Challenges and opportunities in the next 75 years of VHA
In 1946, when Gen. Omar Bradley, the VA’s new administrator, and Maj. Gen. Paul Hawley, MD, its first medical director, charted a course for what’s now known as the “third generation” of Veterans’ health care, they launched a greatly expanded system of integrated facilities designed to care for a new wave of World War II Veterans, and for Veterans of all conflicts.
Bradley and Hawley both served brief tenures with the VA before returning to military service, but the system they designed included core elements that set it apart from other health care systems: close working relationships with major medical schools; a general hospital model that included mental health care and facilities; the expansion of access to care by either VA clinicians or community providers; a deep and varied research and development capacity; and a corps of dedicated volunteers to complement and amplify VHA’s professional staff. Over the decades, these foundations have anchored VHA, even as it has evolved and adapted to meet the health care needs of Veterans from different generations and from different conflicts. A 2018 study by the RAND Corporation, a nonprofit think tank, found the VA health care system performing better than, or similar to, nonVA systems on most measures of inpatient and outpatient care quality.
In its 75th year, VHA’s people and facilities demonstrated their ability to maintain this high-quality care while keeping patients safe and reaching out to boost their quality of life and social engagement during a global pandemic that strained the resources of health care systems around the world – a testament to the agility of VHA’s moving parts and to the dedication of its people.
To maintain this excellence, VHA must continue to adapt. Below, several of its operational leaders offer glimpses of what they see as the greatest challenges – and opportunities – that lie ahead for the people devoted to delivering quality health care and improving the lives of Veterans:
Informed by the past and focused on the future, excellence in VHA’s Office of Clinical Services is rooted in providing top-tier health care tailored to each Veteran’s unique needs. - Kameron Matthews
KAMERON MATTHEWS, MD, JD,
VA PHOTO
KAMERON MATTHEWS, MD, JD, FAAFP, Assistant Under Secretary for Health for Clinical Services and Chief Medical Officer:
The VHA Office of Clinical Services comprises 42 unique parent and sub-specialty program offices, including three transformational editions this year: the Tele-Critical Care Office, Electronic Health Record Modernization (EHRM) Functional Champion Office, and National EHRM Supplemental Staffing Unit.
Informed by the past and focused on the future, excellence in VHA’s Office of Clinical Services is rooted in providing top-tier health care tailored to each Veteran’s unique needs through continuing opportunities to:
• Define clinical strategy and policy in order to assure the provision of an enterprise, patient-driven, evidence-based standard of care and reduce unintended variability of outcomes for all Veterans
• Support and drive data-driven, outcome-oriented, and resource-efficient field-based oversight and operational improvement
• Enable and promote the professional development of clinicians and leaders in order to optimize the operational strength of the health system and delivery of world-class care to all Veterans
• Continue to cultivate meaningful partnerships at the federal, state, and local levels that enhance access to care, improve service coordination, and support the use of critical resources
• Advance suicide prevention broadly through implementation of the full public health approaches of “SP 2.0” and “SP Now”
• Employ a holistic perspective in which physical and mental health and well-being merge into a cohesive whole-health approach based on each individual’s goals and needs
• Transform health care delivery to integrate mental and physical health and focus on the Veteran, employing measurement-based care and care consistent with clinical practice guidelines.
The opportunities are key in addressing the office’s current challenges to:
• Integrate all clinical services to ensure a Veteran-centric approach to the delivery of evidence-based care
• Implement burn-out prevention strategies across the enterprise
• Advance enterprise approaches across the health system to allow for optimized usage of the new EHR
• Holistically and inclusively respond to the full range of diverse needs of each Veteran and his/her family
• Engage Veterans who are not connected to VHA care, particularly those at risk for suicide, and link them to services to support their mental health and well-being
• Embrace a culture of diversity, equity, and inclusion and implement strong practices throughout our organization so there is consistency in how we treat Veterans, their loved ones, and each other
• Provide access to care that addresses Veterans’ needs in the time, place, and manner that works the best for them.
The future of VA health care is bright. As health care across the country shifts from inpatient care toward providing effective and efficient care through more accessible, patient-centered care modalities, VA faces several challenges and has numerous opportunities to address the changing landscape. – Beth Taylor
Beth Taylor, DHA, RN, FAAN, NEA-BC
VA PHOTO
BETH TAYLOR, DHA, RN, NEA-BC, Assistant Under Secretary for Health for Patient Care Services and Chief Nursing Officer:
The future of VA health care is bright. As health care across the country shifts from inpatient care toward providing effective and efficient care through more accessible, patient-centered care modalities, VA faces several challenges and has numerous opportunities to address the changing landscape. First, considering the lightning speed in which technology is evolving, VA must be responsive, versatile, and integrated. In response, VHA’s Office of Connected Care’s integrated telehealth approach has vastly improved the accessibility of clinical services to Veterans. In 2019, VA provided approximately 2.6 million telehealth visits, and was the leading telehealth program in the United States. During the COVID-19 pandemic, telehealth visits increased from approximately 10,000 per month to more than 120,000 per month, an increase of 1,000%, providing services like technology-assisted care transition interventions for Veterans with chronic heart failure and chronic obstructive pulmonary disease. VHA remains agile and committed to utilizing digital services to improve the lives of Veterans.
