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Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations (2012)

Chapter: 4 Initial Results of the Integration Demonstration

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Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
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4

Initial Results of the Integration Demonstration

This chapter analyzes the initial results of the effort to merge the health care centers of the Navy and the Department of Veterans Affairs (VA) in North Chicago into a single integrated health care center that improves access, quality of care, and cost effectiveness; maintains military operational readiness; maintains patient and staff satisfaction; and improves research and training opportunities. Before examining data on these outcomes, however, the chapter documents the organizational results of the merger, especially the degree of integration achieved.

These are initial results because the Captain James A. Lovell Federal Health Care Center (FHCC) had been in operation only for a year and a half when this report was drafted and is still a work in progress. For example, the electronic health records (EHRs) of the Lovell FHCC beneficiaries are not yet fully integrated, which means that inefficient workarounds are required to ensure patient safety, let alone deliver improved care through better coordination. In addition, the bulk of the effort to launch the Lovell FHCC was spent planning and implementing the basic administrative systems necessary to operate the new organization, such as payroll, accounting, computer access, and credentialing. The leadership of the Lovell FHCC plans to focus more attention in the next several years on opportunities to better integrate clinical services (Interviews).

DEGREE OF INTEGRATION

Although the term “integration” has been widely used to describe the consolidation of the North Chicago VA Medical Center (NCVAMC) and

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

the Naval Hospital Great Lakes (NHGL), it was never formally defined. Dictionary definitions of integration range from the process of joining entities together1 to the process of blending into a functioning whole.2 These definitions could apply to very different situations, for example, the simple collocation of DoD and VA clinics in the same building that share a laboratory versus a more ambitious unification of like clinics that are jointly staffed and serve both Department of Defense (DoD) and VA beneficiaries. According to the Lovell FHCC’s concept of operations, the planning assumptions supported the more expansive concept of integration. The assumptions included the following:

  • There is total integration—a single chain of command exists with single departments.
  • There are unified operating systems whenever possible.
  • There is one standard of care.
  • There is a single medical staff.
  • There is seamless transition from active duty to veteran status.
  • The two organizational cultures must blend into one.
  • The integrated facility has flexibility to adjust staffing based upon mission requirements (Lovell FHCC, 2010a, p. 15).

Although the vision of the FHCC planners was total organizational integration, including single operating systems, blended staff, and seamless care delivery regardless of beneficiary status, the implementation history in North Chicago reveals the limits to and the costs of integration, as well as some of the beneficial outcomes that might be realized from the creation of the FHCC. The limits pertain to differences between the beneficiary populations in terms of health needs and eligibility; differences in the departments’ missions in North Chicago (i.e., preparing recruits for deployment versus meeting the health needs of veterans); the limited ability of the two EHR systems to interface to allow an integrated patient record; and the need to continue to meet different standards and reporting requirements of the agencies (the VA, the Navy, and the DoD). The costs pertain to the extra time it takes to meet the requirements of two reporting chains; the duplication of functions that could not be unified; and the need to develop and maintain interoperability capabilities between separate systems (e.g., EHR systems, accounting systems, credentialing systems, drug formularies). The

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1 “1. To make a whole by bringing all parts together; unify; 2a. To join with something else; unite; 2b. To make part of a larger unit” (American Heritage College Dictionary, 3rd ed., Boston, MA, Houghton Mifflin, 1997).

2 “To form, coordinate, or blend into a functioning or unified whole: unite” (Webster’s Ninth New Collegiate Dictionary, Springfield, MA, Merriam-Webster Inc., 1987).

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

benefits were expected to be increased access to care (in terms of a greater range of services for both DoD and VA beneficiaries); better quality of care (in terms of coordination and continuity of care and access to a greater range of specialties for consultation and referral); lower operating costs (because of reduced duplication of both administrative and clinical functions and economies of scale); greater patient and staff satisfaction; and more research and training opportunities.

In this section of the chapter, the extent of integration—defined as the blending of previously separate entities into a cohesive whole—is explored. The degree of integration will be analyzed along three dimensions: (1) functional integration, (2) physician integration, and (3) clinical integration.

  • Functional integration is “the extent to which key support functions and activities (such as financial management, human resources, strategic planning, information management, marketing, and quality improvement) are coordinated across operating units so as to add the greatest overall value to the system” (Shortell et al., 2000, p. 31).
  • Physician integration is “the extent to which physicians and the organized delivery systems with which they are associated agree on the aims and purposes of the system and work together to achieve mutually shared objectives” (Shortell et al., 2000, p. 67).
  • Clinical integration is “the extent to which patient care services are coordinated across people, functions, activities, and sites over time so as to maximize the value of services delivered to patients” (Shortell et al., 2000, p. 129).

Functional Integration

Administrative services are combined and integrated to some extent at the Lovell FHCC, although the need to adhere to the different business rules and procedures of the DoD and the VA requires a certain amount of duplication and limits the realization of optimal operating efficiencies. In addition, some services, or product lines, are provided at the regional or the national level by one department or the other. For example, human resources (HR) services for the NCVAMC were provided by the Veterans Integrated Service Network (VISN) 12. In that case, the FHCC was able to establish an integrated local HR office. In other cases, integration was not possible. For example, the DoD has a national contract to provide appointment call center services at the military treatment facilities (MTFs), which means that there are separate call centers at the FHCC for DoD and VA beneficiaries. In any case, under the terms of the National Defense Authorization Act of 2010 (NDAA 2010), the FHCC cannot cut staff, even though

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

efficiencies from the integration might require fewer staff. In addition, the FHCC has not been under pressure initially to reduce costs because it is receiving the same funding—with inflation adjustments—that it did before the integration during the first several years of operation.

In early September 2009, more than a year in advance of the launching of the FHCC, the communication staffs of the Naval Health Clinic Great Lakes (NHCGL) and the NCVAMC were functionally integrated in a single Department of Communications and Public Affairs. The department was charged with meeting Navy, VA, and Lovell FHCC communication needs and designing and implementing a single, comprehensive communication plan to address the concerns of all the stakeholders (VA, 2010a). In October 2009, education and training programs were functionally integrated in a single Department of Education and Training (Fouse and Faber, 2011). In October 2010, the remaining administrative offices were combined under the Resource Directorate (Offices of HR, Financial Management, Information Resources Management, and Information Security) and the Facility Support Directorate (Offices of Communications and Public Affairs, Managed Care Operations, Protective Services, Patient Administration, Facilities Management, and Logistics). There is a single Office of Performance Improvement in the executive office. The intent was for the operations within these offices to be integrated, that is, to have one set of policies and procedures for the entire FHCC. However, as is documented in Chapter 3, the degree to which integration is possible has been circumscribed by differences in policies and procedures between the parent departments to which the FHCC must continue to adhere. For example, the departments could not agree to have one of the two inspectors general conduct inspections on behalf of both departments, so the Office of Performance Improvement must manage two inspection processes. Although there is a single HR office, there are separate units for VA and DoD personnel.

Physician Integration

The clinical task group recommended from the start that Navy active duty and VA physicians be unified through the development of a single set of medical staff bylaws and organization into single departments under a single chief medical executive. It became evident, however, that it made sense to create a separate organization for dental services because of the volume of dental work and the size of the dental staff, which also conforms to the Navy practice of having separate medical and dental commands. There is a single head of the dental directorate, a Navy captain, with a civilian VA deputy. Most of the dental services are provided at the United States ship (USS) Weeden Osborne Dental Clinic, a branch health clinic on the Navy base, because nearly 75 percent of the recruits require dental

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

work to become operationally ready for deployment (VA, 2010b). Of the 644,700 dental visits during the first year of the FHCC, 5,700 (less than 1 percent) were by veterans at the dental clinic on the west campus; the rest were at the east campus branch health clinics.

