Installation Name: Joint Venture Review 2011 VA/DoD Joint Venture Conference Tripler Army Medical Center (TAMC) and VA Pacific Islands Health Care System (VAPIHCS)

Installation Name: Joint Venture Review 2 Clinical Services - inpatient medical, surgical & psychiatry; outpatient specialty clinic services Ancillary support - laboratory (including blood bank, autopsy & morgue), pharmacy & radiology VA embedded providers – 1 FTE Hospitalist, 1 FTE Ophthalmology, & part time Orthopedic, Hematology Emergency Services (including patient transport) Oral Surgery/Dental - Implant support Health Education & Training (embedded VA resident program, shared training opportunities) PTSD Residential Treatment Program (as of Dec 2005) Nutrition Care Support to Center for Aging, PRRP, Day Hospital Program, Psych Ward CBOC support by Orthopedics Tele-med support in American Samoa Ophthalmology technician – FTE Space & Supplies – Psych Ward & Dialysis; PRRP – space, linen Housekeeping Security Medical Maintenance Radiation Protection Inspections Information Technology/Visual Information Support CMS Support TAMC reimburses VAPIHCS for: DoD beneficiaries on the VA Psych Ward (3B2) and enrolled in the PRRP program (5C1) DoD beneficiaries seen by the VAPIHCS Embedded providers (FTE in Ophthalmology, part time Ortho, Hematology and Pain) Hospitalist FTE Dialysis support (beginning FY09) Tele-TBI space in American Samoa CBOC Services covered under MSA and Joint Policies

Reporting Facility Names: Tripler AMC and VA Pacific Islands Health Care System Agreement: Inpatient (Surgical, Medical, Psychiatry, and Nursing Units) (Provided to VAPIHCS by TAMC): a.TAMC provide beds, on a space available basis, for the referral of acute care. VAPIHCS patients shall be assigned beds within TAMC based on TAMC having available capacity. Sound patient management principles appropriate to the VAPIHCS beneficiaries' medical needs will be utilized. b.Eligible beneficiaries may be admitted provided it does not deny the organization's primary beneficiaries access to care. Admissions may be limited to mutually agreed constraints such as the number of residents available and support services/physician/nursing capacity in certain areas of the facility. c.TAMC will complete inpatient consultations for VA inpatients, which shall be considered part of the inpatient episode of care for patients under the medical management of TAMC medical staff. Inpatient specialty consultations to be provided by TAMC medical staff at the request of the assigned staff physician for inpatients will be provided on a reimbursable basis. d.Social admissions may occur for beneficiaries who do not have safe disposition options to the community or to a home/care setting from the Emergency Room or an outpatient clinic provided it does not deny TAMC's primary beneficiaries access to care. Social admissions are reimbursed on a per diem basis. Inpatient VA Psychiatric Unit: VAPIHCS operates an inpatient psychiatric unit on TAMC Ward 3B2. This service is a locked 20-bed inpatient psychiatric unit staffed by VAPIHCS. TAMC has administrative and clinical oversight of the 3B2 unit, which functions under the general oversight of the TAMC Department of Psychiatry. Patients on this ward are generally VA beneficiaries, but services may be provided to DoD beneficiaries at the request of TAMC. Baseline and Current Status: Services are currently provided in all inpatient areas under our agreement, including a VAPIHCS staffed Psychiatric ward within TAMC. For FY11 to date, the top 5 service areas included medicine (ALOS 8.1 days), orthopedics (ALOS 4.6 days), general surgery (ALOS 10.4 days), urology (ALOS 2.1 days) and psychiatry (ALOS 10.8 days). Claims processed through 12 October 2011 for all inpatient workload totaled $10,509,843.49, exclusive of professional fees. Quantitative Results from the Agreement: Negotiated services are provided at a 15-20% discount over the national rate; psychiatric care is reimbursed on a per diem basis that provides savings to the VAPIHCS over community rates on Oahu. Qualitative Value of the Agreement: Workload provided by VAPIHCS to TAMC increases access for veterans in the Hawaiian Islands and the Western Pacific, supports the Graduate Medical Education program at TAMC, provides access to patient health care information to PCPs and specialists through JANUS for continuity of care. Service Provided: Inpatient medical, surgical and psychiatric JEC Mandate Reporting Format Template CLAIM AMT

