC Director is confident that is about to change because the Chair of Medicine wants to expand the geriatrics footprint at the VA. Following interviews with Pittsburgh’s GEC programs the team will travel to Butler VA, about 40 miles north.Baltimore GRECC will be visited July 19-20. Baltimore has weathered a rocky few years since its founding director was forced to retire following an employee’s accusations of misuse of funds, which were not sustained by an administrative investigation. The errors were determined to be ones of ignorance and not deliberate. At the same time, the Chief of Staff, VAMC Director, and VISN Director all retired. After a protracted search and a year of acting leadership by the Chief of Rheumatology, the AD/C, Dr. Les Katzel, was named Director. After Baltimore, the team will visit the Washington DC VAMC, which is regarded as having a large and dynamic clinical GEC program and affiliated educational activities.New England GRECC will be site visited July 25-26. This program has a long and troubled history. The new Director just named one of two AD/C (one per site); lacks a Research Director at Bedford; and lacks an AD/EE at both sites. One concern is the program’s persistent insistence that the CLC at Bedford is its “clinical demonstration” for long term dementia care—now recharacterized as a “geropsychiatric unit”. Following visits to the GEC programs at both Bedford and Boston, the team will spend half a day at Providence VAMC.Thomas Edes, MD, Executive Director, GEC OperationsDr. Edes discussed several “converging challenges.”Cost of care: Dr. Edes has sought to make a compelling case that GEC patients are VA’s responsibility and that GEC offers solutions that save resources for non-GEC parts of the system (e.g., improved access, reduced readmissions, reduced decline, reduced demand for facility-based long term care). By shifting care to home, VA must take a more active role on behalf of caregivers—again, an unfamiliar expenditure but one that pays off handsomely in averting other costs.Program alignment: As GGAC has observed, different sites have different GEC programs reporting to different services—even within the same VISN. This works to marginalize the programs, because there is inconsistent and unfocused advocacy on their behalf. A proposal is underway, consistent with the recommendation to the Secretary, noting that the new “Universal Geriatrics and Extended Care Services” policy, signed in early November by the Under Secretary, specifies that each VISN has to have a person dedicated to overseeing GEC. The memo that is intended to go out takes the policy several steps further, encouraging each VAMC to also have a GEC lead. This is intended to enhance communication, improve accountability, promote effective management, and foster an improved Veteran experience.Choice: When the May 2014 situation of “secret waiting lists” in Phoenix hit, VA countered with a strong spirit of “transparency”—but the effort was almost exclusively focused on Primary Care; secondarily Specialty Care; and completely ignored extended care. In the same way, the solutions didn’t include GEC programs. Now 2 years on GEC is starting to be included in relevant discussions but much of the infrastructure is settled and often fails to accommodate GEC. For example, the purchased care agreement with the contractors permits a 5-14d delay from initial contact to arrangement for services—which is incompatible with home care as a component of discharge from hospital. Electronic Wait List (EWL): Currently GEC is over 25% of the total wait list, yet because of shifting priorities there is little attention being paid to this now. Dr. Edes is trying to emphasize “urgency” of care, and how a waiting list is neither a clinically reasonable nor humane means for addressing a disconnect between demand and supply. Dr. Halter asked “how long is too long for an EWL? Dr. Edes responded that he and others have been trying to speak in terms of “urgency”—when someone is dependent in ADLs, it isn’t “urgent” like an MI, but the person is going to require assistance or the consequences will begin to mount. With that reasoning, nearly all GEC care should be regarded as “urgent”.Complex Patients: also raised with the Secretary: those with both behavioral issues and challenging chronic diseases, who place strong demands on discharge planning and placement. A task force of GEC and mental health professionals developed recommendations for addressing the issues, including enhanced interdisciplinary teamwork, breaking down silos, enhancing employee skill sets in addressing aversive behaviors, and cross training in both psychiatric and medical management competencies.Maureen McCarthy, MD, Assistant Deputy Under Secretary for Patient Care ServicesDr. McCarthy introduced herself and provided some biographical background. She is a psychiatrist, worked as a mental health chief under Dr. Jain in Salem, Virginia; succeeded him as Chief of Staff at that site; and then came to VACO to be his Deputy. She has been acting Chief for 9 months since his retirement and just recently was appointed to the position.She described Patient Care Services as “the Heart of VA”—Mental Health, GEC, Specialty Care, Care Management/Social Work, etc. Access is a current priority; workforce is another. There are always more demands than there is bandwidth to raise them all to the top—leaders do their best.Dr. Veith