Although the clinical staffs were not officially combined until October 1, 2010, the chief medical officers of the NCVAMC and the NHCGL were already fully engaged in merging the medical staffs, a goal that they strongly supported. The merger of inpatient services in 2006 had some active duty and VA clinicians working together in advance of moving all the active duty clinicians to the west campus (Interviews). The NCVAMC and the NHCGL executive committees of nursing services began meeting jointly in May 2010 (Fouse and Faber, 2011).

Clinical Integration

Acute Inpatient Mental Health Services

The first major step toward creating an FHCC in North Chicago was to have the NCVAMC provide acute mental health services to DoD as well as to VA beneficiaries. The first DoD beneficiaries were admitted in October 2003 under a resource sharing agreement in which VA providers treated Navy mental health patients in the NCVAMC acute mental health inpatient unit and, in return, the Navy paid for the services and provided several psychiatric support staff. The NHGL was able to close its inpatient psychiatric unit and reduce overall staffing.

The NCVAMC continued to provide acute inpatient mental health services to Navy recruits and to other DoD beneficiaries on a reimbursement basis until the Department of the Treasury (Treasury) fund for the FHCC became operational in 2011. The arrangement—for example, VA providers treating VA and DoD beneficiaries—continues, although it is now paid for seamlessly from the joint Treasury fund. Beginning in fiscal year (FY) 2013, a behind-the-scenes reconciliation process will allocate costs between the VA and the DoD in proportion to their respective workloads.

Inpatient Medical, Surgical, and Pediatric Services

The next step in the integration process was to centralize all inpatient medical and surgical services for adults and children at the NCVAMC. In this case, the range of services available to VA beneficiaries was expanded because the NCVAMC did not offer inpatient surgery, only some types of outpatient surgery. Previously, VA patients needing inpatient surgery had to be referred to other area VA facilities or to community hospitals. In addition, VA and Navy inpatient beneficiaries benefit from the availability

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

of consultations with a broader range of specialists than would have been available if the Navy had built a separate hospital.

In June 2006, after four existing operating rooms were renovated and four new operating rooms with recovery beds were constructed in a vacant ward, the NHGL closed its 22 inpatient beds and became the NHCGL (VA/DoD, 2007). Under a resource sharing agreement, DoD beneficiaries needing inpatient medical, surgical, or pediatric care were admitted to the NCVAMC (obstetrical cases are still referred to the community). VA nurses and technicians staffed and operated the nursing units, but Navy physicians who admitted patients could follow them and Navy surgeons could operate on veterans as well as on DoD beneficiaries. The NCVAMC was reimbursed as a TRICARE network provider. Because the NCVAMC was not an MTF, however, DoD beneficiaries were subject to copayments that they did not have to pay to receive services at the NHGL.

Surgical services were essentially integrated before the FHCC came into being formally on October 1, 2010, but on that date a single line of authority, with a single head of the department of surgery under a single chief medical executive, was formally established. The funding arrangement also changed. All inpatient services—mental health, general medical, surgical, and pediatric—are funded by the joint Treasury fund, and beginning in FY 2013, a reconciliation process will allocate costs between the VA and the DoD in proportion to their respective workloads. In addition, as part of the 5-year demonstration project, DoD beneficiaries are not being charged for copayments, just as if they were going to an MTF.

The surgical services offered at the FHCC currently are general surgery, dermatology, otolaryngology, gynecology (women’s health), ophthalmology, orthopedics, podiatry, and urology (Lovell FHCC, 2012b). Physicians are both active duty servicemembers and VA civilians, and in many cases they treat both VA and DoD beneficiaries.

Emergency and Urgent Care Services

The NCVAMC emergency department (ED) was renovated and expanded from a 6-bed open floor plan to a 15-private-room configuration at the same time as the new surgical suites were constructed. In October 2006, all emergency services for DoD beneficiaries were transferred to the NCVAMC, and the NHGL (now the NHCGL), closed its ED. DoD beneficiaries benefited from having access to an ED staffed by board-certified emergency physicians in place of the internists who staffed the NHGL ED. Like DoD inpatients, they also had access to consultations from a greater range of specialties. VA beneficiaries benefited from having access to an expanded and more up-to-date ED, including privacy and gender-specific considerations for female patients. Originally, emergency/urgent care services

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

for DoD beneficiaries were reimbursed to the NCVAMC as a TRICARE network provider. Currently, services for both DoD and VA beneficiaries are paid for from the joint Treasury fund and the costs will be allocated between the departments through the reconciliation process.

Women’s Health Clinic

A new Women’s Health Center was built as part of the ambulatory care center (ACC). This clinic was designed to serve both women veterans and DoD beneficiaries. The center provides comprehensive primary care and gender-specific services in a separate, self-contained clinic space to provide an environment that is secure and supportive. Using Joint Incentive Fund (JIF) monies, the VA hired gynecology staff (replacing a lost Navy physician billet); purchased digital mammography equipment and gender-specific equipment, such as a stereotactic biopsy device and a culposcopy unit; and hired two wellness/case management nurses. Without the combined veteran and military beneficiary populations, the VA would not have had the critical volume to support onsite mammography services or been able to maintain accreditation.

Dental Services

Tentative plans to combine the dental clinic for Navy staff at the NHGL (Building 200H) with the VA dental clinic on the west campus were abandoned when the square footage of the ACC was cut in half. Instead, the Navy dental clinic was moved to the Zachary and Elizabeth Fisher Medical and Dental Clinic on the east campus, which also provides medical care to active duty staff. There is no sharing of services, although the VA clinic does not have specialists such as endodontists and periodontists who are part of the staff at the USS Osborne. This is because the dentists at the USS Osborne are already booked to capacity to ensure that the recruits are ready for deployment.

Ancillary Services

In 2003, rather than renovate and expand its blood donor center to accommodate increasing volume, the NHGL agreed to renovate unused space in the NCVAMC for a new blood donor center. Renovating space in the NCVAMC saved $3 million in new construction costs. In lieu of paying for rent and utilities, the NHGL agreed to provide the NCVAMC approximately 415 units of blood products annually, worth approximately $47,000, or the equivalent of $14 per square foot (Harnly, 2005).

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

Other ancillary services, such as laboratory and radiology, were centralized as part of the move into the ACC that began in December 2010.

Outpatient Services

After inpatient and emergency services were consolidated at the NCVAMC in 2006, the renamed NHCGL continued to provide outpatient services for DoD beneficiaries at the former hospital building until December 2010, when the clinics were moved to the new ACC.

Discussion

Initially, the Navy was going to build the ACC for its beneficiaries and the VA was going to continue to provide outpatient services to veterans from its existing facilities (VA/DoD, 2002). Soon, however, the concept of integrating at least some outpatient services or clinics was adopted, in which both VA and DoD beneficiaries would be treated by either VA or Navy providers, depending on who was available. It was recognized that some services were unique to each department and should not be integrated. For example, the NCVAMC had long-term residential programs for veterans, such as the nursing home, the domiciliary, and residential rehabilitation treatment programs, which were not available to DoD beneficiaries. It was also agreed that the NCVAMC would staff and operate the inpatient mental health unit; the inpatient medical, surgical, and pediatric nursing units; and the ED. The Navy, for its part, had clinics in place on its base to medically process in and provide efficient health care for a large volume of enlisted recruits and students, and it did not make sense to move or to integrate them, except for ancillary services. It also did not make sense to create a joint pediatric clinic because the VA does not have pediatric beneficiaries.

