Utilizing Community Health Centers As a Vehicle for Increasing Access to Primary Care for Veterans Through the Rapid Activation of Community Based Outpatient Clinics (CBOCs)

EXECUTIVE SUMMARY

PROPOSAL:  This paper proposes the use of individual community health centers, or organized networks of community health centers, to serve as a vehicle for increasing access to primary care for Veterans. In this model, community health centers would function as a Community Based Outpatient Clinics (CBOCs) as defined by the Department of Veterans Affairs. This model is based on a strong collaborative relationship between the Health Resources and Services Administration’s Bureau of Primary Health Care and the Department of Veterans Affairs.

Summary Overview

In May 2004, the Department of Veterans Affairs issued its final version of its Capital Asset Realignment for Enhanced Services (CARES) Report. The CARES process was “initiated in 1998 to provide veterans, Congress and the American people with a 20-year plan to provide the infrastructure the VA will need to provide 21st Century veterans with 21st Century medical care.”[1]

This Report calls for VA system wide improvements in the use of vacant space, modernization, operating costs, as well as increasing access to primary care from 73 percent to 80 percent for all eligible[2] veterans. In addressing the need for increased access to primary care, the CARES Commission originally identified the addition of 250 Community Based Outpatient Clinics[3], which would be strategically located throughout the country.  These CBOCs would be in addition to the existing inventory of both staff model and contracted CBOCs that have been operating since 1998.

The final Report prioritized 156 CBOCs out of the originally proposed 250 locations for activation by Calendar 2012.

A crossmatch analysis comparing the 156 prioritized CBOC locations with current[4] BPHC grantees indicates that there are approximately 256 BPHC grantees that could potentially provide access to primary care to 100 percent of the 156 prioritized CBOC locations identified in the 2004 CARES Report.[5]

Rationale

There are a multitude of rationales supporting a community heath center – VA CBOC collaboration in addition to the most compelling resource rationale given above:

• The goal of the CBOC program to increase access to primary care for its Veterans is consistent with the mission of community health centers and the President’s Initiative.
• Community health centers offer the wide range of services that meet or exceed the VA’s requirements for CBOCs including primary care, laboratory, radiology, mental health, and women’s services.
• Veteran patient population health demographics are consistent with the patient health demographics of community health center patients and the program’s efforts to further develop disease collaboratives.
• Community health centers are well suited to meet the CBOC Performance Measures, as established by the VA, in the areas of JCAHO accreditation, travel distance, mental health, patient satisfaction, etc.
• There is a growing community health center commitment to health information technology, high speed internet connectivity, and an electronic health record which is consistent with the Veterans Administration’s commitment to the Computerized Patient Record System (CPRS).
• Community health centers are organized in BPHC/HRSA funded networks that can provide the infrastructure and expertise in information technology, contracting and care management.

The purpose of this document is to organize the experiences, requirements, capacities, and issues that could impact the successful use of community health centers in serving the primary care needs of our veterans.

Community Health Centers as Vehicles For Increased Access to Primary Care for Veterans

Background of the CBOC – VA Staffed vs. Contracted

From 1995 to 1998, the Department of Veterans Affairs approved more than 230 Community-Based Outpatient Clinics (CBOCs). By the end of FY 98, there were 139 CBOCs providing health care to veterans with the number of CBOCs per Veterans Integrated Service Network (VISN) ranging from one to 16.

The predominate staffing model for these early CBOCs was based on the use of VA employees who practiced in VA owned or leased facilitates. During this development period, the VA also began issuing Request for Proposals on a competitive basis in order to contract with existing, community based primary care providers in private practice. Some of the early RFPs were actually awarded to academic medical centers that had concurrent contractual relationships with the regional VA Medical Center for graduate medical education training programs. By April 1998 only 26 of the existing 139 CBOCs were contracted CBOCs.

Current BPHC Grantees with CBOC Contracts

There are approximately 13 community health centers with CBOC agreements across the United States as of August 2004. Eleven of these agreements are direct agreements between the individual health center and the local VA Medical Center. Two of the Virginia health centers participate with the VA as CBOCs through a network master agreement with the statewide health center owned network. The use of organized networks as a contracting vehicle has broad applicability, especially in the areas of pricing, contracting, contract management, compliance, data collection, reporting, and quality improvement.

Description of Need and Authority – 2004 CARES Report[6]

As recommended by the CARES Commission, the VA completed a rigorous re-examination of its forecasting Model by expanding the enrollment base period, completing a lower bound sensitivity analysis, and making Model improvements. These changes resulted in several recommendations regarding facilities, operating costs, and access to primary care, specifically as it concerns the Community Based Outpatient Clinic program.

