Course Description This presentation reviews the 2016 Veteran Health Administration Strategic Service Delivery and Facilities Master Plan for the Veteran Integrated Service Network in the metropolitan New York and New Jersey market (formally VISN 3). Additionally, it presents research on a hypothetical case study built on the strategic plan which incorporates the Veteran CHOICE program, ultimately identifying public and private partnerships for the VA that are in alignment with the Congress Commission on Care Report recommendations. Attendees will gain an in-depth knowledge of the VAFM Service Delivery & Integrated Planning process
Learning Objectives At the end of the this course, participants will be able to:
1) Plan and phase a perioperative suite within an existing building footprint to meet current safety standards, within financial constraints 2) Evaluate existing geographic market of healthcare network, facilities and surgical services available to the population 3) Analyze patient demographics and referral patterns in relation to delivery of health care 4) Identify opportunities for alternate points of care to best serve the patients’ Health, Safety and Welfare with an exploration of Public-Private Partnerships 5) Plan for future growth where points of care are non-accessible
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Introductions
Vlad Torskiy, MHA, ACHE, AORN, IAIA, Lean Healthcare CP Healthcare Studio Leader | Principal, SmithGroupJJR
John Siemsen, MBA, ACHE, HFMA Principal, The Innova Group
Pablo Torresarpi, IAIA, LEED AP Senior Healthcare Planner, SmithGroupJJR
Holly Harris, LEED AP BD+C Architectural Designer, SmithGroupJJR
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The Department of Veterans Affairs operates one of country’s largest, most comprehensive, integrated healthcare systems. VA Hospitals: 152 VA Outpatient Clinics: 800 VA Nursing Home Care units: 126 Domiciliaries: 35 Total Enrollees in VA Health Care System: 9.22 Million Total Number of Unique Patients Treated: 6.26 Million
Current Veteran Population as of September 2017 10%
19.9 Million
90%
Male Department of Veterans Affairs 20182024 Strategic Plan
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Veteran Population By State & Region
1960 Census year
27%
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Veteran Population By State & Region
1970 Census year
25%
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Veteran Population By State & Region
1980 Census year
22%
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Veteran Population By State & Region
1990 Census year
20%
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Veteran Population By State & Region
2000 Census year
18%
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Veteran Population By State & Region
2010 Census year
11%
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Projected Veteran Population By State
2030 Top 10 States
Top 10 Sates
Department of Veterans Affairs 2018-2024 Strategic Plan
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1 2
Service connected disability 30-40%
3
POW or Purple Heart Recipients
4
Catastrophic disabilities (non-service)
5
Low Income
6
Served in specific conflicts or exposed to radiation
7
Income below GMT, agree to copays
8 Westat 2015 Survey of Veteran Enrollees’ Health and Use of Health Care
Service connected disability 50% +
Income above GMT, agree to copays
GMT: geographically-adjusted income limits
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1
VISN 3 : 57% Age 45-64 : 25%
2 VISN 1 : 56% 3 VISN 2 & 8 : 54%
Westat 2015 Survey of Veteran Enrollees’ Health and Use of Health Care
VA Office of Actuary VetPop2014 as of 9/30/2015
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Veteran Integrated Service Networks (VISNs) Selected Veterans Health Administration Characteristics: FY2002 to FY2014
OUTPATIENT INPATIENT TOTAL Fiscal 1 VISITS2 ADMISSIONS ENROLLEES Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
2014
(in millions) 6.8 7.1 7.3 7.7 7.9 7.8 7.8 8.1 8.3 8.6 8.8 8.9
9.1
(in millions) 46.5 49.8 54.0 57.5 59.1 62.3 67.7 74.9 80.2 79.8 83.6 86.4
92.4
(in thousands) 564.7 567.3 589.8 585.8 568.9 589.0 641.4 662.0 682.3 692.1 703.5 694.7
707.4
1 Includes non-enrolled Veteran patients. 2 Includes fee visits.
Source: Department of Veterans Affairs, Veteran Health Administration Office of Policy and Planning Prepared by the National Center for Veterans Analysis and Statistics.