Prior to the integration of outpatient services in late 2010 and early 2011, the NHCGL offered 20 outpatient medical clinics in 200H and the NCVAMC offered 24 medical specialties and subspecialties (Table 4-1) that were candidates for clinical integration. Although the consistent vision of local leaders was to unify clinical as well as administrative staff—to “allow a patient who could be a veteran, active duty servicemember, or family member to be treated by a Navy surgeon, a VA nurse, and a Navy technician” (DoD/VA, 2008)—pragmatic considerations dictated different degrees of staff and clinic integration in outpatient services. One factor was the reduced size of the ACC, which necessitated greater use of space in the VA hospital building (Interviews). Plans to integrate primary care services and dental clinics were changed because it no longer made sense to move or expand the existing VA primary care and dental clinics to serve both populations (Interviews). Instead, the Navy has a separate primary care

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

TABLE 4-1 Projected Fiscal Year 2011 Lovell Federal Health Care Center Full-Time-Equivalent Clinical Providers by Specialty (North Chicago Veterans Affairs Medical Center)/Clinic (Naval Health Clinic Great Lakes)

Specialty/Clinic NCVAMC NHCGL
Audiology 6.09 1.00
Cardiology 1.40 0.95
Dermatology 0.13 1.90
Endocrinology 1.97
Family Practice 6.00
Gastroenterology 3.63
General Surgery 2.11 2.90
Gynecology 1.05 2.00
Immunizations 1.00
Infectious Disease 0.23
Internal Medicine 19.15 5.95
Mental Health Clinic 49.01 11.00
Nephrology 0.70
Neurology 2.64 0.50
Occupational Therapy 0.98
Oncology 0.89
Ophthalmology 1.40 1.00
Optometry 1.88 1.00
Orthopedic 3.15 3.90
Otolaryngology 0.55 1.90
Outpatient Nutrition 2.00
Pediatric 3.89
Physical Therapy 5.95 8.00
Podiatry 1.43 2.00
Primary Care Employee Health 1.00
Pulmonary Disease 2.50
Rheumatology 1.00
Substance Abuse 3.00
Urology 1.10 0.90
Total 109.94 60.79

NOTE: This table pertains to the clinical personnel (e.g., physicians, psychologists, podiatrists, audiologists, nutritionists, and physical and occupational therapists) at the NHCGL’s 200H facility who moved to the ambulatory care center on the west campus, not the clinical personnel in the branch health clinics who remained on the east campus (i.e., at Naval Station Great Lakes) or Veterans Administration personnel providing veteran-only services (e.g., long-term care, domiciliary care, and residential rehabilitation). It also does not include inpatient and emergency room providers. NCVAMC = North Chicago Veterans Affairs Medical Center; NHGL = Naval Hospital Great Lakes.
SOURCE: Lovell FHCC, 2010b.

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

clinic in the new ACC building, and all dental services for DoD beneficiaries remained on the east campus. Another factor was the provision in the executive agreement (EA) that VA providers can be seen by DoD providers, and vice versa, only if there is excess capacity. At the time of the integration of outpatient services, only dermatology and otolaryngology had excess capacity and were fully integrated in terms of staff and patients for regular scheduling purposes; other clinical services were shared on an ad hoc basis when there were openings.

The plan that evolved and was eventually implemented resulted in a variety of organizational arrangements for outpatient services. As mentioned already, some of the health delivery sites on the Navy base continued to do what they did before, the main difference being that the Navy civilians working there became VA employees and administrative and some clinical support services (e.g., laboratory) were centralized. These branch health clinics include the USS Red Rover, which screens recruits for medical and dental problems as they arrive and provides immunizations, eyeglasses, and women’s health services; the USS Weeden Osborne, which provides dental services to recruits, a large percentage of whom have dental deficiencies; the USS Tranquility, which provides medical services to recruits and active duty members of the Recruit Training Command (RTC) staff; and the Fisher Clinic, which provides primary medical and dental care to the active duty staff at the Naval Station Great Lakes (NSGL).

As already noted, the primary care clinics remain separate and are staffed separately by DoD and VA providers. In the DoD primary care clinic (and the pediatric clinic), DoD providers treat DoD beneficiaries and use the Armed Forces Health Longitudinal Technology Application (AHLTA) to document visits while VA providers treat veterans and use the Veterans Health Information Systems and Technology Architecture (VistA). Having the DoD primary care clinic use AHLTA ensured that information affecting deployability, such as immunizations, would be available immediately, especially if the interoperability solutions under development were not operational when the FHCC became operational. The existing VA primary care clinic was little affected because providers did not need to access or document information in AHLTA except for dual eligible retirees. DoD providers treating dual eligible beneficiaries could view their VA health records through the Bi-directional Health Information Exchange, although this is a time-consuming process and is not always done (Interviews).

The women’s clinic has both DoD and VA providers, but DoD providers treat DoD beneficiaries and use AHLTA while VA providers treat veterans and use VistA. The women’s clinic is integrated in another way, however, because it also provides primary care and onsite radiology.

In addition to space considerations, the different policies concerning outpatient scheduling and standards of the VA and the Bureau of Medicine

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

and Surgery (BUMED) also support having separate primary care clinics. For example, the VA requires an appointment within 7 days, and BUMED requires one within 14 days.

Many VA clinicians were part-time (see Table 4-1) at the NCVAMC, available only several times a week. The Navy had a full-time gynecologist, orthopedist, otolaryngologist, dermatologist, and urologist. Although only dermatology and otolaryngology are formally integrated, DoD beneficiaries are seen by VA specialty providers and vice versa on a space-available basis. DoD beneficiaries therefore benefit from access to VA providers with specialties not present among Navy providers, including pulmonary critical care, infectious diseases, gastroenterology, nephrology, endocrinology, rheumatology, and hematology/oncology (Table 4-1). Veterans benefit from the access provided by the expanded clinical staffing. Navy inpatients and ED users also benefit from access to consultations from VA specialists (Interviews).

The pharmacy was designed to be integrated, where the DoD and the VA pharmacists could fill prescriptions for both TRICARE enrollees and veterans. This arrangement was dependent on an orders portability solution for pharmacy, which was not ready for use when the ACC opened and will not be ready until FY 2014, at the earliest. Instead, DoD pharmacists mostly serve TRICARE beneficiaries, using the DoD’s AHLTA, while the VA pharmacists mostly serve veterans, using the VA’s VistA.

Similarly, the efficiency of combining specialty clinics in the ACC on the west campus has been reduced by lack of interoperability between the two EHR systems. The plan was for clinical notes and information about laboratory tests, radiology, and prescriptions for recruits and other TRICARE enrollees seen in the ED and specialty clinics to be entered into VistA and for the information to be automatically populated in AHLTA. Quick, if not instant, entry into AHLTA is required because active duty servicemembers may be transferred on short notice and must take complete medical records with them. The information also might affect whether they are considered to be medically ready to be deployed. These capabilities were not ready for use when the ACC opened, necessitating the use of manual workarounds to duplicate the information entered into VistA into AHLTA, which has significantly affected productivity because of the increased paperwork load.

Conclusions Concerning Degree of Integration

The final organization of the FHCC displays various degrees of integration across services (see Table 4-2). Some services are VA only, such as long-term care and domiciliary, which only veterans can receive. Some are Navy only, such as the branch health clinics on the east campus that serve only active duty servicemembers. Inpatient mental health, medicine,

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

TABLE 4-2 Clinical Integration Status of the Lovell Federal Health Care Center

Directorate Department Division Clinical Section
Patient Care
Medicine
Inpatient Acute/Intensive Care Unit
Emergency
Medical Specialties
Cardiology
Dermatology
Endocrinology
Gastroenterology
Hematology/Oncology
Infectious Disease
Nephrology
Neurology
Pulmonology
Rheumatology
Ambulatory Medical Care
Primary Care
Family Practice
Internal Medicine
Pediatrics
Veterans’ Primary Care
Special Medical Exams
DoD Specialty Exams
VA Specialty Exams
Surgery
Perioperative
Anesthesia
Operating Room
Surgical Subspecialties
General Surgery

Gynecology/Women’s Health

Ophthalmology
Optometry
Orthopedics
Otolaryngology
Podiatry
Urology
Mental Health
Acute Inpatient
Outpatient/Consultation Services
Consultation Liaison