Second, the U.S. Census Bureau reports that by 2030, the number of U.S. residents age 65 and over is projected to be 82 million. The projected number of Veterans age 60 and older is 11 million, and Veteran health care is often multifocal and complex, requiring a collaborative, integrated, and comprehensive model of care that facilitates meeting attainable health care goals for each older adult Veteran. Subsequently, 90 percent of Americans wish to age in place, in the least restrictive care settings possible. The VA fully supports Veterans remaining in their homes for as long as possible. In response, VA has served approximately 509,500 unique Veterans and spent approximately $3 billion on programs designed to keep Veterans in their home. Services include: Adult Day Health Care; Home Based Primary Care (HBPC); Homemaker/Home Health Aides; Medical Foster Homes (MFHs); Palliative, Hospice, and Respite Care; Skilled Home Health Care; and Veteran-Directed Care. VA continues to develop innovative strategies to provide ongoing support and improve the lives of Veterans, family members, caregivers, and survivors, as they receive care with dignity in the care settings of their choice.
The Veterans Health Administration did not solicit or approve this content
Last, according to the Bureau of Labor Statistics’ Employment Projections 2019–2029, there will be 175,900 openings for RNs per year through 2029, resulting from nurse retirements and workforce exits. As the largest professional group in VHA, at more than 113,000 who serve on the front lines and at every level of the organization, the profession of nursing is the foundation of our health care system. We will ensure that VA’s nursing workforce is capably and optimally positioned to lead all four statutory missions by optimizing nursing practice, strengthening the nursing pipeline, and supporting lifelong learning and career development.
Carolyn Clancy, MD
VA PHOTO
CAROLYN CLANCY, MD, Assistant Under Secretary for Health for Discovery, Education and Affiliate Networks (DEAN):
VHA’s collective efforts responding to COVID-19 demonstrated substantial capability in pivoting from in-person to virtual care; successful risk mitigation for Veterans living in congregate settings (e.g., nursing homes, spinal cord injury centers) through employee and patient testing and restriction of visitors; exceptional ability to execute important research studies on vaccines and treatments; and unprecedented service to the nation through VHA’s fourth mission.
The opportunities to transform health care in the future by retaining successful strategies include:
• Continued evolution of digital strategies, including remote monitoring, to provide care matched to Veterans’ needs and preferences as well as to train future health professionals • Expansion of research that translates into improved Veterans outcomes
• Enhanced and persistent focus on health equity.
Immediate challenges: addressing the impact of burnout and stress on our most important asset, our employees; expanding effective virtual and in-person mental health strategies; understanding the scale and scope of Veterans affected by long-haul COVID; and continuing to balance direct and community care to assure that Veterans consistently receive only the best care.
Gerard R. Cox, MD, MHA
VA PHOTO
GERARD R. COX, MD, MHA, Assistant Under Secretary for Health for Quality and Patient Safety:
Unintended patient harm is ubiquitous in the American health care system. In recent years, the Veterans Health Administration has committed to avoiding medical errors and reducing preventable harm to Veterans by adopting the principles and methods used by high reliability organizations (HROs). HROs achieve fewer-than-anticipated accidents or events of harm despite operating in highly complex, high-risk environments – think about commercial aviation or the nuclear power industry. They do so by cultivating leaders who are committed to reducing harm as an organizational priority, by creating a safety culture, and by continuously examining and improving their processes.
The Veterans Health Administration did not solicit or approve this content
VHA’s HRO journey presents both challenges and opportunities. Sustaining leadership commitment despite frequent turnover and competing priorities is an ever-present challenge. Transforming the culture of large, complex health care systems requires years of constant attention and focus. In particular, a culture of safety depends on empowering all employees to identify risks and speak up without fear of reprisal, which represents an ongoing challenge if organizational stakeholders unduly emphasize individual accountability or discipline in response to unintentional human error. At the same time, implementing HRO tools and principles provides VHA the opportunity to achieve our vision of “Excellence, Every Veteran, Every Time.”
The incredible dedication, flexibility, and resilience of the entire VHA workforce highlighted for the nation our commitment to high-quality health care for all of America’s Veterans - Renee Oshinski
Renee Oshinski
VA PHOTO
The incredible dedication, flexibility, and resilience of the entire VHA workforce highlighted for the nation our commitment to high-quality health care for all of America’s Veterans. In these difficult times, we opened our doors to those struggling with the COVID-19 pandemic. We supported state Veterans homes, community nursing homes, longterm care facilities, community hospitals, and alternate sites of care in multiple states. We have much to be proud of!
