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Green: VA focus is on care

The scheduling scandal that has plagued Veteran Affairs hospitals in recent weeks has had a direct impact on the Hefner VA Medical Center in Salisbury and its clinics, according to Director Kaye Green.
The drumbeat of negative news about scheduling abuses at other hospitals has hurt morale, but it has also brought new attention — and new funding — to an area that Green says she and her staff already knew was a problem, access.
They started working on a plan last year to shorten the time veterans had to wait to get appointments with their doctors.
The Salisbury VA Healthcare System employs more than 2,300 people.
With a staff of 200 physicians and an annual budget of $360 million, the Salisbury VA system in 2013 served 91,562 patients and had more than 787,723 outpatient visits.
And it has seen rapid growth in both patients and services.
Green and several members of her staff sat down with the Post on Thursday for an interview about the scheduling controversy and other challenges facing the VA Medical Center.
This is an edited transcript of part of that interview with Green:

Q: How has the controversy over scheduling in VA medical centers affected the people here, at the Hefner VAMC?

A: I think it’s been demoralizing for staff. …Our message has been stay focused on providing the best care we possibly can.
We actually started working on improving our access here about a year ago. We sent an initial plan in in May 2013, because we recognized we had some longer wait times here than were acceptable. So we really analyzed where those were and we put together a funding request and we did receive supplemental funding. I really think that’s why our numbers look as good as they do right now, because we’ve been working on this.

Q; What made you aware of the problem?
A: It’s the data, multiple venues … complaints at times that make us look into specific areas. We really do monitor access on a weekly of not daily basis here.
We review anyone who is on an electronic waiting list, which is anyone who is waiting greater than 90 days. We really use that electronic wait list almost as a pass-through. Because anyone who’s waiting longer than 90 days that we can’t get in, we send them to a community provider, whether it’s Rowan Regional if they’re local or Wake Forest if they’re in Winston.

Q: Were you surprised by the findings of the initial audit?
A: I really wasn’t surprised. The whole 14-day measure I don’t think was ever a reasonable metric. I don’t think the hospitals were really consulted when that metric was put into place.
It’s all based off of the desire date, what the scheduling clerk enters as the desire date. By definition of our scheduling directive, that’s a negotiated date between when the provider wants to see the patient back and when the patient wants to be seen.

Q: Does this happen usually over the telephone?
A: It can be the telephone, it can be face-to-face.

Q: So the doctor might have a time when he’d like to see the patient and the patient may have a time when he’d like to be seen. Which one takes precedence?
A: The patient.
There’s a national group looking at that national VA scheduling directive. I believe one of the recommendations that will be coming forward is to change that, so that it will be weighted toward the clinical needs, which will be determined by the provider.

Q. Does each department have its own schedulers?
A. A few departments have their own schedulers, but for the most part they work for Health Administration.

Q. How many schedulers do you have in Salisbury?
Ken Green, chief of Health Administration Service: 281
A: We had over 800 people, employees, who actually had access to schedule appointments here. Some were nurses, some where physicians. That’s one of the things we’re looking at. Probably all those people don’t need the access to the scheduling package. That just leads to not everyone having the same understanding.
We’re retraining all of our schedulers in the system on the correct ways to schedule and to determine the desire date.

Q: Is there much turnover in the scheduling positions?
A: There is a lot of turnover. They’re some of our lower graded staff, and they come in those positions to get their foot in the door as employees. Then those who are really good move up into other positions. So there’s a constant training and retraining that has to take place.

Q: Why is the 14-day goal unattainable?
A: It’s not realistic, not just in the VA but even in the private sector. To give you an example, when I moved to Salisbury a year and a half ago, I needed to find a new primary care provider. And it took me two and a half months, as a new patient, to get in with a primary care provider.
Of course they asked if I had an urgent need, and the answer was no. You know, we do the same thing here. Although we get our new patients into primary care here typically within 30 days — actually it’s about 22 or 23 days, on average. That is a number I feel very confident in.

Q: Do you need more doctors?
A: We do. We know where we have areas of waits.
Let me talk about two areas. One initiative last year when we tried to improve our access, was we hired gap providers in primary care.
Our typical, target panel size for a primary physician is a panel of 1,200 patients. In the past, the practice was to wait until every provider was at capacity or over before we started to hire another primary care provider.
Last year we changed that and we hired gap providers. …
If another provider is sick, the gap provider can step in and see their patients that day… then when all the primary care teams get close to capacity, we’ve already got the next provider on board and we just have to recruit the nurse and the medical support assistant.
That’s actually helped us get ahead of the curve and be sure that we have access for new patients in the primary care.
The second is that we have been working very hard to increase our complexity here, in terms of the services we offer. We’re on the verge of having a joint replacement program. And we started vascular surgery this year. Last year we started robotic surgery for urological procedures. Charles (Dr. Charles de Comarmand, interim associate chief of staff for medicine and chief of Infectious Disease Service) started an oncology program three years ago. We’ve expanded our infectious disease program.
So our challenge is that we serve the most veterans in terms of a VA facility in North Carolina. But we don’t have the complexity of services, for example, that the Durham VA offers. …We feel that our veterans deserve to have those services locally.

Q: What does Durham have that you don’t have?
A: Durham has a cardiac surgery program. We don’t do cardiac surgeries; we don’t even do cardiac caths at the present time, although that’s in our plan.
Durham also does neurosurgery, and that’s something we will probably never do here.
To have those really complex services, you have to have a close affiliation with a medical school, We are affiliated with Wake Forest, but we’re not right next door to Wake Forest.

Q: Is there a particular area where you have the hardest time recruiting doctors, a particular specialty?
A: Previously we had a hard time recruiting psychiatrists. We turned the corner on that about a year ago.
We’ve got seven vacancies now, but we’ve got four psychiatrists that we’ve recruited and are in the pipeline of being hired.
So that leaves us three additional psychiatry slots, and we don’t have any viable candidates for those. That’s a challenge throughout the country; there’s a shortage of mental health providers.

Q: How about patient growth?
A: We saw 91,000 unique users in fiscal 2013. …[T]he growth rate is much different than it is nationwide. We’re in one of those areas that continues to see significant growth.
For so many years the Salisbury facility was known for being a mental health facility and a long term care facility. Those are very important missions, but with the large veteran population we serve, it’s also our responsibility and our obligation to provide them with the full continuum of medical and surgical care that they need. …
Last year alone in 2013, we increased our complexity by 18 percent over the prior year, in one year. And we’re on par to have a similar increase this year.

Q: (Looking at a graph showing a rapid rise in patients) How would a graph of funding look? Does funding track the rise in patients?
A: Funding has not quite kept pace. We have two factors here at Salisbury.
One, we’re growing in number of new enrollees, but we’re also growing in terms of complexity. Our funding model in the Veterans Health Administration is a two-year lag. So what we were funded for this year was determined by the workload we had two years ago. That’s fine if you’re in a stable situation…, but if you’re in a growth mode, it puts additional pressure on your system.
Now that all of this has come to light nationally, the VA has what’s called the Accelerating Care Initiative.
Our goal is really to get patients in within 30 days. We are working very hard every day to try to create additional capacity in our system. We actually got $21 million through that initiative that just came today.
So we’ve targeted areas where we know we need to build capacity; we’ll run some Saturday clinics. Some staff will be required to work overtime, We’ve asked some of our part-time physicians who also work in the community if they could increase their hours with us in the short term to help us with this.
Where we just can’t build capacity fast enough, we’re going to give veterans the option of being seen in the community, at our cost.

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