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VA Outpatient Reliance 80% of enrollees are eligible for other public insurance and/or have private insurance. 21% of enrollees were 100% reliant on VA OP care, utilizing the VA for all OP needs. 52% of enrollees were 0% reliant on VA OP care, receiving all OP care from community providers. 27% of enrollees received OP care from both VA and community providers. Measured from October to December 2014. Multivariate regression analysis revealed that lacking insurance coverage and “high” priority group (1 to 6) were the strongest drivers of reliance. Westat 2015 Survey of Veteran Enrollees’ Health and Use of Health Care. Prepared for Strategic Analysis Service (SAS) & Office of Strategic Planning and Analysis (OSPA) VHA Department of VA.
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Current & Planned Future Use of VA Healthcare 32.5% of enrollees use VA services to meet all of their health care needs. 44% of enrollees plan to use VA health care as the primary source of health care. 19% plan to use VA as a back-up for minor services, or just for prescriptions or specialized care. 19% plan to use VA as a “safety net” only if needed. 7% of enrollees have no plans to use VA health care. There has been very little change in planned future use of VA services over the past five years. Westat 2015 Survey of Veteran Enrollees’ Health and Use of Health Care. Prepared for Strategic Analysis Service (SAS) & Office of Strategic Planning and Analysis (OSPA) VHA Department of VA.
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President Herbert Hoover signed Executive Order which elevated the Veterans Bureau to a federal administration - creating the Veterans Administration.
August 2014 July 21, 1930
Commission on Care Final Report recommended the VA outsource specialty care & invest in Primary Care and VHA special-emphasis resources.
Bill Passed to Extend Choice Program Launch of test program with the CVS Pharmacy that will allow veterans in the Phoenix area to be treated at “MinuteClinics”
August 2017 December 2017
September 2016
June 2016 The Veterans Access, Choice, and Accountability Act of 2014 (Choice Act) Signed Into Law.
VA authorized 6.1 million appointments in the private sector in 2017. A 64% increase from the 3.7 million privatesector appointments in 2016
April 2017 FY 2016, VA processed 18.9 million claims for all community care programs. This was a 13% increase since FY 15.
Aug: Congress passed legislation for $2.1 billion emergency funding for Choice program. Dec: An additional $2.1 billion emergency funding approved by Congress.
How does this affect the public/private market?
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“As VA moves forward with its modernization efforts, we will incorporate Veterans’ input to build a system that works best for them – a customer and clinically-driven system… To ensure success, VA will focus resources on foundational services that Veterans need most, and leverage Federal partners, community providers, and private partners to offer care and services where needed. This will provide Veterans access to the best of both VA and the private sector.” -Department of Veteran Affairs, FY 2018-2024 Strategic Plan
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Veteran CHOICE Program – the basics 1.
The VCP is a critical program that increases access to care for Veterans by authorizing millions of appointments for Veterans in the community.
2.
Veteran Eligibility: a. Residence is 40 or more travel miles from closest VA medical facility b. Wait time is 30 or more days from clinically indicated date c. Excessive burden is accessing VA medical facility • Geographic/Environmental Challenges, Medical Condition, other
3.
Providers interested in participating must establish a contract with one of the contractors, Health Net Federal, or TriWest Healthcare Alliance. https://www.va.gov/opa/apps/locator/#
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Veteran CHOICE Program – the basics 1.
The VCP is a critical program that increases access to care for Veterans by authorizing millions of appointments for Veterans in the community.
2.
Veteran Eligibility: a. Residence is 40 or more travel miles from closest VA medical facility b. Wait time is 30 or more days from clinically indicated date c. Excessive burden is accessing VA medical facility • Geographic/Environmental Challenges, Medical Condition, other
3.