[The following is excerpted from May 2004 CARES Report, Chapter 2. Pages 6-8.]

Commission Recommendations: The CARES Commission made several recommendations for enhanced access to veterans’ health care through Community-Based Outpatient Clinics (CBOCs). Recognizing the need to apply uniform criteria and consistent national standards, the Commission reaffirmed that final decisions regarding the establishment of new CBOCs should remain under the purview of the Under Secretary for Health and the Secretary. Under that national framework, the Commission made several additional recommendations about how VA should prioritize CBOCs.

The Commission found that the prioritization methodology ... disproportionately disadvantaged veterans living in rural areas that are underserved and lack appropriate

access to care. They also sought flexibility for VISNs to relieve space deficits at parent facilities by adding new sites of care. Finally, the Commission recommended VA improves the efficiency of operations at existing sites and supply basic mental health services at all CBOCs.

Secretary’s Response and Implementation: The VA will continue its ongoing efforts to meet national standards or access to care for our Nation’s veterans by establishing new sites of care through CBOCs. The Commission made several positive recommendations regarding CBOCs, and VA will act to ensure they are met. To that end, VA revised its national criteria for establishment of CBOCs to include emphasis on the importance of access to care for rural veterans, use of CARES travel guidelines to assess access to care, the availability of mental health services, and the flexibility for VISNs to relieve space deficits at crowded parent facilities by moving care to a nearby outpatient setting.

These actions complement existing CBOC criteria that include a focus on caring for Priority 1–6 veterans, ensuring that VISNs have necessary funds to operate new sites, developing well conceived business plans before implementing new sites, ensuring new CBOCs will increase access to care, and other factors. Further, VA will continue to explore opportunities to improve management of existing CBOCs through more effective staffing, expanding hours of operation, and examining opportunities to augment services where appropriate. VA will proceed with development of new CBOCs through CARES and will prioritize clinics that meet specific criteria.

Priority criteria include CBOCs that:

1. Are in markets that have large numbers of enrollees outside of access guidelines and are below VA national standards for primary care access;
2. Are in markets that are classified as rural or highly rural and are below VA national standards or primary care access;
3. Take advantage of VA/DoD sharing opportunities;
4. Are associated with the realignment of a major facility; and
5. Are required to address the workload in existing overcrowded facilities.

These priorities reflect determination to produce more equitable access to VA services across the country, particularly in rural and highly rural areas where there are often limited health care options. They also reflect the Department’s ongoing commitment to strengthening sharing opportunities with the Department of Defense.

The 156 priority CBOCs listed at the end of this response will be implemented by 2012 pending availability of resources and validation with the most current data available. This list reflects VA’s priorities for planning based upon the most current information. As VA proceeds in implementing CARES and as it engages in future planning, the locations of these CBOCs may change, but the priorities will remain constant. VA will enhance access to care in underserved areas with large numbers of veterans outside of access guidelines and in rural and highly rural areas. VA also will enable overcrowded facilities to better serve veterans and will continue to support sharing with DoD. These principles will remain priorities even if management strategies to meet them evolve as new data and information becomes available. Recognizing that resources are not available to open all of these clinics immediately, VA will manage implementation of CBOCs by applying the revised CBOC criteria within the existing National CBOC Approval Process.

These priorities reflect determination to produce more equitable access to VA services across the country, particularly in rural and highly rural areas where there are often limited health care options, ensure a careful and considered implementation that mandates VISNs develop sound business plans, ensures national criteria are met, and that resources are available to provide the quality of care veterans expect from the Department. Resource requirements that must be in place to open new CBOCs include the capacity to manage specialty referrals and inpatient needs of new populations.

These priorities do not prohibit VISNs from pursuing other CBOC opportunities identified in the DNCP. VISNs will be able to propose any CBOC in the DNCP for activation; however, they must be able to demonstrate their ability to open priority clinics on schedule before they can open a clinic that is outside of the priority criteria. VISNs will immediately begin preparation of proposals for development of CBOCs for this year.

[End of excerpt.]

Testimony - Veterans Affairs Under Secretary for Health

In his testimony before the Subcommittee on Health, House Committee on Veterans Affairs on June 27, 2006, then VA Under Secretary of Health, Dr. Jonathan Perlin recognized the value of community health centers by acknowledging the potential for collaboration:

“The VA continues to look for ways to collaborate with complementary Federal efforts to address the needs of health care for rural veterans…. VA services are complemented by the services of community health centers (CHCs), which are local, non-profit, community-owned health care providers serving low income and medically underserved communities. For nearly forty years, this national network of health centers has provided primary care and preventive services to communities in need. Most centers try to arrange specialty care for clients with hospitals and individual health providers.