briefly described the earlier interaction with Secretary McDonald and stated his intention to keep GEC in the spotlight. The Non-Institutional Care situation has persisted with minimal progress for years; and it was concerning that it was overlooked in all the early efforts in Choice5. Dr. McCarthy noted that the Deputy Secretary (Sloane Gibson) has recently asked for information on long term care—this could be a turning point. Dr. Halter noted the growing Wait List and speculated that might be part of Mr. Gibson’s interest; Dr. Veith added that the costs of LTC are not trivial, and that has to send a message. Dr. Halter noted that a story that Dr. McCarthy had told about her father and his VA experiences demonstrated how interdisciplinary teamwork had made a difference. Could the need to expand that approach drive greater awareness? Dr. McCarthy pointed out that not only GEC but also PACT and social work are experts in team care.Lisa Minor, MSN (Operations) and Marianne Shaughnessy, PhD, APRN (Policy), Directors of Facility-Based Long term Care. Ms., Minor reviewed how Community Living Centers will be assessed both through eleven Quality Measures (generated from the Minimum Data Set) and unannounced surveys. Scoring is by quintiles and color (red -- lower performing, blue higher performing). The CLC SAIL (like the SAIL report that used in for VA Medical Centers) has a radar chart, and both provide a scorecard and can be used to compare centers and/or follow trends over time. Furthermore, it uses the same scoring system CMS utilizes, facilitating comparisons with the community, and efforts are currently underway to replicate the Nursing Home Compare Five-Star Quality Rating System using data from VA CLCs. In particular, CLC SAIL will be deployed on the VA intranet in May of 2016 and reported quarterly (including Q3 of FY2013 through Q2 of FY2016). This was viewed as a powerful tool in improving the delivery of care in facility-based long term care. Kathy Lee Frisbee, PhD and Neil Evans, MD, Connected CareDr. Frisbee initially filled in for Dr. Evans because he was delayed due to traffic. She introduced herself and her background: originally trained as a pharmacist, she then earned an MPH and most lately a doctorate in system engineering—reflecting her perspective that a better way to do health care is to focus on making it easier for patients to do the right thing. Her newest responsibility is to help stand up the Office of Connected Care, which focuses on Veteran and family, is Veteran-centric, and strives to keep consumers in continuous contact with the providers—much like retail has transformed. The challenge is integrating massive amounts of data about patients into the electronic health record in a manner that assists providers. But the flip side is to automate communications with patients in a manner that doesn’t require much provider input after initial set up, e.g., reminders about lifestyle changes and health monitoring. Dr. Evans offered his outlook on Connected Care: it is supportive without replacing the relationship with a patient: an approach that works for some, but not for everyone; an additional set of tools.Current efforts are directed to bringing telehealth into the home. Predictions are that this could soon be a $330B/yr set of services nationally. My HealtheVet now has 3 million registered users. Patients can download their health records and provide the information to a community provider without the non-VA provider having to resort to dealing with the internal VA procedures for Release of Information. The patient can take the responsibility for the reverse as well—getting information from community providers to share with VA.There is a growing “App Store” of capabilities for patients and providers: Dementia care; “Ask a Pharmacist”; “Care for Caregivers”; Gait and Balance assessment; tablets into which peripherals (BP, pulse Ox, etc.) can be plugged; mobile electronic health record for HBPC staff; nursing apps to sequence tasks, assist with schedules.Gene Migliaccio, Deputy Chief Business Office for Community CareDr. Migliaccio introduced himself and described his prior experience as a hospital administrator for the Air Force and US Public Health Service. He also worked in a Congressional Office with the late Claude C. Pepper and has both a masters and a doctorate in public health, both with geriatric concentrations. The Business Office is soon to sunset and will become Community Care, charged with “paying the bills” for the approximately $12B of care and services purchased by VA each year. Currently there are seven distinct programs for purchasing care (Fee, ARCH [Rural], Project Hero, Emergency care, academic affiliates, Non-VA Community Care, and PC3 [Patient-Centered Community Care Contract—a contract, primarily for specialty care, with Tri-West and HealthNet]—these are being folded into a single authority and process, per a recommendation of VA to Congress in October—it should be finalized this June in an Omnibus Bill. Based on broad stakeholder input, it is intended to streamline eligibility determination and payment.Both short- and long-term improvements are anticipated. In the short-term, delays in paying contractors are being targeted for improvement. VA had a practice of not reimbursing until all paperwork had been received—rather than when the care was ordered—and this is not the industry standard. Sometimes