Providers interested in participating must establish a contract with one of the contractors, Health Net Federal, or TriWest Healthcare Alliance. https://www.va.gov/opa/apps/locator/#
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CASE STUDY
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VAFM Service Delivery & Integrated Planning
The Goal Develop an Integrated Service & Facility Plan for the VHA, VBA, & NCA assets within VHA’s VISN geography for a 10-year projection
The Objectives 1. Planning processes that result in demand-driven operational non-capital and capital plans. 2. An agile VA infrastructure footprint fully comparable to the best in the nation. 3. Capital investments based on approved strategic, operational and facility master plans. 4. A continually updated process with local flexibility that is able to reflect the unique circumstances of the various States and markets served by VA. VAFM Integrated Planning Handbook (May 2014)
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Health Service Delivery & Facility Master Planning 15%
30%
50%
65%
85%
100%
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2014-2020 Strategic Plan
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2018-2024 Strategic Plan Greater Choice
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Metropolitan New York
Long Island
New Jersey
Manhattan VAMC – 734,000 DGSF
Brooklyn VAMC – 444,000 DGSF
St. Albans CLC – 888,000 DGSF
Bronx VAMC – 888,000 DGSF
Montrose VAMC – 547,000 DGSF
Castle Point VAMC – 264,000 DGSF
East Orange VAMC – 656,000 DGSF
Lyons VAMC – 859,000 DGSF
Northport VAMC – 817,000 DGSF
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Zoom-in on New York Harbor
Primary Service Areas
Referral Patterns
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VISN 3 HSDP: 35 Points of Care 2 Tertiary Care Hospitals (Bronx, Manhattan)
4 Hospitals (Brooklyn, East Orange, Montrose, Northport) 2 24/7 Mental Health/CLC Facilities (Lyons, St. Albans) 1 HCC with CLC (Brick-Tom’s River) 1 HCCs >12,000 (Castle Point)
11 Multi-Specialty CBOCs > 3,000 uniques 9 CBOCs < 3,000 uniques
2 Purchase Care Feasibility Studies < 2,040 1 Special Mission site (Bay Shore)
2 Partnerships with neighboring VISN
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FMP Priorities & Goals
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FMP Priorities & Goals NY Harbor Submarket Priorities • Quaternary Care Level • Precision Medicine Model Manhattan VAMC FMP Key Actions • Private Inpatient bedrooms • Surgical/Interventional Platform
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Existing Condition
Proposed Condition
Final State
SICU SICU/MICU SURGERY
PACU
ANESTHESIA
SOILED LIFT
10
SUPPORT
LOCKERS/
WAIT/ CONSULT/ ADMIN SOILED LIFT
LOCKERS/
SUPPORT
SUPPORT
To Prep/Recovery Holding 10S
To Prep/Recovery Holding 4N
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Phase 1: Relocate Anesthesia to Phase 3: Construction of allow for maneuvering space. new staff support and Phase 2: Temporarily relocate lockers. Phase 4: Construct staff support and lockers. 2 ORs
Phase 5: Construct 2 ORs (including Hybrid)
Phase 6: Construction of 2 new OR’s (including Cath/CV) & renovate clean core
Phase 7: Vacate partial PACU/SICU/OR space. SICU & PACU maintain operations
Phase 9: Renovate & combine SICU/MICU for 14 beds
Phase 10: Construct waiting, consult & admin
Phase 8: Construct 6 PACU bays & support
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FMP Phase Implementation
$43.1 M phased over 9 years to reach Quaternary Care Perioperative Platform in Existing Hospital
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FY 2019 Capital Projects Proposed for Funding
The (FY 2019) Long Range Action Plan capital plan includes 4,199 capital projects that would be necessary to close all currently-identified gaps within a 10-year planning horizon.