Mental Health/Life Skills

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×
Affiliation of Head Campus Patients (VA, DoD, or Both) Clinical Providers (VA, DoD, or Both) EHR System
VA
VA
VA West Both Both VistA
VA West Both VA VistA
DoD
VA West Both Both VistA
DoD West Both Both VistA
VA West Both VA VistA
VA West Both VA VistA
VA West Both VA VistA
VA West Both VA VistA
VA West Both VA VistA
VA West Both VA VistA
VA West Both VA VistA
VA West Both VA VistA
DoD
DoD
DoD West DoD Both AHLTA
DoD West DoD Both AHLTA
DoD West DoD Both AHLTA
VA West VA VA VistA
DoD
DoD West DoD Both AHLTA
VA West Both Both VistA
VA
VA
VA West Both VA VistA
VA West Both Both VistA
DoD
DoD West Both Both VistA
DoD West Both Both Both
VA West Both Both Both
DoD West Both Both VistA
DoD West Both Both VistA
DoD West Both Both VistA
VA West Both Both VistA
DoD West Both Both VistA
VA
VA West Both VA VistA
DoD
VA West Both VA VistA
DoD Both Both Both Both
Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×
Directorate Department Division Clinical Section
     

Mental Health Case Management

     

Psychosocial Rehabilitation and Recovery Center

    Special Programs
      Homeless
     

Posttraumatic Stress Disorder

     

Substance Abuse Rehabilitation Program/Addiction Treatment Program

     

Vocational Rehabilitation

Patient Services      
Ancillary Services
Audiology and Speech Pathology
Nutrition and Food Services
Pastoral Services  
Pharmacy  
Prosthetics  
Rehabilitation
Kinesiotherapy
Occupational Therapy
Physiatry/Electromyography
Physical Therapy
Geriatrics and Extended Care
Community Living  
Geriatric Medicine  
Home and Community-Based Care
Diagnostic Services
Blood Donor Processing
Imaging and Radiation Safety
Pathology and Laboratory
Education and Training
  Clinical Education  
  Employee/Military Education
Dental
Dental Services
  General Dentistry
USS Osborne
USS Red Rover
Fisher Clinic
Dental Prosthetic Care    
Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×
Affiliation of Head Campus Patients (VA, DoD, or Both) Clinical Providers (VA, DoD, or Both) EHR System
VA West VA VA VistA
VA West VA VA VistA
 
VA
VA West VA VA VistA
VA West VA VA VistA
 
DoD West Both Both Both
 
VA West VA VA VistA
VA
VA
VA West Both Both VistA
VA West Both VA VistA
VA West Both Both VistA
DoD West Both Both Both
VA West Both VA VistA
VA
VA West Both VA VistA
VA West Both VA VistA
VA West Both VA VistA
DoD West Both Both VistA
VA
VA West Both VA VistA
VA West Both VA VistA
VA West VA VA VistA
DoD
DoD West Both DoD DBSS
VA Both Both Both Both
VA Both Both Both VistA/CoPath
DoD
VA West Both Both NA
DoD West NA Both NA
DoD
DoD
VA West VA VA VistA
DoD East DoD DoD AHLTA
DoD East DoD DoD AHLTA
DoD East DoD DoD AHLTA
DoD East DoD DoD AHLTA
Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×
Directorate Department Division Clinical Section
Fleet Medicine
Fisher Clinic
  Primary Care
Optometry
Sick Call
  Administration
   

Active Duty Specialty Examinations/Overseas Screening

    Medical Liaison
   

Periodic Health Assessments/Physical Examinations

    Records
USS Tranquility  
Primary Care
  Recruit Primary Care
  Special Physicals Staff Primary Care
Preventive Medicine
Recruit Evaluation Unit

SMART (Sports Medicine and Rehabilitation Therapy)

USS Red Rover
Audiology
Immunizations
Medical Assessment
Optometry
Women’s Health
Occupational Health and Medicine
  Occupational Medicine

Hearing Conservation B237

Immunizations 133EF
Immunizations B237

Occupational Health East B237

Occupational Health West B133CA

Preventive Medicine

Preventive Medicine B1007

Preventive Medicine B237

NOTES: DBSS = Defense Blood Standard System; CoPath is an anatomic pathology system used by the Military Health System. SOURCE: Information provided by the Lovell FHCC to the IOM committee.

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×
Affiliation of Head Campus Patients (VA, DoD, or Both) Clinical Providers (VA, DoD, or Both) EHR System
DoD
DoD
DoD
DoD East DoD DoD AHLTA
DoD East DoD Both AHLTA
DoD
DoD East DoD NA AHLTA
 
DoD East DoD NA AHLTA
DoD East DoD NA AHLTA
 
DoD East DoD NA AHLTA
DoD
DoD
DoD East DoD DoD AHLTA
DoD East DoD DoD AHLTA
DoD East DoD DoD AHLTA
DoD East DoD DoD AHLTA
DoD East DoD DoD AHLTA
DoD East DoD DoD AHLTA
 
DoD
DoD East DoD DoD AHLTA
DoD East DoD DoD AHLTA
DoD East DoD DoD AHLTA
DoD East DoD DoD AHLTA
DoD East DoD DoD AHLTA
VA
DoD
DoD East Both Both AHLTA
 
DoD East DoD Both AHLTA
DoD East DoD Both AHLTA
DoD East DoD Both AHLTA
 
DoD West VA Both VistA
 
DoD
DoD West DoD Both AHLTA
 
DoD East DoD Both AHLTA
Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

surgery, and emergency services are integrated, although Navy surgeons generally operate on DoD beneficiaries and VA surgeons on veterans. The main problem is the lack of EHR system interoperability, which requires manual workarounds to enter treatment information entered into VistA into AHLTA, which has reduced productivity.

For several reasons (discussed above), primary care services are separate. Specialty clinics are integrated to the extent that they have excess capacity; that is, there are not enough VA patients to fill the time of the VA providers or enough DoD patients to fill the time of the DoD providers. Only dermatology and otolaryngology routinely schedule patients regardless of the department affiliation of the beneficiary or who employs the provider.

Lack of interoperable EHR systems has significantly hindered the capacity to deliver integrated care, and the workarounds required to integrate patient information have reduced productivity. The lack of a joint or an interoperable EHR system that supports seamless clinical workflow for both VA and DoD beneficiaries is the largest contributor to the Lovell FHCC’s inability to operate combined ACCs and to gain the full benefit of an integrated medical staff.

The composition and scope of outpatient clinics and provider specialties was primarily shaped by the existing staffing of the NHCGL and the NCVAMC. These were rationalized into a unified structure as much as possible, but the current organization is probably not ideally designed or sized to meet the current demand for health care services. Lovell FHCC leaders plan to integrate clinical services fully but decided to delay implementation until an interoperable EHR system is available and after completing an assessment of the changing clinical demand.

Theoretically, the merger of a VA and a military center should result in efficiencies, administrative and possibly clinical. The Lovell FHCC experience provides some insights into why the observed efficiencies will be less than expected. First, Congress placed restrictions on the degree of and legislatively mandated policies that limit efficiencies, such as the extent of staff reductions that can be achieved. Second, both departments have required the Lovell FHCC to maintain duplicative systems, business rules, standards, and reporting requirements, creating a fair degree of redundancy, administrative overhead, and duplication of effort. Third, the VA/DoD Health Resources Sharing and Emergency Operation Act of 1982 only allows the sharing of services when a facility has excess capacity, even though it may be more productive overall to combine fully utilized services.3

__________________

3 According to the act, providing health care for the other department’s beneficiaries may not “adversely affect the range of services, the quality of care, or the established priorities for care provided to the primary beneficiaries of the providing department.”

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

Funding from the VA/DoD Joint Incentive Program, known as JIF awards, has played an important role in extending the range of services that could be provided by the Lovell FHCC. The JIF grants funded the start-up and initial operating costs for 2 years of services that did not exist at either the NHCGL or the NCVAMC. During the pre-2010 joint venture phase, the centers received eight grants totaling nearly $8.5 million (see Box 3-1 for brief descriptions). In addition, $111 million was provided to the VA and the DoD enterprise information technology (IT) programs to identify and fund the development of software that would enable critical information entered in one EHR system to be viewed and manipulated in the other EHR system, although, as documented in Chapter 3, most of the software was not ready for use when the FHCC began operations in late 2010 and early 2011.

