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Geriatrics and Gerontology Advisory Committee (GGAC) Virtual MeetingSeptember 17-18, 2019Meeting MinutesAttendees: Committee MembersDavid Gifford, MD, MPH - ChairHarvey Cohen, MD – Vice ChairJudith Beizer, PharmDRichard BrowdieJoseph Ouslander, MDBarbara Smith, PhDKathy Welsh-Bohmer, PhD, ABPPEx-Officio MembersLori Gerhard, Ex-OfficioStaffAlejandra Paulovich, DFOScotte Hartronft, MDThomas Edes, MDMarianne Shaughnessy, PhD, CRNPSusan Cooley, PhDSherri DeLoof, LMSWGuestsLatonya Small, PhDJenny KimCall to OrderThe meeting was called to order at 1:00 pm. Ms. Alejandra Paulovich, Designated Federal Officer (DFO), GGAC, opened the meeting with a set of introductory remarks and announcements.Ms. Shurhonda Love recently accepted a position with the VA. Because of this, she had to resign from the committee. A new member package is currently being processed to fill the VSO vacancy on the committee.A new member was also appointed to the committee. Dr. Vito Imbasciani joins the group from California, where he is currently serving as the Secretary of the California Department of Veterans Affairs.Ms. Paulovich recently accepted a new position with VA. As a result, this is her last meeting with the committee. Dr. Marianne Shaughnessy will be nominated serve as the new DFO.David Gifford, MD, MPHWelcome Remarks from the ChairDr. David Gifford, the Committee Chair, welcomed members and guests to the meeting. Scotte Hartronft, MD and Barbara Hyduke, MSAGeriatrics and Extended Care (GEC) LeadershipDr. Scotte Hartronft was recently appointed as the Executive Director for VHA’s Office of Geriatrics and Extended Care. Dr. Hartronft highlighted his main priorities which include: addressing the Veteran aging demographics and increasing number of higher service connected priority levels; increasing the use of less costly home care to prevent/delay more expensive nursing home care; finding ways to increase awareness and access to GEC programs through the MISSION Act; improving the quality of care across all GEC service lines; implementing the Choose Home Pilot Project; and ensuring GEC programs fall in line as a High Reliability Organization Service Line.Dr. Hartronft also provided members with an update on Choose Home. Dr. Hartronft sits on the steering committee implementing the program. GEC is charged with developing a Choose Home Registry. Some of the key accomplishments include the launch and implementation of the pilot to 21 sites with an expected national roll out by the end of the calendar year.Other highlights included the State Veteran Home regulation taking effect in December 2019, the implementation of the MISSION Act, the expansion of Home Care Home Health to 35 sites, and the near completion of GEC’s dashboard. Kristin J. Cunningham, PMP and Kimberley Kelley, LMSWMISSION ActMs. Cunningham and Ms. Kelley provided members with an update on the implementation of the MISSION Act. The MISSION Act was launched on June 6, 2019. Due to the strong communication efforts, risk assessment, and mitigation planning leading up to the launch of the program, the program launched with minimal issues. Any issues that arose were quickly resolved to due continency plans that were put in place.Some of the achievements include: an improvement in the prompt payment of providers; training for national and local VSOs; heavy communication efforts of the program; accelerating virtual care growth; and the establishment of a community urgent care network.The country has been broken down to six regions for implementation. Region one will be fully deployed by December 2019, Region 2 by April 2020, and Region 3 by May 2020. Region 4 is currently under protest and Regions 5 and 6 are in the pre-solicitation phase.There is also a new Veterans Care Agreement. This agreement can be used to purchase care when it is not available through a VA facility, contracts, or through shared agreements. This option is to be used primarily for Homemaker/Home Health Aide, Respite Care, Dental, Bowel & Bladder services, and Community Nursing Homes. Thomas Edes, MDCERNER/Electronic Health Record (EHR) MigrationDr. Edes is currently detailed from the Office of Geriatrics and Extended Care to work with the CERNER/EHR implementation team. Dr. Edes provided members with a briefing on the implementation of the CERNER/EHR migration.The reason for the change from CPRS VISTA to CERNER was due to the workability of the systems. CPRS VISTA needed a massive overhaul as it is difficult to maintain. It is also more difficult to make enhancements within the system.CERNER/EHR is expected to go live in Veterans Integrated Service Network (VISN) 20 by the end of March 2020. The roll out will begin with Spokane, then Seattle and American Lake. Dr. Edes currently Chairs the GEC council for CERNER/EHR. Prior to his involvement, the field of geriatrics and GEC services had not really been on the radar of CERNER/EHR strategic planners. Members were pleased to hear that GEC and geriatric services are now being included in the CERNER/EHR build.Dr. Edes mentioned the importance of