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FY 2019 SCIP 10-Year Budget Requests MAJOR Projects MINOR Projects NRM Projects
$1,127,486,000 (1 Trillion for VHA) $706,889,000 (449 Million for VHA) $1,445,565,000 (All for VHA)
$3,279,940,000 ($2,899,000,000 for VHA)
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Veteran Care Options Veterans Affairs Medical Center
VA Community Based Outpatient Clinic
Public/Private Institutions Partnership though CHOICE
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Existing Surgery Physician Partnerships
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Number of Existing Surgery Physician Partnerships by Affiliation
NYU Langone Orthopaedic Surgery Associates University Orthopaedic Associates
NYU Cardiothoracic Surgery Associates NYU Center for Musculoskeletal Care Brooklyn Anesthesia Research NYU Lutheran Family Health Centers Sunset Park
Cunningham Ortho
NYU Langone Ortho
NYU Suny Vascular Downstate Surgery Medical Associates Center Hub
NYU Plastic Surgery Associates NJ Medical & Health Associates LLC
NYU NYU Lutheran Radiology Associates Associates – Medical Art Pavilion
Garrick Cox MD LLC
CTR Surgical Associates PC
DOCS Medical Practice of Yonkers
Summit Medical Group PA
MSKCC Surgery Group
White Plains Hospital / Physician Associates
SunyDown State Medical
University Surgeons at Downstate
NYU General Surgery Associates
NYU Pathology Associates
NYU HJD Associates
NYU Lutheran Associates
Northeast Orthopedics & Sports Medicine PLLC
Mount Sinai NYU Transplant Associates Hospital NYU Otolaryngolo gy Associates NYU Wound Healing Associates New York University University Physician Associates of NJ Center for Vein Restoration NJ LLC
Ortho Sports Med & Rehab Center PA South Mountain Ortho Assoc. LLC Sovereign Medical LLC The Plastic Surgery Center Transplant Dept. of Mt Sinai University Physician Assoc. Cardiovascular Care Group
New York Harbor Health Care System – Manhattan Campus
# of Choice Providers
https://www.va.go v/opa/apps/locato r/# as of September 2017
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Number of Existing Surgery Physician per city per state
https://www.va.gov/opa/apps/locator/# as of September 2017
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NY-NJ Hospitals
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NY-NJ Hospitals & Ambulatory Surgery Centers
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NY-NJ Hospitals: Outpatient Surgery Volumes NYU Langone Surgical Services (IP & OP) Acute Care (SICU at Manhattan VAMC) Bariatric Cardiovascular Colon and Rectal Endocrine General
Neuro Orthopedic Robotic Surgical Oncology Transplant Trauma Vascular/Endovascular
Mount Sinai Surgical Services (IP & OP) Breast Cardiac Colon and Rectal General Metabolic Endocrine & Minimally Invasive
https://www.ahd.com/ as of September 2017
Plastic/Reconstructive Renal Transplant Robotic Surgical Oncology Thoracic Vascular/Endovascular Wound Care
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NY-NJ Hospitals: Inpatient Surgery Volumes NY – Presbyterian Surgical Services (IP & OP) Cardiothoracic Colon and Rectal Craniofacial Dental, Oral and Maxillofacial Endocrine General
https://www.ahd.com/ as of September 2017
Hand Head and Neck Lung Volume Reduction Ophthalmological Plastic Thoracic
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VAMC Ratio of In-house vs. Outsourced Complex Surgeries (2015)
In-House Encounter
Major procedure - breast (P1A)
1,835
970
Major procedure - colectomy (P1B)
2,100
203
Major procedure - cholecystectomy (P1C)
697
64
2,764
323
608
249
Major procedure - explor/decompr/excis disc (P1F)
3,280
1,557
Major procedure - Other (P1G)
77,281
29,497
Major procedure - turp (P1D) Major procedure - hysterctomy (P1E)
Major procedure, cardiovascular-CABG (P2A)
2,969
839
Major procedure, cardiovascular-Aneurysm repair (P2B)
1,817
303
Major Procedure, cardiovascular-Thromboendarterectomy (P2C)
1,927
110
Major procedure, cardiovascular-Coronary angioplasty (PTCA) (P2D)
6,881
