1. Veterans Health Administration Community Care Overview
Kristin J. Cunningham, PMP
Executive Office to the Deputy Under Secretary for Health for Community Care
April 25, 2019

2. Agenda History of VA Community Care Community Care Overview
Community Care Vision
VA MISSION Act of 2018
Community Care Major Initiatives

3. History of VA Community Care
1945
Hometown Program
VA sets precedent for collaboration with community
Providers through Hometown Program provider agreements
1947
1983
2007
2011
2012
2013
2014
2015
2018
2019
Department of Defense
Congress enacts the VA and DoD Health Resources Sharing and Emergency Operations Act to promote health care resource sharing between VA and DoD
Project ARCH
Congress establishes Project Access Received Closer to Home (ARCH) to increase access care for rural Veterans
Academic Teaching Affiliates
VA continues to expand care and training through academic teaching affiliates
Project Hero
Project Health Effectiveness through Resource Optimization (HERO) established as a pilot program to improve managed strategies
Indian Health Service Tribal Health Service
Reimbursement for direct care services provided to Veterans
PC3 & National Dialysis Contract
Patient-Centered Community Care (PC3) established as contracting vehicle to partner with community providers. National Dialysis Contracts to assist in purchasing care
Veterans Choice Program (VCP)
Congress expands Veterans access to community care in response to excessive wait-times and delays
Plan to Consolidate
VA submits Community Care consolidation plan to Congress
VA MISSION Act
A new law appropriates $5.2 billion in funding for VCP to continue to provide care until the new consolidated Veterans Community Care Program is operational in 2019
Community Care Network
CCN Contract Awards
Throughout its history, VA Community Care has had a number of separate programs that have become a part of the broader community care tapestry over time.

4. VA Office of Community Care – Current Roles
Our Goal for Community Care: Deliver a program that is easy to understand, simple to administer, and meets the needs of Veterans and their families, community providers, and VA staff
Key Functions and Activities:
Operate Veteran and Family Member Community Care Programs:
Operate Veterans Choice Program and other community care programs to purchase care outside of VA
Operate claims processing and customer service operations for community care programs
Contract with vendors to maintain a network of community providers
Bring Revenue to VA
Revenue cycle management - billing of private health insurance and Veteran copayments
Manage Fraud, Waste & Abuse
Programs for Veterans
Veterans Choice Program (VCP)
Traditional Community Care
State Home Per Diem Program
Indian Health Service / Tribal Health Program (IHS/THP) Reimbursement Agreements Program
Foreign Medical Program
Family Member Programs
CHAMPVA
CHAMPVA In-house Treatment Initiative (CITI)
Children of Women Vietnam Veterans
Spina Bifida Health Care Benefits
Camp Lejeune Family Member
Caregiver Support Program

5. Vision
“Achieving personalized, integrated, and high-quality care for our Veterans”
Support VA’s vision of a single, high performing network
Seamless extension of VA’s network of facilities
Meet the needs of all Veterans, VA staff, community partners, and other stakeholders

6. VA MISSION Act Key Elements
Empowers Veterans with increased access to community care
Combines multiple community care programs into a unified integrated experience
Establishes access to urgent care in the community
Expands eligibility for caregiver services to all eras of Veterans
Strengthens VA’s ability to recruit and retain clinicians
Establishes a VA Center for Innovation for Care and Payment
Creates ability for VA to match infrastructure to Veteran needs
Authorizes “Anywhere to Anywhere” telehealth provision across State lines
Internal Use Only

7. Eligibility Criteria Overview
6 Community Care eligibility criteria established by MISSION Act
Best medical interest of the Veteran
Care or services are non-compliant with VA’s standards for quality
Care or services not provided within designated access standards
Grandfathered eligibility from Veterans Choice Program
Lack of full-service medical facility
Required care or services are not offered
ACCESS
STANDARDS
Primary Care, Mental Health, Non-institutional Extended Care
Specialty Care
Drive Time
30 minutes
60 minutes
Wait Time
20 days
28 days

