How VA’s community health system slowed down in the pandemic

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When the pandemic first hit, it had a big effect on the Veterans Health Administration. Among the effects: Veterans had trouble getting routine health care appointments at outside facilities, under the VA’s community care program. For more on what happened, VA deputy assistant inspector general, Leigh Ann Searight, joined the Federal Drive with Tom Temin.

Interview transcript:

Tom Temin: Ms. Searight, good to have you back.

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Leigh Ann Searight: Thank you, Tom, it’s great to talk to you again.

Tom Temin: Now, in looking at this report, did anything actually surprise you about what you found? Because I think everyone everywhere going to any medical situation had a delay, especially the early days of the pandemic, when everything clamped shut quickly.

Leigh Ann Searight: Right. I think actually the most surprising thing to me was that the delay in getting veterans scheduled for community care, for those that chose to get scheduled, didn’t really extend beyond normal delays that VHA had experienced prior to the pandemic. It went from a 30-day average to a 42-day average — which, as the normal citizen, we saw lots of delays in our care through the pandemic, so I thought that that wasn’t actually all that extensive.

Tom Temin: It took me nine months to get back to my dentist.

Leigh Ann Searight: Exactly

Tom Temin: So a lot of things happen. But the metric for VA is 30 days between when a veteran calls a community care facility and when they get an appointment.

Leigh Ann Searight: Not exactly. The metric is when a veteran is approved for Community Care, and then through that process, the community care department has 30 days to attempt to schedule the veteran. So their appointment could be beyond that 30-day window.

Tom Temin: So it could be anything from 30 plus one days to a couple of months, depending on the specialty or whatever.

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Leigh Ann Searight: Exactly.

Tom Temin: And you were looking at routine appointments. That means everything except for, say, a COVID-related illness?

Leigh Ann Searight: Even just basic COVID could potentially be a routine illness, depending on the severity of it. So like dermatology or annual exams, primary care, even behavioral health to a certain extent can be considered a routine appointment, depending on the severity of the need.

Tom Temin: If it was something, say, you were doing regularly, like once a month or once a week, some sort of a therapist then that could have been held back also.

Leigh Ann Searight: Right, exactly.

Tom Temin: How did you go about the study? Because there are thousands and thousands of facilities. Where did you go for the data?

Leigh Ann Searight: So what we did is we looked at all of the routine community care consults that were outstanding as of October of 2020. And we did a statistical sample and reviewed about 225 of those open consults to see what VA had done. So whether they were contacting the veteran to attempt to schedule appointments, whether they were documenting that contact and offering alternative care. So telehealth became a big crutch to VA, and really to the healthcare industry, in providing care to personnel. And then we looked at whether they prioritize those appointments. So whether if it was a priority one to priority four to make sure that we got those scheduled as needed depending on that priority.

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Tom Temin: Because VHA itself, in its own facilities, pivoted to a lot of telecare. And we’ve documented that and talked about that. And that was a major effort. Do you get the sense that they worked to ensure that the community care, where possible, would be able to also pivot, if you will, to the tele-methods?

Leigh Ann Searight: Through the consult process, what VA was trying to do was evaluate all those consults and see if there was an alternative that could be offered to the veteran. Whether the alternative was actually to stay within VA, and be offered telehealth within VA, or whether telehealth was a viable option in the community. Telehealth itself changed the format of that change through the pandemic. You know, what we used to be able to qualify for telehealth prior to the pandemic to now has advanced light years.

Tom Temin: We’re speaking with Leigh Ann Searight. She’s Deputy Assistant Inspector General at the Veterans Affairs Department. And also you reported that a lot of the veterans themselves were reluctant to seek care in the community, as I guess many, many citizens in general were worried they could get it — COVID — at those places, perhaps.

Leigh Ann Searight: Exactly. We had a decent population. So about 100,000 of the 476,000 consults that we reviewed — those appointments, we found either that there was hesitancy on the veteran side or they weren’t returning calls to be scheduled, or that there was unavailability in the community, whether they couldn’t get an appointment or that provider was no longer providing services or had shuttered their facility through the height of COVID. So you know, we found of those 110,000, about 60,000 of those were veterans who really didn’t either return calls or chose to not be seen during this.