1,463
Major procedure, cardiovascular-Pacemaker insertion (P2E)
6,536
926
Major procedure, cardiovascular-Other (P2F)
63,743
14,015
Major procedure, orthopedic - Hip fracture repair (P3A)
1,056
305
Major procedure, orthopedic - Hip replacement (P3B)
3,563
793
Major procedure, orthopedic - Knee replacement (P3C)
5,873
1,588
Major procedure, orthopedic - other (P3D)
National Office of Surgery: VAMC Total
20,081
New York Harbor HCS Manhattan Campus
Outside Fee DELTA %
5,696
203,011 58,901
52.86% 9.67%
Anesthesiology
-
9.18%
Cardiac surgery
146
11.69%
Ear, nose, throat (ENT)
116
40.95%
General surgery
320
47.47%
Neurosurgery
234
38.17%
Ob/gyn
6
Ophthalmology
256
28.26%
Oral surgery
12
16.68%
Orthopedics
230
5.71%
Peripheral vascular
184
21.26%
Plastic surgery
92
Podiatry
136
14.17%
Proctology
-
21.99%
Thoracic surgery
112
28.88%
Transplantation
-
22.26%
Urology
324
27.04% 28.37%
29%
Grand Total (2015) 6 ORs
2,168
629
Estimated Outsourced Cases
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NYU Langone Health
NYU Langone owns and leases more than 6 million square feet throughout the 5 boroughs, with more than 2 million square feet of that on the main campus alone.
Tisch Hospital
Extensive remodeling of the upper floors of Tisch Hospital: • Renovation of patient care units to contain all single-bed rooms, • a new clinical core lab, • new vascular and interventional radiology and endoscopy suites, and • expansion of the Anatomical Pathology Department.
Helen L. and Martin S. Kimmel Pavilion
Building the Helen L. and Martin S. Kimmel Pavilion (opening in 2018) • 830,000 square feet • 21 stories • Directly connected to Tisch Hospital sharing central sterile and support services • emergency services, • surgery and interventional services, • imaging, • ICU and Med/Surg Beds • Children’s services, • cardiac and vascular services, • neurosciences, and • clinical support services
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NYU Langone Health
NYU Langone owns and leases more than 6 million square feet throughout the 5 boroughs, with more than 2 million square feet of that on the main campus alone.
NYU Langone Brooklyn
NYU Langone Plans to invest $500 Million in NYU Langone Hospital—Brooklyn Expansion over the next five years. (2017) • Former Lutheran Medical Center, NYU Langone in Brooklyn houses 11 ORs • $83.7 million ambulatory surgery center in Sunset Park • 6 ORs - cases in orthopedics, general surgery, ophthalmology, otolaryngology, vascular surgery and breast surgery.
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Mount Sinai Downtown Network
Over $500 Million Investment to Create the New Mount Sinai Downtown Multi-Campus Network. New Hospital construction to begin in 2018, expected completion in 2021.
New Mount Sinai Downtown Network
NYU MC Tisch Hospital Manhattan VAMC
http://www.mountsinai.org/
Mount Sinai Downtown will include: • A brand new Mount Sinai Downtown Beth Israel Hospital and ED on 14th Street and Second Avenue, two blocks from the existing Beth Israel Hospital • More than 220 beds throughout the Downtown network • Three major sites performing surgeries with over 35 operating and procedure rooms • Major expansion of walk-in services, including primary and specialty care • An extensive network of 16 physician practice locations with over 600 physicians • Enhanced behavioral health services at Beth Israel’s Bernstein Building • New York Eye and Ear Infirmary of Mount Sinai’s world-class services will be preserved and many will be enhanced
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How to partner through CHOICE Must accept Medicare rates
Meet Medicare Conditions of Participation and Conditions for Coverage, or other criteria as established by the Veterans Affairs. Be in compliance with all applicable federal and state regulatory requirements. Have same or similar credentials as VA staff. Submit a copy of the medical records to the contractor for medical care and services provided to Veterans for inclusion in the VA electronic record.