1. The VA Healthcare System Robert Petzel, MD Destination Digital ABMU Health Board June 23, 2016

2. U.S. Department of Veterans Affairs Veterans Health Administration (VHA) Veterans Benefits Administration (VBA) National Cemetery Administration (NCA ) 2

3. VHA is the largest integrated health care system in the U.S. 289,000+ Total VHA Employees 9.4 million Enrollees $56 Billion dollar Budget Largest medical Educator 5,000 education affiliations 10,500 Residents Second Largest Research Program ($1.5 Billion Budget) 3

4. In 1996, VA began the creation of Veterans Integrated Service Networks (VISNs) to transform VA Health Care from a “Hospital System” to a “Health System.” VHA currently has 18 VISNs. 4 152 Medical Centers 1,000 Outpatient Clinics 130 Community Living Centers 103 Domiciliaries 300 Vet Centers Hospital System to Healthcare System

5. 5 VA ensures that all eligible Veterans have access to all the health care services necessary to promote, preserve and restore their health. Services include: Primary Care Mental Health Care Preventive Care Specialty Care Care Management Inpatient and Outpatient Pharmacy Women’s Health Care Geriatrics & Palliative Care Long Term Services & Support VA Health Care Services

6. In addition to providing standard health care services, VA focuses on providing specialized health care services that are uniquely related to Veterans’ health and special needs Post-Traumatic Stress Disorder (PTSD) Care Substance Abuse Care Military Sexual Trauma Counseling Readjustment Counseling Polytrauma Care Traumatic Brain Injury (TBI) Care Spinal Cord Injury Care Post-Deployment Health Care Environmental Exposure Care Blind Rehabilitation Care Prosthetic and Sensory Aid Assistance 6 Veteran-focused Services

7. VHA as An Integrated System Systemic Integration: Single Source of Financing that Promotes Integrated Care A Common Set of Outcome Measures Governance is Uniform Across the System Multiple Program Offices Provide for Consistent Implementation Across the Entire System 7

8. Person-Centered Care Clinical Integration Professional Integration System Integration Self-Care Programs in COPD, Diabetes, Congestive Heart Failure Nation-Wide Patient Centered Care Program Shared Decision Making Goal to Provide Personalized, Proactive Patient-Driven Care All Services Coordinated Through Primary Care Teams Single Point of Entry Extensive Use of Clinical Pathways Named Care Coordinators for Many Chronic Conditions Care is Delivered by “Peer” Teams Clinical Professionals Share Responsibility and Accountability for Patient Care Outcomes The Veterans Healthcare System has a Nation-wide Set of Over 100 Clinical Measures that are Publically Reported One Set of Objectives and Strategies for the Entire Organization Incentives are Shared and Based on Measureable Outcomes 8

9. Fundamentals of Integration Integrated medical record Shared financial responsibility Shared clinical outcomes responsibility Shared principles and governance

10. 1995 Re-Invention of Veterans Health Administration Computerized Medical Records Organized in Veterans Integrated Service Networks Decentralization Emphasis on Quality and Safety Performance Measures Performance Management Visionary Leadership Ambulatory Care 10

11. VHA Principles 11 VHA’s principles are the philosophical pillars that are embedded in VHA’s vision. They are embodied in our goals, objectives, and every initiative undertaken. Data-Driven/Evidence Based Patient Centered Providing Value Continuously Improving Team Based Prevention/Population Health

12. Ambulatory Care

13. Medical Centers are Dangerous Places 12% of physician orders are not executed as written Hospital acquired infection One in 6.5 hospitalizations are complicated by drug error 240,000 patients die each year because of inpatient errors 13

14. Total Beds in Veterans Health Administration 1960Over 800,000 beds 201424,000 beds 14

15. Patient Aligned Care Teams (PACT) 15 Patient Aligned Care Teams (PACT) is VA’s care delivery model that emphasizes a team-based, patient-driven approach to care that is more comprehensive, better coordinated, and more accessible. VA is implementing PACT system-wide in an effort to become a more personalized, proactive, patient-driven health care system.