The JIF program was also used to meet the emergency need for a pharmacy workaround when the interoperability capability for preventing negative drug interactions and allergic reactions was not ready for use at the time the ACC was activated. The JIF program was the only way for the DoD and the VA to jointly fund health care until the Treasury account for the Lovell FHCC was established in 2011. The award, which was supposed to be a 1-year stopgap, is being extended at $1 million a year until the joint pharmacy capability is developed as part of the VA/DoD integrated EHR initiative, currently scheduled to be ready in FY 2014.

In sum, the example of the Lovell FHCC demonstrates that it is possible to merge an MTF and a VA medical center (VAMC) into a single organization, although, as Chapter 3 documents, it was a lengthy and costly process. The start-up costs were substantial, including hundreds of meetings at all levels of the DoD (the Navy and the Office of Health Affairs) and the VA; almost $10 million in direct JIF awards; more than $100 million worth of IT software development to make the two EHR systems work together (a partial success); and $13 million to upgrade the NCVAMC’s surgical facilities. Future FHCCs might be able to avoid some of these costs by adopting the solutions developed at the Lovell FHCC or, where solutions were suboptimal or failed, spend their time and resources finding other solutions.

The Lovell FHCC example also shows that there are serious limits on the extent to which such a joint health care center can be unified internally if it has to perform as an MTF for DoD purposes and as a VAMC for VA purposes. This in turn constrains the extent to which the Lovell FHCC can provide coordinated care to patients or increase efficiencies through running one instead of duplicate programs and administrative systems. To the extent that problems developing EHR interoperability software at the Lovell FHCC motivated the department secretaries of the DoD and the VA to decide to develop a single, joint EHR system, the Lovell FHCC merger

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

experience will have eliminated a critical obstacle to VA/DoD health services integration.

PERFORMANCE MEASURES

The April 2010 EA establishing the Lovell FHCC addressed the 12 areas of agreement that the NDAA 2010 required. One of the 12 agreement areas was performance benchmarks. The DoD and the VA agreed on 15 benchmarks and how to measure their attainment in what is called the Integration Scorecard.

Integration Scorecard

The 15 benchmark measures are

  1. Patient satisfaction measures meet VA and DoD benchmarks
  2. Maintenance of military medical readiness
  3. Stakeholders Advisory Council determination that the FHCC meets both DoD and VA missions
  4. Successful annual Comptroller General review
  5. Validation of fiscal reconciliation by annual independent audit
  6. VA clinical and administrative performance measures exceed mean for all VA medical centers
  7. Meet all access to care standards
  8. Evidence-based health care measures meet or exceed the VA and DoD mean
  9. Satisfactory clinical and facility inspection outcomes from external oversight/accreditation groups
  10. Officer promotion/retention and enlisted advancement/retention meet or exceed Navy mean
  11. Information Management/Information Technology (IM/IT) implementation timeline met and no impact on patient safety
  12. Staff satisfaction and other appropriate measures identified VA and DoD as benchmarks
  13. Relative value unit (or RVU)/relative weighted product (or RWP)/dental weighted value (or DWV) production meets business plan targets
  14. Maintain pre-FHCC academic and clinical research missions
  15. Trainee satisfaction as measured by the Learner Perception Survey

Each of the benchmarks is based on one or more measures. For example, patient satisfaction is derived from two measures, one from a VA survey of patients, the other from a DoD survey of patients. In total, there

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

are 37 measures for the 15 benchmarks. Each measure is reported on a 5-point scale according to a 117-page technical manual. The scale ranges from highly successful (5), to very successful (4), successful (3), unsuccessful (2), and highly unsuccessful (1).

Most of the integration benchmark results are updated monthly. Some, such as the annual audit reports and facility inspection results, are updated less often.

As of June 2012, most scores had stayed the same as they were at baseline: for example, there were 23 fives (highly successful) compared with 19 at baseline; 5 fours (very successful) compared with 7 at baseline; 6 threes (successful) compared with 6 at baseline; 1 two (unsuccessful) compared with 2 at baseline; and 1 one (highly unsuccessful) compared with a 0 at baseline (one measure, officer retention, did not have a baseline score). The scores for some measures have varied, but rarely more than one point up or down or for more than 1 or 2 months.

Two measures scored a one or a two in June 2012, which are less than successful scores: (1) the DoD component of evidence-based health care and (2) IM/IT implementation. The failure to achieve evidence-based health care goals is attributed to vacancies in the active duty provider workforce due to rotation and deployment. The delay in IM/IT has been documented in Chapter 3 of this report as well as in Government Accountability Office (GAO) reports (see below).

Most of the performance measures are specific to the VA or to the DoD rather than to the integrated performance of the FHCC, because the main purpose of the performance benchmarks was to address the concerns of the respective departments that the Lovell FHCC experiment might fail badly before the end of the 5-year demonstration period (Interviews). Also, one measure that is critical to integration—that is, the implementation of joint IM/IT capabilities—has not been successful, as noted in Chapter 3, and is unlikely to improve further until parts of the new EHR system being developed jointly by the DoD and the VA become available, beginning with a joint pharmacy program scheduled to be operational in 2014.

Integration Areas

Integration benchmarks was 1 of the 12 integration areas identified in the April 2010 EA, in accordance with the requirements of the NDAA 2011. The 12 areas that had to be addressed in the EA were

  1. Governance structure
  2. Patient priority system
  3. Fiscal authority
  4. Workforce management
Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×
  1. Property
  2. Contingency planning
  3. Quality assurance
  4. IM/IT
  5. Research
  6. Integration benchmarks
  7. Reporting requirements
  8. Contracting

The committee was not asked to report on progress in the 12 integration areas, but the NDAA 2010 directed the GAO to do so annually. In its latest report, issued in June 2012, the GAO found that 6 of the 12 were fully implemented (governance structure, patient priority system, contracting, research, quality assurance, and contingency planning), compared with 4 in 2011. Integration benchmarks was one of the 5 areas “in progress” (the others were reporting requirements, workforce management, property, and fiscal authority). The GAO found that one area—IM/IT—was delayed, requiring workarounds that were resulting in additional costs for the Lovell FHCC in terms of reduced provider productivity and increased administrative burden. The GAO found, as did this committee, that the FHCC has not quantified the extra costs, but that it has engaged the Center for Naval Analyses to assess costs and document any savings from integrated patient care (GAO, 2012).

OUTCOMES

The goals of the Lovell FHCC leadership, taken from the April 2010 EA, are to “improve access, quality, and cost effectiveness of health care delivery for the beneficiaries” of both the DoD and the VA (DoD/VA, 2010, pp. 1–2). The EA says that the FHCC should also promote “operational readiness, continued employee benefits, continued education of health care professional trainees, and approved research projects” (DoD/VA, 2010, p. 1). Patient satisfaction is another goal stated in various places. This section of the chapter analyzes the impact of the Lovell FHCC on these outcome goals to the extent they are known at the 1.5-year mark.

Some but not all of the goals of creating the Lovell FHCC are addressed by the integration benchmarks. These are access, quality of care, operational readiness, patient and provider satisfaction, and research and training opportunities. This section of the report includes summaries of what is known about outcomes in these goal areas, as well as of cost effectiveness, the goal not included in the integration benchmarks.

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

Access

The Integration Scorecard shows that access to VA primary care has scored a 5 on a 5-point scale every month since October 2010. Access to DoD primary care has not scored as well. It scored 5s during the early months, but has scored a mix of 2s (3 months), 3s (4 months), and 4s (4 months) since then.

TRICARE patient ratings of “getting needed care” at the FHCC increased from 64 (on a 100-point scale) in FY 2006 to 86 in FY 2010, then fell to 79 in FY 2011, the first year of the full integration (see Figure 4-9 in a later section of this chapter).