We will use this foundation to transform our health care delivery system in the future by building on some of our successful strategies, including:
• Embracing the new generation of Veterans and enhancing our use of telehealth modalities to improve access
• Incorporating an even larger female demographic into the Veteran population
• Embracing a new generation of VA employees and ensuring a diverse workforce that reflects our Veteran population.
Immediate challenges:
• What does the state of VA post COVID look like, and how to embrace the “new normal” in a post-pandemic era (if/when we ever get there)
• Continued balancing of in-house versus purchased care
• How to ensure preventative care gaps are met; some Veterans may have been delayed routine visits due to COVID-19 concerns
• How to build trust between leadership and staff to ensure a “just culture” and employees report errors
VHA’s response to COVID-19 demonstrated the strength and agility of an integrated health care system geographically distributed across the United States and operating as a single enterprise, and the criticality of VHA as an essential component of U.S. homeland defense and public health preparedness and response. – Deborah Kramer
Deborah Kramer, MS
VA PHOTO
DEBORAH KRAMER, MS, Acting Assistant Under Secretary for Health for Support:
VHA’s response to COVID-19 demonstrated the strength and agility of an integrated health care system geographically distributed across the United States and operating as a single enterprise, and the criticality of VHA as an essential component of U.S. homeland defense and public health preparedness and response. It also demonstrated the fragility of the public health supply chain, the shortcomings of VHA’s antiquated supply chain and support service information systems, and the increased need for VHA infrastructure recapitalization to replace our aging facilities.
Our opportunities include:
• Working collectively with our interagency partners to build and sustain a resilient public health supply chain as a critical element of national security
• Modernizing our supply chain and support system information technology systems and business practices
• Updating, renovating, and replacing our aging infrastructure to support a safer, sustainable, greener, person-centered national health care model.
Our near-term challenges include:
• Changing our approach to purchasing products to entice on-shoring of U.S. manufacturing to improve our national capability against future pandemic and biologic threats
• Undertaking multiple simultaneous major information technology investments, including deployment of a new health care record system, a new financial management system, and a new supply chain system while conducting COVID-19 response and recovery efforts
• Developing clinically driven standard designs for our new hospitals and health care clinics that are versatile, modifiable, convertible, scalable, and sustainable, and which contribute to better health care outcomes for our Veterans.
Julianne Flynn, MD
JULIANNE FLYNN, MD, Acting Deputy Assistant Under Secretary for Health for Community Care:
With implementation of the VA MISSION Act, community care has become an increasingly essential health care option for Veterans alongside care provided to Veterans within VA facilities. As Veterans have increasingly accessed community care, however, it has highlighted the necessity for greater integration with care provided in VA facilities to achieve better outcomes in the areas of customer service, cost-efficiency, care coordination, and operational agility.
The COVID-19 pandemic has demonstrated the critical importance of VA health care facilities as the backbone of Veteran health care and highlighted some of the challenges associated with care provided by community providers. For example, while community providers were and have been at times unable to provide services to Veterans over the course of the pandemic, VA facilities have been able to operate continuously. At the same time, while VA facilities have been able to quickly adjust based on the latest conditions associated with COVID-19, the highly complex contracting requirements associated with managing VA’s community care network has made it more difficult to evolve and adapt to the latest conditions, due to VA having less immediate and direct control over providers in its network.
These realities have highlighted several opportunities for improvement in order to address long-term challenges in seamlessly integrating care provided within VA facilities and in the community.
Opportunities include:
• Integrating financial management of both VA and community care
• Integrating and standardizing referral processes at the VA-facility level
• Strengthening proper utilization of community emergency care
• Simplifying the overall process associated with community care
• Implementing value-based care. Our near-term challenges include:
• Cost management associated with increased use of community care and assuring we have optimized care delivery
• Complex eligibility and payment requirements for community emergency care
• Inconsistent knowledge of VA requirements among community providers.
Jessica Bonjorni, MBA, PMP, SPHR
JESSICA BONJORNI, MBA, PMP, SPHR, Chief, Human Capital Management:
VHA’s workforce, over 377,000 people strong, is above all resilient. We have demonstrated that not only during the challenging response to the pandemic, but also throughout our 75-year history. But the expectations of the workforce are shifting, both internal to VHA and those who have not yet joined our team. VHA must be well positioned to attract and retain the best talent to care for our Veterans.
Our opportunities include:
• Investing in our workforce with the right balance of professional development, technical skill-building, and upward mobility opportunities
• Building our talent pipeline through scholarships, fellowships, and health professions training programs
• Partnering with academic affiliates, interagency partners, and private-sector health care organizations to share resources and continue to enhance the diversity and strength of our workforce.
Our challenges include:
• Competing in the ever-tightening health care labor market, where predicted shortages of some occupations and specialties will have widespread implications for the broader U.S. health care workforce
• Preparing for the future of work as expectations shift around location and timing of how and where we do our jobs
• Sustaining our workforce with an eye toward reducing burnout, effectively balancing work and home, reducing administrative burdens, and ensuring we are all able to find joy in the work we do.