Reporting Facility Names: Tripler AMC and VA Pacific Islands Health Care System Agreement: Baseline and Current Status: Services provided by TAMC to VAPIHCS. a. Ambulatory Services. All outpatient referrals to TAMC will have appointments pre-authorized by the VAPIHCS; appointments are coordinated through the TAMC VA Referral Center (VARC). Patients who present without an authorization shall be evaluated for urgent/emergent need. Patients who present to a TAMC clinic for urgent or emergent services will be rendered care in the clinic(s). Requests for retrospective authorization will be accompanied by clinical notes. To ensure continuity of care, adjunct services deemed necessary by the provider to complete workup for an episode of care will be considered for retroactive authorization. Both TAMC and VAPIHCS will provide a list of capabilities outlining services available at each organization. b. Emergency Services. Eligible veterans who reports to the Emergency Room (ER) will be triaged by the ER physician to determine urgent/emergent conditions. For non- urgent/non-emergent conditions, veterans may be referred after triage to their PCP at the Ambulatory Care Clinic (ACC) for care during normal business hours in the event TAMC is on inpatient "divert status", all eligible veterans on TAMC grounds referred by VAPIHCS providers for emergency management will be evaluated and stabilized at the TAMC ER before diversion to the community if further inpatient treatment is required. c. Ancillary services. Ancillary services (including Pharmacy, Laboratory, Radiology will be provided to inpatients and are considered part of the inpatient episode of care with the exception of the professional component. Routine and non-emergent high cost services such as ultrasound, CT, nuclear medicine, MRI or PET scan require preauthorization by the VAPIHCS in support of the outpatient specialty care (non-ER). Prescriptions required outside of the normal VAPIHCS pharmacy duty hours, or at the discretion of the specialty provider, may also be filled at the TAMC pharmacy and will be reimbursed. The VA will provide refill medications through its Pharmacy. Radiology and Nuclear Medicine Service studies will be provided in accordance with established policies. Laboratory and Pathology services will be provided in accordance with established policies. Services provided by VAPIHCS to TAMC. VAPIHCS provides support to TAMC for chronic and acute dialysis, Post Traumatic Rehabilitation and augmentation of providers in ophthalmology, orthopedics, hematology and pain services. Reimbursements to VAPIHCS for these services totaled $1,073,100 as of 30 Sept Quantitative Results from the Agreement: Services are currently provided in a majority of the outpatient specialty clinics under our agreement. A Service Availability Report (SAR) is provided to VAPIHCS on a periodic basis which outlines service availability and areas where specialty services may be curtailed due to excess workload or manpower shortages. VAPIHCS has augmented staff in several clinical areas, including ophthalmology (FTE), orthopedics, (partial FTE), hematology (partial FTE), and pain (partial FTE. The top 5 referral areas for FY11 to date included ophthalmology, orthopedics, pain, urology and vascular surgery. Claims processed through 12 October 2011 for all outpatient (visits and APV) and ancillary workload totaled $5,280, Qualitative Value of the Agreement: Workload provided by VAPIHCS to TAMC increases access for veterans in the Hawaiian Islands and the Western Pacific, supports the Graduate Medical Education program at TAMC, provides access to patient health care information to PCPs and specialists through JANUS for continuity of care. Service Provided: Outpatient medical, surgical and subspecialty services (clinic visits and APV); ancillary support (including pharmacy, laboratory, and radiology JEC Mandate Reporting Format Template CLAIMAMT

Installation Name: Joint Venture Review Joint Venture Performance Measures 5 PMs USED TO TRACK JV SUCCESS: 1. Efficiency in Appointing Referrals 2. Streamline work flow processes i.e. doing more with less 3. Access to Care 4. Quality of Care 5. Billing and Paying Metric (Pipeline Report) DATA SOURCES USED FOR THE PMs: 1. eDR workload and cost were utilized for the costs reimbursed from VAPIHCS to TAMC 2. eDR 3. eDR 4. Respective patient surveys 5. eDR OUTCOMES FOR EACH PM LISTED: 1. 80% of the referrals are appointed within 5 working days; 99+% are appointed within 10 working days 2. Before eDR it took 85+ minutes to make an appointment per referral; now it takes under 5 minutes 3. TAMC is able to process 100 referrals per week without any increase in staffing 4. There have not been any patient care complaints; care ranks in the 95+ percentile from a patient perspective 5. Goal is to achieve outpatient billing within 7 days from end of encounter and 21 days after inpatient stay; currently average outpatient billing is 14 days and inpatient billing is days. Paying metric is under development pending VACO release of IPAC inclusion to VistA Fee

Installation Name: Joint Venture Review Future Initiatives and/or Proposals 6 NEAR TERM (1-2 YEARS) INITIATIVES: 1. Ambulatory Surgery Center construction (groundbreaking this fall) 2. Post Traumatic Stress Disorder Recovery Rehabilitation Program (PRRP) construction (groundbreaking this fall) 3. Collaborative submitted six JIFs during the FY 2012 data call (awaiting approval notification) 4. Multi Market Site (approach to major construction for health care delivery on Oahu) 5. IDES Space Consolidation LONG TERM (>2 YEARS) GOALS / INITIATIVES / STRATEGIES: 1. Billing claims within 7 and 14 days (outpatient and inpatient respectively)/eDR CMBB/started in October Paying claims and capturing workload within 5 working days after receipt/IPAC patch to VistA Fee/started in April Unified approach to healthcare delivery on Oahu/Multi site Market study/coordinated major construction 4. Focus Tripler campus primarily for inpatient and specialty care/identify activities that move off of TAMC campus/ 5. Build new inpatient tower/identified on MILCON list/MSM study

Installation Name: Joint Venture Review Additional Information as Desired 7 Best Practices: eDR Referral Management Module Charge Master Based Billing Module Analytics Module 3 rd party collections module JANUS with GUI interface (IEHRWAYFORWARD) Sleep Lab Dialysis Unit Governance structure GME support Lessons Learned: Conflicting coding and billing guidance VA DoD workload capture within VACO FACWORK (budget) guidelines is extremely challenging Many business processes are fragmented or non existent Tendency to stay with existing manual and time-intensive workarounds then to fix the problems (resistance to change)

Installation Name: Joint Venture Review Current Issues (other than IM/IT) 8  Reduce patient traffic and parking congestion on Tripler campus  Improve access to care for both DoD and VA beneficiaries living on the west side of Oahu  Expansion of inpatient, specialty, and rehabilitation services on the Tripler campus  Coding and billing conflict