Quality of Care

Like all health care delivery systems, the Lovell FHCC reports on measures of quality, such as the Healthcare Effectiveness Data and Information Set (HEDIS) developed by the National Committee for Quality Assurance, the Surgical Care Improvement Project (SCIP), and ORYX, a set of hospital performance measures developed by the Joint Commission.

Quality of care at the FHCC as measured by HEDIS, ORYX, and SCIP scores does not indicate a significant change in either the positive or the negative direction. Generally, HEDIS scores improved for several years before the 2010 merger before declining slightly in 2011, the first full year of FHCC operation (Figures 4-1 through 4-3). Only 2 of the 18 ORYX measures reported declined from 2010 to 2011 (from 100 to 95 percent in each case) (Figures 4-4 through 4-6). Of the 9 SCIP measures, 4 were the same in 2010 and 2011, 3 were higher, and 2 were lower (from 99 to 97 percent and from 100 to 93 percent) (Figure 4-7).

In September 2011, the Lovell FHCC was 1 of 405 U.S. hospitals named a top performer on key quality measures by the Joint Commission (Joint Commission, 2011).

Quality of Inpatient Heart Attack Patient Care

The Lovell FHCC’s ORYX scores for heart attack patients were 100 percent in 2008 and remained at that level in 2010 and 2011 (Figure 4-4).

Quality of Inpatient Heart Failure Patient Care

The Lovell FHCC’s ORYX scores for heart failure patients were also 100 percent in all 3 years, with one exception: the percentage of heart failure patients given discharge instructions dipped to 91 percent in 2010 before returning to 100 percent in 2011 (Figure 4-5).

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

image

FIGURE 4-1 Selected HEDIS results for the Lovell Federal Health Care Center, 2005–2011 (percentage of patients) (Part 1).
NOTE: Results for 2009 are not included because composite measures were used that year rather than individual measures. BP = blood pressure; HEDIS = Healthcare Effectiveness Data and Information Set.
SOURCE: Provided by Lovell FHCC.

image

FIGURE 4-2 Selected HEDIS results for the Lovell Federal Health Care Center, 2005–2011 (percentage of patients) (Part 2).
NOTE: Results for 2009 are not included because composite measures were used that year rather than individual measures. AMI = acute myocardial infarction; BP = blood pressure; DM = diabetes mellitus; HBA1c = hemoglobin A1c (blood test for diabetes); HEDIS = Healthcare Effectiveness Data and Information Set; LDL-C = low-density lipoprotein cholesterol.
SOURCE: Provided by Lovell FHCC.

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

image

FIGURE 4-3 Selected HEDIS results for the Lovell Federal Health Care Center, 2005–2011 (percentage of patients) (Part 3).
NOTE: Results for 2009 are not included because composite measures were used that year rather than individual measures. HEDIS = Healthcare Effectiveness Data and Information Set; LDL-C = low-density lipoprotein cholesterol.
SOURCE: Lovell FHCC.

image

FIGURE 4-4 ORYX results for heart attack patients at the Lovell Federal Health Care Center, 2008–2011 (percentage of patients).
NOTE: Results for 2009 are not included because composite measures were used that year rather than individual measures. AM-1 = heart attack patients given aspirin at arrival; AM-2 = heart attack patients given aspirin at discharge; AM-5 = heart attack patients given beta blocker at discharge; AM-6 = heart attack patients given beta blocker at arrival; AM-10 = statin prescribed at discharge.
SOURCE: Lovell FHCC.

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

image

FIGURE 4-5 ORYX results for heart failure patients at the Lovell Federal Health Care Center, 2008–2011 (percentage of patients).
NOTE: Results for 2009 are not included because composite measures were used that year rather than individual measures. HF-1 = percentage of heart failure patients given discharge instructions; HF-2 = percentage of heart failure patients given an evaluation of left ventricular systolic function; HF-3 = percentage of heart failure patients given ace inhibitor or arb for left ventricular systolic dysfunction; HF-4 = percentage of heart failure patients given smoking cessation advice/counseling. SOURCE: Lovell FHCC.

Quality of Inpatient Pneumonia Patient Care

In 2011, most of the Lovell FHCC’s ORYX scores for patients with pneumonia were 100 percent, either the same or higher as they were in 2010. Two of the nine measures dipped, from 100 percent in 2010 to 95 percent in 2011 (Figure 4-6).

Quality of Inpatient Surgical Care

Five of the Lovell FHCC’s seven SCIP scores in 2011 were the same or higher than in 2010, at or near 100 percent. Two measures fell: the overall rate of prophylactic antibiotic received within 1 hour prior to surgery (from 99 percent to 97 percent), and the overall rate of prophylactic antibiotic discontinuation with 24 hours after surgery (from 100 percent to 93 percent) (Figure 4-7).

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

image

FIGURE 4-6 ORYX results for pneumonia patients at the Lovell Federal Health Care Center, 2008–2011 (percentage of patients).
NOTE: Results for 2009 are not included because composite measures were used that year rather than individual measures. PN-1 = pneumonia patient oxygenation assessed; PN-2 = pneumonia patients assessed and given pneumococcal vaccination; PN-3a = blood cultures were performed within 24 hours prior to or 24 hours after hospital arrival for patients who were transferred or admitted to the intensive care unit (ICU); PN-3b = initial emergency room blood culture was performed prior to the administration of the first hospital dose of antibiotics; PN-4 = smoking cessation advice/counseling given; PN-5c = initial antibiotic received within 6 hours of hospital arrival; PN-6a = initial antibiotic selection for community-acquired pneumonia (CAP) in immunocompetent ICU patient; PN-6b = initial antibiotic selection for CAP immunocompetent non-ICU patient; PN-7 = pneumonia patients assessed and given influenza vaccination.
SOURCE: Lovell FHCC.

Cost Effectiveness

No evidence was found regarding cost effectiveness, but some was found with regard to cost savings. The notable savings were in avoidance of construction costs and the reduction of Navy inpatient full-time equivalent (FTE) positions because the VA took over staffing of the nursing wards. There are also some operating efficiencies. However, there was no quantification of extra cost of duplicate administrative services to meet different standards and reporting requirements for similar functions.

Staff at the Lovell FHCC prepared a cost-benefit analysis of the Lovell FHCC merger in February 2009. The analysis reported that the annual savings from the Phase I move of inpatient mental health services from the

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

image

FIGURE 4-7 Selected SCIP results for the Lovell Federal Health Care Center, 2008–2011 (percentage of patients).
NOTE: Results for 2009 are not included because composite measures were used that year rather than individual measures. SCIP = Surgical Care Improvement Project; SCIP-1a = prophylactic antibiotic received within 1 hour prior to surgical incision-overall rate; SCIP-2a = prophylactic antibiotic selection for surgical patients-overall rate; SCIP-3a = prophylactic antibiotics discontinued within 24 hours after surgery end time-overall rate; SCIP-6 = surgery patients with appropriate hair removal; SCIP-CARD-2 = surgery patients on beta blocker therapy prior to admission who received a beta blocker during the perioperative period; SCIP-VTE-1 = surgery patients with recommended venous thromboembolism prophylaxis ordered;SCIP-VTE-2 = surgery patients who received appropriate venous thromboembolismprophylaxis within 24 hours prior to surgery to 24 hours after surgery.
SOURCE: Lovell FHCC.

NHGL was more than $1 million per year. The one-time cost avoidance of constructing the Navy blood processing center in the NCVAMC instead of retrofitting a building on the Navy base was $3.1 million, and the annual operating costs were $370,000 a year less. The Phase II transfer of inpatient medical, surgical, and pediatric services and the ED from the NHGL to the NCVAMC was saving more than $900,000 per year, primarily because the Navy was able to reduce staffing by more than 50 FTEs, most of them active duty servicemembers who were reassigned to other billets in North Chicago or to other Navy facilities. The analysis estimated that building the 201,000-square-foot ACC instead of the 364,000-square-foot facility the Navy had planned to build would save approximately $67 million in construction costs. Operating the combined ACC-NCVAMC facility was

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

expected to be about $19.7 million a year less than operating both a new Navy hospital and the NCVAMC would have been.