Tom Temin: Let’s hope they brush their teeth and floss because you got to take care of the basic health yourself during all this time. I seem to be fixating on dentistry today. And also you reported that a priority system was set up 1234 for different types of external appointments. And was that fully effective, or were there some issues with the priority program?

Leigh Ann Searight: Yeah, the prioritization was not fully effective. But it wasn’t fully effective because when it was initially rolled out, it was really not required to be implemented. So I believe they rolled out the prioritization in May of 2020. And it really didn’t become mandatory until September of 2020. So each facility sort of took that prioritization — either didn’t do it at all, or they did a different priority ranking, you know, maybe not a one to four scale, but a high, medium, low scale. And so it was really hard for us to determine — or really we weren’t able to determine — whether that prioritization really worked or not.

Tom Temin: And all of this is interesting, but it’s also a retro objection, going back to a couple of years now. And as we speak, the pandemic seems to be receding in the mask mandates and all of it, it’s kind of melting away. And life could be back to normal in a few weeks, we hope. So are there any lessons learned that are applicable here? Or is this just an academic look at something that happened at a time and place?

Leigh Ann Searight: Lessons learned, I think the lessons learned is really that there are tools available to VA that would help them to monitor these consults a little more closely. So whether there’s a pandemic or not a pandemic, you know, we want to ensure that through the scheduling process, that veterans are being contacted for outreach, and that those appointments are being scheduled, and that VA has a requirement to reach out to the veteran twice if it’s a normal appointment, and four times if it’s a mental health appointment, to make sure that they’re attempting to get those appointments scheduled. But the tools available to monitor whether those contacts were occurring and to document those contacts were somewhat lacking. So we really want to ensure that that continues forward. And then through all of this VA has modernized a lot of their processes. They’ve modernized their console toolbox quite a bit over the last few years, and through that, that has given them some more tools to be able to manage consults better as well. But again, it’s about training their MSAs, their schedulers, to use that toolbox effectively, and really to ensure that all those monitors and checks and balances are being leveraged to ensure that the veteran is getting the care that they need.

Tom Temin: And just a detail that comes to mind, the scheduling has to be through VA in order to get to a community care — that is to say, the veteran doesn’t go directly to that  community care place for his or her appointment.

Leigh Ann Searight: No. So the veteran has to be approved or authorized for community  care, but then the veteran is given the option to call and schedule their own appointment if they choose to do so.

Tom Temin: Well maybe just clarify, then, how it does work that the veteran gets the appointment. If they call directly, what is the VA role here? Just maybe sort that out for us.

Leigh Ann Searight: So if they call directly, the MSA is still able to determine that an appointment was scheduled. And so through their monitoring processes, they can see that a veteran has an appointment. So they can follow up and ensure that care has occurred. Really the process is that, once that authorization is approved for the veteran to have care, then the MSA reaches out to the veteran and says, okay, we’re going to schedule you for this appointment. And the veteran can, you know, what are some good days for you, and the veteran at that point can make the choice, I’d like to schedule it myself. You know, just give me a list of options, and I’ll go schedule. And so then MSA in the record would annotate that the veteran is self scheduling.

Tom Temin: Got it. So one way or another, VA knows who’s going where and when for medical care, even if it’s outside into the community. I guess just add this all up, then — it looks like the pandemic was a pressure test almost of the community care system at the time when VA is still trying to establish excellence in it, you know, because it’s not that old in the expansion of it from Congress. And so maybe this was a good way to find out where the pain points are. Even though the pandemic has passed, as you say, they can still learn from this on how to keep it improving.

Leigh Ann Searight: I think it probably brought to light that there is, you know, a level of dependency that we can have on community care and that, you know, in-house care is still necessary or still an option that we can fall back on as needed, you know, where VA can provide those services. I think it has definitely given VA an opportunity to work, like you said, work through some kinks in terms of better record keeping and monitoring those appointments as they occur.

Tom Temin: Leigh Ann Searight is Deputy Assistant Inspector General at the Veterans Affairs Department. Thanks so much.

Leigh Ann Searight: Thank you.

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