8. Urgent Care Overview
Establishes a new benefit for urgent (walk-in) care
Does not require pre-authorization
Veterans can go to a provider in the contracted network when it is convenient for them
Must meet specific eligibility requirements
Enrolled in VA healthcare
Received care through the VA in the last 24 months prior to the visit
Provides Veterans with access to urgent, non-emergency care (e.g. non-life threatening conditions) through the VA contracted network of community providers (Tri-West or CCN contractor)
Does not include preventive health care
Should be coordinated and managed by a primary health care provider that can address important disease prevention and treatment goals
Includes services such as: flu shot, ear infections, strep throat, pink eye

9. VA Community Care Major Initiatives
Provider Profile Management System (PPMS):
Master database of community providers and facilities
(commercial product)
Decision Support Tool (DST):
Helps identify eligible Veterans and schedule care with the Veteran’s preferred provider
(in-house product)
PPMS
DST
eCAMS & Community Care Reimbursement System (CCRS): Industry standard claims processing (commercial product)
CCN VCA PC3
Community Care Network (CCN) & Veterans Care Agreement (VCA): Established robust community provider network
eCAMS CCRS
Veterans
Community Providers
VA Staff
Enrollment System (ES):
Provides VA enrollment information on Veterans and if they meet certain eligibility criteria for community care
Health Share Referral Manager:
Referral and authorization tool for community care
(commercial product)
Other Points:
Completed approximately 30.5 million appointments in the community for Veterans in FY 2018, an increase of 64% from FY 2014
Major transformation initiatives for Community Care underway to keep up with the robust growth ES
HSRM
VHIE
VirtruPro CV
Health Records Sharing (Veterans Health Information Exchange (VHIE), VirtruPro, Community Viewer (CV):
Secure methods of exchanging information with participating community providers

10. Community Care Network (CCN)
The Community Care Network (CCN) is a new set of region-based contracts to provide health care services in the community through a contractor who builds and credentials the associated network and processes claims.
Benefits of the CCN:
Gives VA control of Veteran care and experience
VA is taking back scheduling, care coordination, and customer service functions
Gives VA convenient access to a network of qualified, credentialed providers
by having a provider network accredited by a nationally recognized accrediting body
by increasing local collaboration on network development
by having visibility into the provider network via the Provider Profile Management System (PPMS)
Gives VA a streamlined community care processes
by including more services under CCN
by no longer adjudicating claims
VA awarded the contract on Dec. 28, 2018 to manage the provider network for Region 1 of VA’s new Community Care Network (CCN), the department’s direct link with community providers that will ensure VA provides the right care at the right time to Veterans.
CCN Region 1 contract was awarded to Optum Public Sector Solutions, Inc.
Region 1 includes VA medical centers in Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, North Carolina, Pennsylvania, Rhode Island, Vermont, Virginia, Washington, D.C., and West Virginia.
Achieved in Partnership
VACO
Contractor
VAMC
Region/ VISN

11. Community Provider Resources
VA Community Provider Website
VHA Provider Updates Newsletter
VA Community Provider Webinar Series
Update with latest Community Care Network, MISSION Act, etc. fact sheets,
Post any Community Care programs and policy changes,
Provide links to external websites of interest/use for providers
A monthly e-publication for community providers that delivers scheduled updates about programs, policies and changes.
Subscribe at:
Office of Community Care Overview Series: An overview of Community Care Programs.
Accredited Topics Series: Accredited webinars with VA experts presenting on health care-related topics.
Register at:

12. Other Resources Information for Providers:
Publications of the VHA Office of Community Care
Billing Fact Sheet for VA Community Care Programs
Additional Information on Claims Payment
Community Care Claims Process Video
VHA TRAIN – No cost, Veteran-focused training for community providers
VHA Office of Community Care Announcements Digest – March 2018
VA Emergency Care Video
Viewing Claims Status
Vendor Inquiry System Fact Sheet
Vendor Inquiry System
As stated previously, please feel free to download this presentation for your future reference and to access the resources listed on this slide.

13. Questions