16. Our PACT with Veterans 16 PACT teams help make it easier for Veterans to be more proactive in their health care. Every patient is assigned a PACT team that they can count on to help coordinate and personalize their health care. Primary Care Provider (Physician, Physician Assistant, or Nurse Practitioner) Clinical Pharmacist RN Care Manager LPN or Medical Assistant Clerk PACT teams include a: PACT teams are supported by: Social Workers Nutritionists Behavioral Health Staff

17. Why Ambulatory Care ? Better Quality (Quality) Patients Prefer It (Satisfaction) Less Costly (Cost) More Accessible (Access) 17

18. Connected Health VA is aligning virtual care technologies to create a seamless, unified experience for Veterans across all VA patient-facing technologies. 18 VA’s virtual care technologies include: Clinical Video Telehealth Home Telehealth Store and Forward Telehealth Telemental Health Mobile Health MyHealtheVet Secure Messaging SCAN-ECHO Mobile Apps VA Point of Service Kiosks

19. Home Telehealth 19 VA’s home telehealth program aims to make the patient’s home the preferred place to receive care, whenever possible. In FY 2013, VA’s home telehealth program supported 125,000 Veterans, with 39,000 avoiding long-term institutional care as a result of these services.

20. Expanding On-the-Go Resources The “PTSD Coach” mobile app is one of the first in a series of VA and DoD jointly-designed resources to help Service members and Veterans manage their readjustment challenges and get anonymous assistance. Downloads via iTunes and Android Market 126,000+ 20

21. Support for Self-Management of Health through Education and Peer Support Veterans Health Library Research trusted Health Information and resources 21

22. Patients Sharing Health Information with their Care Teams between Visits for Improved Self-Management of Health Journal App Patients can share short videos if ordered Journal App Patients can share short videos if ordered Dementia Care Family Members share ADL information if ordered Dementia Care Family Members share ADL information if ordered PTSD Coach Patients share PTSD Check List & self- manage PTSD Coach Patients share PTSD Check List & self- manage MHPro Patients share Mental Health Outcomes if ordered MHPro Patients share Mental Health Outcomes if ordered Pain Coach Patients share information about pain & self-manage Pain Coach Patients share information about pain & self-manage Fit Heart Used for Cardiac Rehab, Patients share data & self- manage Fit Heart Used for Cardiac Rehab, Patients share data & self- manage TeleDermatology Patients share images with their care teams if ordered TeleDermatology Patients share images with their care teams if ordered Mobile Kidney Used to manage Chronic Kidney Disease, Patients share data & self-manage Mobile Kidney Used to manage Chronic Kidney Disease, Patients share data & self-manage 22

23. My HealtheVet A personal My HealtheVet account provides Veterans with 24/7 online access to a variety of tools to manage their health care. Communicate with Participating Patient Aligned Care Team Members View Appointments and Health Information Refill Prescriptions Download and Share Personal Health Record 23 www.myhealth.va.g ov

24. Secure Messaging 24 Patients and providers are able to communicate securely online through VA’s Secure Messaging accessible through My HealtheVet. In FY 2013, VA expanded its use of Secure Messaging in: Primary Care Specialty Care Surgical Care In FY 2013, VA launched Secure Messaging in: Mental Health Dentistry Rehabilitation Prosthetic Services

25. The New Health Care Workplace Patient Centered Care Delivered by Teams Continuously Improves Data-driven, Evidence-based Preventive and Population Health Provides Value 25

26. 12 Principles of Patient-Centered Care 1.Honor the Veteran’s expectations of safe, high- quality, accessible care 2.Enhance the quality of human interactions and therapeutic alliances 3.Solicit and respect the Veteran’s values, preferences and needs 4.Systemize the coordination, continuity and integration of care 5.Empower Veterans through information and education 6.Incorporate nutritional, cultural and nurturing aspects of food 26

27. 12 Principles of Patient-Centered Care (cont.) Provide for physical comfort and pain management Ensure emotional and spiritual support Encourage involvement of family and friends Ensure that architectural layout and design are conducive to health and healing Introduce creative arts into the healing environment Support and sustain an engaged workforce as key to providing patient-centered care. 27

28. Desired Outcome Integrated providers, medical centers and patients