reducing the documentation burden during the roll out. GGAC members discussed the importance of the office of Electronic Health Record Management (EHRM) working closely with GEC on their national roll out of the MISSION Act, to standardize geriatric terms in the EHRM system, and to work on streamlining Veteran access of Blue Button and their Personal Health Record. Members also discussed the standardization of assessment tools for GEC related conditions and the importance of incorporating them into the EHR. Members believe the new EHR system should allow providers to query questions to help with use of the data collection and analysis required for effective health care delivery. Marianne Shaughnessy, PhD, CRNPLong Term Services and SupportsDr. Shaughnessy shared GEC’s official organizational chart. GEC is currently hiring aggressively and recruiting 17 positions. This is the first time GEC has had a dedicated arm of staff dedicated to data analytics, research, and quality improvement. When fully staffed, GEC will have the bandwidth needed to manage data to guide decision-making and proactively return information to the field. Dr. Shaughnessy provided an update on the executive summary of the GEC survey. The key findings include the decrease in the numbers of geriatric trained workforce both inside and outside the VA, specific challenges in managing behavioral issues with Veterans who are aging and an issue with access to dementia care. GEC staff recognize that dementia resources are spread thin. GEC has asked the GRECCs to help expand the use of telehealth. A call was sent out to the GRECCs for clinical demonstration funds for FY2020. Funding will most likely be granted based on proposals related to Community Living Center (CLC) quality or telehealth expansion.Dr. Shaughnessy briefed members on GEC’s recent LEADS conference. This was the first time that representatives from each GRECC were invited. The conference was successful, focusing on who GEC serves, how can GEC serve them, and what needs to be accomplished. The conference also included interactive breakout sessions, GRECC posters of clinical demonstrations, and networking opportunities for the GEC LEADS and GRECC representatives. Staff from each VISN worked together to develop action plans to improve access and services for older Veterans. GEC staff will send members copies of the VISN action plans and program staff presentations. Judith Beizer, PharmD and Barbara Smith, PhDData Workgroup DeliberationsMembers discussed the preliminary work developed by the GGAC Data Workgroup. The workgroup will continue their work. The Chair reminded members that data requests should be specific and should align with GGAC’s statutory charge and charter.GEC staff are going to provide the workgroup with metrics and measures for post-acute care, and data on institutional long-term care in CLCs and contracted nursing homes to include long-term and short-term stays. GEC staff will provide current data and reports that are publicly available.Additional questions the committee are interested in are: Where are Veterans living and is VA meeting their needs? What is the utilization of services for those Veterans? What is the quality of care they receive? How can GGAC evaluate the impact of the Mission Act on the older Veterans?What is the balance between Veterans Equitable Resource Allocation (VERA) incentives vs. the incentive to meet the needs of the community? Are special populations shifting (Women Veterans, Veterans with mental health needs, etc.)? Dr. Gifford is going to meet with the GGAC Data Workgroup to clarify the workgroup objectives.Thomas O’Toole, MDClinical Operations 10NC LeadershipDr. O’Toole provided members with an update on VHA direction under current leadership. Current leadership is working to modernize by implementing a 10-lane system which includes the CERNER/EHR migration and supply chain management. Part of this modernization also includes transforming VHA into a High Reliability Organization (HRO) with a focus on improving quality in VA culture and in the services it provides. Additionally, clinical service lines will be integrated. This integration will organize VHA’s program office into 6 integrated service lines coupling different services in order to streamline leadership and communication to and from VACO, to the VISN, and to the field. Integration models are still in the process of being developed.Dr. O’Toole also indicated that VA central office will be reorganized. Dr. O’Toole does not believe that this reorganization will not affect GEC. Impacts will likely occur above the program level. The intent with this reorganization is to downsize and move decision making to the VISN level, by flattening hierarchy at the mittee members discussed some of the concerns that were raised during previous presentations and committee meetings including: the hiring and retention issues of healthcare professionals, VA’s struggle to communicate and circulate good news stories in the media, and the need for a new Geriatric, Research, Education, and Clinical Center (GRECC) focusing on long-term