The Lovell FHCC issued a press release when the center opened in October 2010, in which Patrick Sullivan, the director, was quoted as saying that taxpayers would be saving approximately $20 million annually from the integrated operation. He said that because of the integration, “staff members are able to care for a larger population of patients, and that by combining staffing and resources, patients are able to benefit from robust, state-of-the-art health care.”4

Patient Satisfaction

Patient satisfaction is one of the 15 measures of the success of the integration effort agreed to by the VA and the DoD. Samples of DoD and VA beneficiaries are surveyed separately and the results are updated monthly.

The DoD conducts a quarterly survey of TRICARE beneficiaries. In 2009, the VA adopted the Consumer Assessment of Healthcare Plans and Systems survey, a nationally standardized tool. The Navy uses a survey of MTF users developed by the BUMED.

TRICARE

The TRICARE Management Activity has posted the results of its patient surveys for the years 2003–2011. In 2011, TRICARE users gave the Lovell FHCC more favorable ratings on access questions and less favorable ratings on other questions concerning physician-patient communication and quality of health care and health care providers, compared with all Navy users of TRICARE (Figure 4-8).

There was also a general drop in most ratings from 2010 to 2011, which was the first year of full integration of the Lovell FHCC. For example, the average score on a 100-point scale of patients surveyed for how well doctors communicate, which had increased from 84 in 2008 to 94 in 2010, fell to 81 in 2011 (Figure 4-9). Measures of access, such as getting care quickly and getting needed care, similarly increased until 2010, then declined from 80 to 76 and from 86 to 79, respectively (Figure 4-9). Other ratings also tended to drop in 2011, compared with 2010 (Figure 4-10). Whether these rating drops are a trend or reflect transitory effects of the first year of implementation—or are random—will not be known until several years of data are collected.

__________________

4 Jonathan Friedman, Historic VA/DoD integration accomplished. http://www.lovell.fhcc.va.gov/LOVELLFHCC/features/integration.asp (accessed September 13, 2012).

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×
Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

image

FIGURE 4-10 TRICARE patient ratings of aspects of care at the Lovell Federal Health Care Center, 2003–2011 (100-point scale).
SOURCE: http://www.tricare.mil/survey/hcsurvey/annual-report.cfm (accessed September 13, 2102).

Department of Veterans Affairs

The VA survey results show that veteran satisfaction with outpatient and inpatient care at the Lovell FHCC was higher in 2011, the first year of full integration, than in 2010. Satisfaction with outpatient care at Lovell was higher than average veteran satisfaction with VA outpatient care nationally, but the opposite was true for inpatient care (Figures 4-11 and 4-12).

Lovell Federal Health Care Center

The FHCC tracks and reports patient satisfaction by normalizing the DoD and the VA scores around the overall average score for BUMED and VISN 12, respectively, and using a 5-point scale. For example, if the DoD survey result for the FHCC deviates 16 percent or more below the overall result for BUMED as a whole, it gets 1 point. If it is between 15 and 11 percent below, it gets 2 points. If it is between 10 and 6 percent below, it gets 3 points. If it is between 5 percent above and 5 percent below the BUMED average, it gets 4 points, which is considered to be “very good.” If

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

image

FIGURE 4-11 Department of Veterans Affairs outpatient satisfaction scores, fiscal years 2009–2011.
NOTE: The VA changed the scoring methodology in 2009, making results for 2008 and earlier noncomparable.
SOURCES: Lovell FHCC and VA, 2011.

image

FIGURE 4-12 Department of Veterans Affairs inpatient satisfaction scores, fiscal years 2009–2011.
NOTE: The VA changed the scoring methodology in 2009, making results for 2008 and earlier noncomparable.
SOURCE: Lovell FHCC and VA, 2011.

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

TABLE 4-3 Department of Defense Patient Satisfaction Scale for the Lovell Federal Health Care Center

Score Basis
5 (Excellent) More than 5 percent above the BUMED average
4 (Very Good) Between 5 percent above and below the BUMED average
3 (Good) Between 5 and 10 percent below the BUMED average
2 (Fair) Between 10 and 16 percent below the BUMED average
1 (Poor) 16 percent or more below the BUMED average

SOURCE: Lovell FHCC, 2010c.

it is more than 5 percent above the BUMED average, it gets 5 points, which is considered to be “excellent” (Table 4-3).

The similar score is derived from the VA surveys except that the comparison is the overall average for VISN 12 and the intervals are different (Table 4-4).

The benchmark considered successful is a score of 4 or higher.

Both DoD and VA patient satisfaction scores were 4s (very good) on the eve of full integration in October 2010. The measure of VA patient satisfaction was lower than the benchmark (a score of at least 4) in the early months of the integration effort and again in the summer of 2011, but the measure jumped to excellent (5) and stayed there at the beginning of the second year. The measure of DoD patient satisfaction has alternated between good (3) and very good (4) during the same initial 16-month period (Figure 4-13). These trends indicate that both sets of beneficiaries have been less satisfied than they were before the Lovell FHCC took over operations, although VA beneficiaries have been much happier recently.

TABLE 4-4 Veterans Administration Patient Satisfaction Scale for the Lovell Federal Health Care Center

Score Basis
5 (Excellent) More than 5 percent above the VISN average
4 (Very Good) Between 0 and 5 percent above the VISN average
3 (Good) Between 0 and 5 percent below the VISN average
2 (Fair) Between 5 and 10 percent below the VISN average
1 (Poor) 10 percent or more below the VISN average

SOURCE: Lovell FHCC, 2010c.

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

image

FIGURE 4-13 Lovell Federal Health Care Center patient satisfaction scores, October 2010–June 2012.
SOURCE: Lovell FHCC.

Provider Satisfaction/Morale

The FHCC is subject to an annual organizational climate survey by the Defense Equal Opportunity Management Institute which asks questions in two areas: equal employment opportunity climate and organizational effectiveness. The latest survey was conducted in January 2012. The response rate was a little more than 40 percent for both civilian and active duty responders and also proportional across pay grades/ranks.

The respondents were asked to rate their job satisfaction, their trust in the FHCC, the cohesion and the effectiveness of their work group, and their perception of the cohesion of the FHCC leadership on a 5-point scale, in which a higher number means greater satisfaction, trust, commitment, and cohesion. The results show that the ratings by FHCC personnel in January 2012 were generally comparable to those by all Navy, all DoD, and all federal civilian personnel (Figure 4-14).

The average ratings by FHCC personnel in 2012 were also comparable to the ratings done in 2011, essentially bracketing the first year of the FHCC (Figure 4-15).

Mission Readiness of Navy Staff, Recruits, and “A” School Students

The impact of the FHCC integration on the operational readiness of active duty personnel was of paramount concern to the Navy. Great Lakes is the only enlisted boot camp in the Navy and the location of many of the

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

image

FIGURE 4-14 Average ratings of organizational effectiveness of their workplace by active duty and civilian staff at the Lovell Federal Health Care Center, all Navy facilities, all Department of Defense facilities, and all federal civilian workplaces in 2012.
NOTE: Respondents to an annual survey of the organizational climate at federal facilities administered by the Defense Equal Opportunity Management Institute were asked to give their perception of certain organizational features on a 5-point scale rate in which a higher number is better; e.g., a 4 means greater job satisfaction than a 3. DoD = Department of Defense; FHCC = Federal Health Care Center.
SOURCE: Lovell FHCC, 2012a.

image

FIGURE 4-15 Average ratings of organizational effectiveness of the Lovell Federal Health Care Center by its active duty and civilian staff in 2011 and 2012.
NOTE: Respondents to an annual survey of the organizational climate at the Lovell Federal Health Care Center administered by the Defense Equal Opportunity Management Institute were asked to give their perception of certain organizational features on a 5-point scale rate in which a higher number is better; e.g., a 4 means greater job satisfaction than a 3.
SOURCE: Lovell FHCC, 2012a.