As of January 2006, more than 1,000 CHCs provide health care to community, migrant and homeless veterans and operate in more than 3,600 communities in every state and territory. Over 37,000 health care professionals work in areas designated as underserved or experiencing acute provider shortages. Three hundred sixty-one (361) CHCs are located greater than sixty minutes away from a VHA access point and are providing care to rural veterans.

As VA continues to look for ways to enhance access to health care for rural veterans, targeted partnerships with CHCs to meet specific, locally defined, health care needs in rural locations may provide an additional service delivery option to the array of practices already deployed by VA medical facilities. VHA will consider current policies and next steps that would assist VISNs and facilities to explore this option.”

Basis for Collaboration

Community health centers are uniquely positioned to meet the needs of the Veterans Administration in providing increased access to primary care for its Veterans.

Current Collaboration between the Department of Health and Human Services (HHS) and Department of Veterans Affairs – On February 25, 2003, the Department of Health and Human Services and the Department of Veterans Affairs entered into a Memorandum of Understanding (MOU) to encourage cooperation and resource sharing between the Indian Health Service (IHS) and Veterans Health Administration (VHA). Five mutual goals were established in the MOU (www.vha.ihs.gov). There are current successful examples of increased access to health care under this MOU. 

Available Inventory of Community Health Centers - The current inventory of community health center grantees within those programs supported by the Bureau of Primary Health Care are operating in all 156 priority locations identified in the CARES Report for CBOC activation. Activation of these 156 CBOCs would increase access to primary care for eligible Veterans to the 80 percent level targeted by the Veterans Administration. Activation of additional CBOCs within BPHC grantee operations has the potential to exceed the 80 percent target levels for primary care access.

Compliance with VA Quality Standards – Community health centers are committed to becoming accredited by the Joint Commission and are supported by the Bureau of Primary Health Care in achieving this accreditation. This accreditation standard is consistent with the Veteran Administration Medical Centers’ accreditation efforts.

Commitment to Information Technology – Community health centers are increasing their focus and capacity to acquire electronic health records, integrate disease registries, implement telemedicine solutions, and improve the overall quality of care provided to its patients through measurable outcomes. This growing commitment to information technology is being fueled by several factors including the successful acquisition, implementation and support of health information technology within a health center controlled network.

Experience as a Contracted CBOC – Although somewhat limited in number, there are specific, successful examples of existing community health centers acting as a CBOC through the competitive awarding of a CBOC contract. These contracts have been awarded to either individual health centers or to a health center controlled network. These community health center based CBOCs can provide real time information on the experiences in serving veterans in a CBOC model, financing, utilization of services, use of the VA’s version of an electronic health record (CPRS), and overall contract compliance.

Veteran’s Administration Commitment to Collaboration – The CARES Report clearly states the VA’s commitment to collaborate with the Department of Defense in meeting the goals of the Report. This model is based on the assumption that the VA would extend their willingness to collaborate to community health centers as described in Dr. Perlin’s testimony previously discussed, as well as allow for a similar collaboration as described in its MOU with the Indian Health Service.

Benefits to the Veterans Administration

1. Readily accessible facilities and staffing for the activation of planned CBOCs.
2. Simplified contracting processes which could decrease the activation costs of new CBOCs.
3. Improved patient care for veterans through existing community health center disease management programs and other enabling services.
4. Improved veteran patient satisfaction through the increased accessibility of primary care.
5. Improved veteran patient satisfaction through the ability of community health center CBOCs to serve not only the veteran, but the veteran’s family members for primary care regardless of their ability to pay for services.
6. Improved veteran patient satisfaction with the provision of culturally sensitive health care services.
7. Decreased reliance on VA resources for support of information technology interfacing between community health centers and the CPRS system.

Benefits to the Community Health Centers

1. Increased patient base with an accompanying revenue source.
2. Improved provider satisfaction with the increased professional educational opportunities available to VA medical staff.
3. Contracting, disease management, information technology and financial management activities do not have to be developed and managed with new community health center resources, if these activities are housed within an existing health center network organization.
4. Improved standing in the community via increased interaction with veteran organizations such as VFW, AMVETS, etc.