institutional care. Gina Screen, Deputy Executive DirectorVHA CommunicationsMs. Screen provided members a briefing on what VISNs and medical centers can do to promote good stories in the media. She also described the work her office does at the national level and the role of Public Affairs Officers (PAOs) at the local and VISN level.Ms. Screen emphasized the importance of good stories being told at the VAMC level, having a communications plan, and a crisis mitigation plan. During the discussions, members suggested VHA Communications develop a step by step guide on how GRECCs can get good news stories to the public. Ms. Screen will also provide GEC staff with the geriatrics POC from her office. Marianne Shaughnessy, PhD, CRNPGeriatric, Research, Education, Clinical Centers (GRECCs)Dr. Shaughnessy provided members with an update on post site visit correspondence. Most of the correspondence has been closed. New England, Pittsburgh, and Palo Alto are expected to provide a 6-month update by the end of the calendar year. Dr. Gifford would like GEC staff to follow up with Palo Alto recommendation in regard to the GRECC Director participating in leadership training. Members were also briefed on the site visits that occurred in San Antonio, Salt Lake City, and Minneapolis. There were no major issues to report from these three locations. Some concern was mentioned about the Minneapolis GRECC being solely focused on dementia,Five GRECC site visits are planned for FY2020: Denver, Birmingham/Atlanta, Gainesville, Greater LA, with an out of schedule site visit planned for New England-Bedford location. GEC staff will reach out to the site for site visit dates. GGAC members will be provided a proposed schedule in which they can volunteer to participate. Dr. Cohen will be chairing the site visit to Denver in October 2019 and requested that a tour of the GRECC be included on the agenda. Jessica Pierce, MBA and Martin Eason, MD, JDWorkforce Management and Office of Academic AffiliationsMs. Pierce and Dr. Eason spoke to members about the efforts Workforce Management (WFM) and the Office of Academic Affiliations (OAA) are working on to increase the hiring and retention of healthcare professionals. Two VA trainee recruitment events have been held with a third scheduled for the first quarter of 2020. A training and hiring workgroup have also been created to address the challenges and barriers impacting healthcare professional trainees. The workgroup is also tasked with developing and implementing innovative solutions to support VA Trainee Recruitment events. GEC is not currently involved in this workgroup. GGAC recommended that GEC be included as part of the workgroup. WFM and OAA are also working to promote awareness of different hiring authorities for meeting critical healthcare hiring demands in VA. Primary Care and Mental Health are two of the most predominant critical demands. It is not clear if geriatrics falls under primary care or under the critical demand for positions. These critical hire positions are eligible for the Student Loan Repayment Program, which members expressed would be of great interest to geriatricians and geriatric health care professionals. Ms. Pierce is going to follow up with the succeeding information: confirm whether or not geriatricians are a high demand specialty for VA; provide a workflow for hiring; confirm if the student loan repayment program can be used for staff working in geriatrics and if the program applies to non-MDs; verify if geriatrics falls under primary care or specialty care; and provide a copy of the pay scales for hiring healthcare professionals.Finalize Recommendations and Next StepsDavid Gifford, MDDuring discussions, the following recommendations were developed: A recent GEC survey found that there are fewer geriatric trained professionals working at VA. GGAC members applaud VA’s efforts towards hiring, recruiting, and retaining trained geriatricians, however, as our previous letter stated (April 2018), the hiring and retention of VA trainees remains a problem. Due to VA’s aging Veteran population, VA’s demand for geriatric services will exceed the availability of the resources required to adequately meet their healthcare needs. Geriatricians also receive additional training - yet despite this - geriatricians and geriatric clinicians are paid less than physicians and specialists in other areas of primary care. As such, the GGAC is concerned that personnel with geriatric competency to meet the anticipated demand for geriatric services needs to be bolstered. Recommendations:GGAC recommends that VA leadership develop an incentive and expectation for VA health care professionals to receive training and retraining in the field of geriatrics (primary care, APN, etc.). GGAC recommends VA alleviate barriers to the hiring of existing healthcare professional trainees by adding the field of geriatrics to VHA’s list of critical hiring needs and utilizing alternative hiring options, such as the direct hiring authority for geriatricians. GGAC recommends that the Student Loan Repayment Program be offered to health care professionals