these even resulted in Veterans being taken to small claims court for overdue bills, and VA is settling those. And care coordination is being enhanced.Longer term, VA is expecting to see advantages of dealing with local and regional contractors rather than national ones. Eligibility and authorization will be increasingly automated. Timeliness standard will be to receive appointment within 5d; seen in 30d; “urgent” in 2d. Additional goals are automated payment and copayments; and retention of the relationship with affiliates.Emergency care is still in need of improvement. Provider agreements are going to become a possibility—they are more timely than contracts—this is being piloted in Homemaker/Home Health Aide and soon will also be brought on line for Adult Day Health Care and Respite. Dr. Halter asked about the demographics of Veterans served by Choice. The response was that they are 60% over age 60. Dr. Halter asked why it seemed that HM/HHA, ADHC, and Respite looked like afterthoughts, given the case mix? Dr. Veith pointed out that GGAC heard very concerning stories of disrupted relationships with vendors of non-institutional purchased care due to Choice. Mr. Migliaccio stated that Choice will sunset in FY2017 and that disruptions described (which dated from December 2015) should be turning the corner now.Kim Kelley, LCSW (Policy) and Dayna Cooper, MSN (Operations), Directors of Home and Community-Based Care.The pressure to “rebalance” LTC by building up its use of non-institutional modalities while diminishing facility-based modalities became a budgetary factor in 2015, although it had been called for dating back to 1998. In the FY15 budget the shift was 2%--but realistically, to approach parity with the non-VA world it should probably follow something closer to 3-4% per year.Ms. Kelley and Ms. Cooper provided GGAC with a table that the office had prepared as part of briefing the Under Secretary prior to his approval of Handbook 1140.11: Universal Geriatric and Extended Care Services. The table lists the full spectrum of the GEC offices’ clinical programs but it also makes a distinction between “mandated” and “recommended but not mandated” programs. Subsequent to the approval and issuance of 1140.11, the Chief Business Office asked for reconsideration of the “recommended but not mandated” distinction, asserting it was artificial and potentially at odds with VHA providing the services so specified. Dr. Shay explained the history of this, and Dr. Allman emphasized that the offices are working to remove that language and reissue a revised policy.Ms. Kelley and Ms. Cooper went on to describe the initial adverse impact of Choice on purchased GEC services, but told the group that the addition of Provider Agreement Authority for Homemaker/Home Health Aide is paving the way for that service, as well as Veteran-Directed home and Community-Based Cares and Services, respite, and Adult Day Health Care to be covered under Choice (under the “failure to appoint” authority, because the contractors, HealthNet and TriWest, do not offer these services). Ms. Cooper predicted this will be settled by June 2016. Despite these concerns and the growing wait list for GEC purchased care services (now accounting for 25% of VA’s total wait list), access to GEC LTC was increased by 8.3% in FY15—varying according to program by 2-40%. A remaining downside is that Purchased Skilled Care, which the contractors do provide and thus will be able to be provided through that model, will therefore have only a limited range of options available. For example, purchased skilled care in the Chicago area pre-Choice had a pick of about 150 agencies—now there are only two. Ms. Cooper expressed her concern that inevitable delays in obtaining timely purchased skilled care can be counted on to increase inpatient lengths of stay. Dr. Veith asked how the Community Nursing Home program was affected: will they be allowed to use Provider Agreements? The response was that separate legislation is needed to obtain that authority. While it is expected to come about eventually, it can be counted on to be some time in the future.Ms. Cooper pointed out another emerging problem. Choice pays Medicare rates—but Medicare doesn’t offer the various NIC services, so contractors are required to either follow a “local fee schedule” or to bill as they see fit—and they will only receive up to the fee schedule rate. Presently a Freedom of Information Act request is necessary to obtain the local fee schedule, so most vendors choose to bill and accept the inevitable delay from overbilling initially and then having to resubmit for the specified rate. The problem is that the “local fee schedule” is based on the 75th percentile of billed charges—which then represents an incentive for providers to bill high rates, in order to push the rates higher in coming schedules. In FY16, a 40% increase in fees on the fee schedule was observed for this reason.Dr. Allman pointed out that, in his handout showing the continuum of GEC services, those in red fonts are under very serious consideration for being moved under the authority of the future Office of Community Care. His concern is that VA is alone in providing most of these services as part of its health benefits, yet the dominant expertise within Community Care matters is on CMS and state systems—neither of which include support for many of the VA programs. The GEC perspective