Considerations for a Health Center – Department of Veterans Affairs CBOC Model

THE MODEL—The proposed “model” advocates for a high level of formalized collaboration between the Department of Health and Human Services and the Department of Veterans Affairs allowing community health centers to be considered the “primary option” for locating and activating a CBOC according to the requirements set forth by the Veterans Administration. This collaboration would include an agreed upon process to allow “qualified and ready” BPHC grantee community health centers[7] to be designated as CBOCs and provide those Scope of Services currently required by the Department of Veterans Affairs. Community health centers would have to meet all operating requirements of the CBOC program and be held to the same performance standards as existing contracted CBOCs.

There are numerous issues that would need to be addressed in order to successfully implement a community health center/Department of Veterans Affairs CBOC collaboration. Many of these issues concerning existing Federal contracting laws, acquisition rules, intergovernmental agency cooperation, Federal budgets, etc. are outside the scope of this document.

These issues notwithstanding, the following considerations could be explored based on current community health center CBOC experiences:

• Currently, CBOC RFPs and contracts are developed, issued, and awarded at the individual VA Medical Center or VISN level. The RFP system is fragmented and is based on individual VA Medical Center/VISN schedules and budgets. They are governed by a competitive bidding process. Consideration:  Create a collaborative contract environment that provides BPHC grantees first right of refusal for announced CBOCs. Only those community health centers that are deemed “ready” may participate in the contracting process (see below).
• Contracts for CBOCs between VISNs may vary in Scope of Services, and other terms and conditions of an agreement. Consideration: A national community health center CBOC RFP could be developed that would minimize the variability in contract documents and decrease the cost of contracting.
• There are varying degrees of willingness within the VA system to accommodate an outside organization’s ability to interface with the CPRS system. Consideration: A Memorandum of Agreement could be developed between HHS and Department of Veterans Affairs that lays the groundwork for ongoing cooperation in the area of information technology, or the CBOC program in general, similar to that of the IHS.
• Community health centers may be willing to become a CBOC and become excited about the opportunity without a realistic assessment of their capacity to serve veterans. Consideration: A standard readiness assessment could be developed and conducted at community health centers in order to properly prepare to accommodate veterans. This may require technical assistance resources.
• Community health centers may not have the sophistication required to properly analyze the requirements of a CBOC RFP including the scope of services, financial management, contract compliance, etc. Consideration: Technical assistance resources could be identified by the BPHC or NACHC to serve interested community health centers in support of these contracting and financial requirements in order to ensure success.
• Mental health in the primary care setting is an important issue for both the VA and community health centers. Often times, there is an expectation for CBOCs to provide mental health services, although the actual Scope of Services re: mental health varies from filling out an assessment form to actual staffing requirements. In some instances, however, the VA has mental health resources that they are willing to provide in a CBOC facility to serve its veterans even though that facility is a contracted CBOC for primary care. Consideration: In those contracted CBOC locations where the VA has a mental health resource available to see veterans, explore a “reverse contract” whereby the community health center can use that VA mental health resource for all of the patients being seen at the community health center. Adjust the contractual reimbursements accordingly.
• The May 2004 CARES Report makes no reference to any alternative methodology for implementing CBOCs. The Report relies on existing VA policies and procedures for activating a CBOC and only references collaboration with the Department of Defense on a limited basis, mostly for facilities changes. Consideration: Offer an Addendum to the CARES Report that is based on a broader view of collaboration with other Federal agencies that share a common purpose i.e. the BPHC’s mission of increasing access to primary care.

Conclusion

The purpose of this paper was to make an initial attempt at identifying the potential for increasing access to primary care for veterans through the use of community health center contracted CBOCs. It is not meant to be an all-inclusive discussion of the issues nor an attempt to limit the collaborative opportunities to one group of federally supported grantees.

Contact Information

Chief Executive Officer
Community Care Network of Virginia
6802 Paragon Place, Suite 630
Richmond, Virginia 23230

[1] Chapter 1 – Statement of Secretary , CARES Report May 2004

[2] According to the Veterans Administration Primary Care Access Guidelines

[3] CBOCs are outpatient primary care access points that are generally located in areas of high concentrations of veterans populations, and are 1-2 hours driving time from regionally located VA Medical Centers.

[4] Cross match conducted August 2004 and includes all BPHC web site posted grantees including community health centers (CHC), migrant health centers (MHC), health center networks (ISDI), health care for the homeless (HCH), FQHC Look-a-Likes (FQHCLA), healthy communities access program (HCAP), and healthy schools healthy communities (HSHC) grantees.

[5] Cross match analysis does not take into account any increase in community health centers as a result of President Bush’s Initiatives I or II.

[6] Excerpted from May 2004 CARES Report, Chapter 2, pages 6-8

[7] The reference throughout this paper to community health centers is based on current experience and does not imply that other federal grantee organizations could not serve as a CBOC site.