in the geriatric field. GGAC members understand that VA is striving towards being a High Reliability Organization (HRO). During these efforts, GGAC recommends that VA leadership address accountability and expectations with metrics that are measurable and can be evaluated yearly to help expedite the move toward becoming an HRO. 3. GGAC applauds VA’s preparation, risk mitigation, and roll out of the MISSION Act. The MISSION Act makes great strides in increasing access of care to Veterans across the country and the initial rollout appears to have gone very well considering the enormous scale and changes happening all at once. However, with any new program, there may be unforeseen consequences. GGAC members are concerned that the increased access of care may create a fragmentation in Veteran patient care.Recommendation: GGAC recommends VA ensure a program is in place to identify and correct such unintended consequences as well as conduct a review and evaluate of the coordination of care through the exchange of clinical information with community providers and its effect on health care outcomes.GGAC also recommends that VHA’s Choose Home program be integrated into the MISSION Act. 4. GGAC members are pleased to see the recognition of GEC services in the CERNER and Electronic Health Record Modernization (EHRM) build. GGAC members strongly encourage VA leaders to recognize that VA provides more GEC services to Veterans than those offered in the private sector. As a result, VA’s GEC services are a vital benefit to its aging Veteran population.Recommendations: GGAC members recommend the Office of EHRM continue to work closely with VHA’s office of Geriatrics and Extended Care on their national roll out of the MISSION Act, to standardize geriatric terms in the EHRM system, and to work on streamlining Veteran access to Blue Button and their Personal health Record. GGAC recommends VA leadership consider adopting standardized assessment tools for GEC related conditions and incorporating them into the EHR. The new EHR system should also ensure functions in the system will allow providers to query questions to help with use of the data collection and analysis required for effective health care delivery.Next steps: Based on the feedback from GGAC members, the following action items were identified:Spring 2020 Agenda TopicsMISSION Act update on Quality of Care Section (109) SAIL and GEC related measures under the HRO plex Problem PatientsGEC Leads Results: SWOT analysisPresentation on demographic imperative on purchased skilled serves and facility-based care. VISN Action Plans -- Any common threads?VAMCs inventory of GEC servicesGEC Data AnalysisChoose Home UpdateEHRM Cerner Pilot – Feedback from SpokaneGGAC Data WorkgroupWorkforce Management: Hiring and Retention – Data on Retention of 2019 gradsVERA model as it relates to geriatric care. How are geriatric services incorporated? VHA Communications UpdatesGGAC Data Work GroupWhat data reports currently exist? GEC Staff will share with data workgroup.Need information on metrics and measures related to post-acute care in CLCs. GEC Staff will share with workgroup.Need data on volume of institutional long-term care, services provided in CLCs and contracted nursing homes in relationship to long-term care and short-term stays. GEC Staff will share with workgroup.Where are Veterans located geographically and is VA meeting their needs? What is the utilization of services in relation to those Veterans? What is the quality of care those Veterans receive? GEC Staff will share with workgroup.How can GGAC evaluate the impact of the MISSION Act on older Veterans?GGAC Chair to arrange a meeting with GGAC Data Workgroup to clarify work group objectives. GEC staff will initiate.Site Visit RelatedInclude time on upcoming site visit agendas with facility Public Affairs Officer (PAO).Include last 5 years of MOUs for site visit meeting prep documents.Reach out to sites for potential site visit dates. Confirm Chair and Vice Chair availability for site visits. Poll members for availability and interest. GEC staff to initiate.Vice-Chair requested a tour of ECHS VAMC during October site visit. Dr. Gifford to send unavailable dates to GEC staff for 2020 site visits. OtherGEC staff should share good news stories with GGAC members. GGAC members can spread the good news to increase awareness.Identify point of contact for geriatrics in VHA communications. Request a step by step guide on how to get good news out on social and local media and distribute to the field. GEC staff to initiate. Questions for Jessica Pierce (WFM):Confirm that geriatricians are a high demand specialty. Describe workflow for hiring. Describe loan repayment program benefits and pay scales for hires with training in geriatrics. Set up an Admin call in Feb 2020 to prep for April meeting. GEC staff to initiate.Meeting adjourned on September 18th at 3:29 pm.______________________________ Date: November 15, 2019 David Gifford, MD, MPH, Chairman Geriatrics and Gerontology Advisory Committee (GGAC) ................
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