is that it makes sense to move from seven payment authorities to one only if all the needs of the seven are adequately addressed. VA wants to be “one VA” yet there are “two GECs”; Community Nursing Home and State Veterans Homes are themselves covered by four offices (GEC Operations, GEC Policy, Construction and Per Diem), although they address the same patient care need. Yet there is no effort underway to meld all these together. Dr. Halter pointed out that Choice was intended to fix problems, but it seems that with respect to purchased non institutionalized care it is creating new problems. Clearly it is imperative that GEC develop and maintain a strong relationship with the Office of Community Care. Dr. Edes emphasized the widespread confusion in VA over purchased care: the regulations specify they are to be provided “as resources allow” which VA’s Office of General Counsel interprets to mean “if the agency has the funds”—and if the agency does NOT have the funds, the Secretary is compelled to limit ALL “services as resources allow” according to established VA Priorities. But the field often interprets “as resources allow” to apply to a site’s own discretionary resources, and often takes the prerogative to limit expenditures on purchased care when budgets are tight. Of concern, even the Office of Finance is unclear on this, confusing community living center eligibility issues with those for non-institutional extended care. Open GGAC Discussion: Dr. Leff observed that there is an abundance of internal education that needs to go on. He speculated that perhaps the John A. Hartford Foundation might consider sponsoring a workshop that in turn could generate a report to force awareness of the issues2. He suggested Dr. Allman communicate with Dr. OBrien-Suric as a first step in developing that concept. He also observed that it works against GEC’s interest to focus so strongly on the distinct programs. For example, a health system has a “Surgery Program”—not an appendectomy or laryngectomy program. There is strength in unity—if, as Dr. Edes described, there can be a unified “GEC Program” at each site, the local “GEC Director” is then charged with offering the various component programs. He also suggested that a review of the epidemiology of older Veterans in the professional literature might help to draw attention to issues8.Mr. Atizado offered his perspective that Dr. Edes and Dr. Allman are charged with educating VA—it is up to GGAC to educate Congress. He noted that the last Senate Veterans Affairs Committee hearing concerning Long Term Care was in 2007, and suggested efforts be taken to promote awareness of the need for one. That said, hearings tend to be very reactive, focusing on one or more adverse situations; it is far more desirable to build an ongoing relationship and engage in open communication covering wide-ranging topics9. He pointed out the importance of redoubling efforts to have ongoing dialog with both “appropriators” and “authorizers” (which he likened to “Operations” and “Policy,” respectively). Discussion followed, touching on the protocol through which Dr. Veith might convey this. It was agreed that, if a representative of SVAC were to contact Dr. Veith (e.g., in reaction to the cover letter to the annual report), that would be acceptable; whereas Dr. Veith initiating contact in order to make this suggestion was not. Mr. Atizado said that when he needs to share something with either HVAC or SVAC it is important to find a day when a hearing is not being held, and call a meeting and bring lunch to encourage participation. Dr. Halter noted that GGAC had visited the Hill a few years back, and suggested Dr. Shay circulate a list of House and Senate Oversight Committee members, so GGAC members might identify whether anyone from each member’s Congressional delegation might have a role to play. Dr. Veith wondered if that was anything that the John Hartford Foundation might be able to assist with. Dr. OBrien-Suric said it would be a possibility—and also asked that newsletters that the GRECCs develop might be shared with Congressional delegations. Dr. Shay stated he was about to send out the latest issue and would make a point to remind GRECCs to share with their delegations. Dr. Veith suggested it might be helpful if future GGAC meetings might include some focus on marketing and communication10. He also suggested Dr. Shay incorporate selected graphics into the minutes11.Ms. Chin-Hansen and Mr. Marsh each offered brief personal statements on their qualifications to Chair GGAC and what thoughts they had for future committee directions and activity. Dr. Shay asked the committee to discuss, as an alternative to selecting a single person as Chair for the next 4 years, instead the election be for a Chair and a Vice-Chair, with one serving for two years and then possibly the two trading positions. This would reduce the commitment for the Chair to go on every site visit because some could be the responsibility of the Vice Chair. MOTION: Dr. Halter moved, and Dr. Leff seconded, to modify the election to elect a Chair and a Vice Chair, each to serve for two years. In two years’ time, a new Vice-Chair will be elected and the initial Vice-Chair will have the option to ascend to the Chair or step down12. Passed unanimously. Adjournment:Meeting Adjourned at 12 noon on April 20, 2016 ................
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