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

Navy’s advanced training schools; therefore, a slowdown of training would negatively affect the entire Navy. On the other hand, having sailors with untreated health problems while on an extended cruise is also disruptive. This issue was mostly dealt with by keeping the recruit medical processing operation and the recruit and student health and dental clinics in place on the base, and not trying to move and integrate them with the rest of the FHCC’s patient care and patient services. However, some services for Navy personnel, including recruits and students, were moved and integrated (e.g., specialty care; emergency care; acute inpatient psychiatry, surgery, and general medicine; women’s health; and laboratory and pharmacy services). Administrative services such as purchasing of supplies and computer system support for the Navy branch health clinics were also centralized.

The Navy agreed on three measures of military medical readiness that collectively are being tracked as one of the 15 measures of integration success. They are the following:

  • keeping recruits in temporary holding units for medical reasons after they graduate under 5 percent,
  • keeping students not under instruction for medical reasons less than 2 percent, and
  • keeping the medically indeterminate status of active duty staff under 5 percent.

Recruits in Temporary Holding Units for Medical Reasons After They Graduate

Enlisted recruits who graduate from boot camp but are medically unable to transfer are assigned to temporary holding units. It is the responsibility of the MTF, in this case the Lovell FHCC, to provide the care needed to keep this rate as low as possible. According to the FHCC’s scorecard, Lovell has scored mostly 5s since it was launched in October 2010, meaning that the rate has been 2 percent or less (Lovell FHCC, 2010c). However, the rate jumped to more than 6 percent in January 2011 and also experienced a lesser increase (to less than 5 percent) in August and September 2011.

Enlisted Students Not Under Instruction for Medical Reasons

The percentage of enlisted students unable to attend training for medical reasons fell by half, to less than 1 percent, in September and October 2010 and, except for 1-week spikes in January 2011 and January 2012, it has trended downward to about 0.5 percent (Figure 4-16).

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

image

FIGURE 4-16 Percentage of enlisted students not under instruction for medical reasons, November 2009–April 2012.
NOTE: A lower score is better.
SOURCE: Lovell FHCC.

Medically Indeterminate Status

An active duty servicemember can be fully medically ready, partially medically ready, or not medically ready, or his or her medical readiness can be indeterminate. To be fully medically ready, servicemembers have to meet a list of requirements. Those who are ill or pregnant or who have acute dental problems are considered not medically ready. Those who are lacking some tests or immunizations are partially ready. Finally, those with overdue periodic health assessments, overdue periodic mental examinations, or lost medical records are classified as medically indeterminate.

In December 2010, 82 percent of active duty personnel at Great Lakes were medically ready for deployment, 4 percent were partially ready, 10 percent were not ready, and the status of 4 percent was medically indeterminate (FHCC communication). This was much better than the U.S. Armed Forces as a whole. In December 2010, the equivalent numbers were 67, 8, 13, and 12 percent, respectively (Woodson, 2011). However, Great Lakes is the Navy’s major training center where most servicemembers are relatively healthy young recruits and students, and the expectations for operational medical readiness are high.

The Navy chose to track the percentage of medically indeterminate active duty servicemembers, those whose status is unknown, as its measure of active duty individual medical readiness. In addition, an MTF’s percentage

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

of personnel whose individual medical readiness status is indeterminate is a factor in the Navy’s performance-based budgeting formula for MTFs.

During September 2010, the medical readiness indeterminate rate was between 4 and 5 percent. From October 2010 through January 2012, the scorecard score was 4 for most months, which means it was between 2.5 and 5 percent. It was a 5 in October 2010 and in January and June 2011, meaning it was 2.5 percent or less.

Findings and Conclusions Concerning Military Operational Readiness

The data presented on military medical readiness are consistent with the statement the RTC commander made to the committee at its third meeting. He said that the establishment of the FHCC has not had a noticeable effect on the rate of recruits who are able to graduate on time and transfer to their next assignments, some to additional training and some to immediate duty on ships. He said that when an issue does arise, it is addressed immediately and satisfactorily by the FHCC leadership. An early example was when a recruit was released from the inpatient psychiatric ward without notice to the RTC. The FHCC immediately worked out a procedure with the RTC to prevent such a reoccurrence.

Several interviewees indicated that maintaining operational readiness involved more effort than was previously necessary. They reported that it takes more time to keep medical records up to date because the DoD and the VA EHR systems do not interface and, therefore, the documentation of specialty, inpatient, and emergency services provided on the west campus must be manually entered into AHLTA. IT and laboratory services are provided centrally rather than locally, which is more cost effecive overall but can reduce responsiveness to branch health clinics’ needs. Although the two campuses are only 1.5 miles apart, it takes 20–30 minutes each way to travel from one campus to the other because the roads are not direct and the naval base can be accessed only through a few secure gates. Unless the base ambulance service is used in an emergency, the transportation is often provided by hospital corpsmen, which reduces their availability in the clinic.

Training and Research

The creation of the FHCC has generated opportunities for improved training and research that are not yet exploited but are in the plans of the Lovell FHCC and its affiliated medical school, the Rosalind Franklin University of Medicine and Science. These were discussed in the presentations to the committee at its September 2011 meeting in North Chicago and in an earlier site visit to the university by the committee staff. Those

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

discussions centered on several features of the combined FHCC, including the opportunities that the larger and more diverse patient population and the broader range of clinical services offer for both teaching and research.

Rosalind Franklin has been affiliated with the NCVAMC since 1980, when the university moved from downtown Chicago to North Chicago. The university has many doctoral and masters degree programs requiring clinical experience that is provided in part by the FHCC. There are schools of medicine, podiatry, pharmacy, and health professions, and a school of basic science that grants doctorates in the biomedical sciences. About 45 medical students a year have third-year clerkships in psychiatry, internal medicine, and neurology. There are about 40 residents a year in psychiatry and general internal medicine and 10 fellowships in endocrinology, pulmonology, infectious diseases, and cardiology. The 140 residents in podiatry do rotations at the FHCC, as well as 7 psychology students, 7 physical therapy students, 2 nurse anesthesiology students, and 18 students from other programs. The university has started a school of pharmacy, and there are plans for the 12 initial pharmacy students to rotate at the FHCC pharmacy.

The FHCC also has affiliations with Loyola University Chicago and the University of Illinois, and each year provides training for more than 400 residents, interns, and medical students, as well as students of other disciplines, including health services administration, audiology/speech pathology, biomedical engineering, dental assisting, medical technology, pharmacy, nursing, physical therapy, podiatry, psychology, and social work.

Training Opportunities

In their presentation to the committee, the director and deputy director of the FHCC said it has added new clinical disciplines for training experience, for example, family medicine, pediatrics, and hospitalist practice, as well as increased faculty and medicine. Trainees can now also be exposed to other disciplines, such as dermatology, ophthalmology, gynecology, and emergency medicine. There are more ambulatory care preceptors. The FHCC will also be able to increase the pool of speakers and the diversity of topics for grand rounds and multidisciplinary conferences.

Rosalind Franklin will be able to make greater use of the FHCC as one of its training institutions because of the expanded number of specialties and subspecialties offered there. Many VA providers have faculty appointments, and the university has now appointed Navy clinicians as faculty.

Research Opportunities

According to the integration performance benchmark, the amount of research funding at the Lovell FHCC is larger than it was leading up to

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

October 1, 2010. The leaderships of both Rosalind Franklin and the FHCC see the greater diversity of the patient population, now including women and children and the entire age range, as new research opportunities. The expansion of clinical staff increases the number of potential researchers.

Both institutions also mentioned having access to DoD research funding as well as to VA research funding. Although a VA clinician has had a major research program at the university on battlefield critical care, funded by the DoD, the FHCC and the university are not currently collaborating on clinical trials, although the NCVAMC and the university have in the past.

REFERENCES

DoD/VA (Department of Defense/Department of Veterans Affairs). 2008. Good News [newsletter]. February. http://www.tricare.mil/DVPCO/downloads/DoD-VA-Good-NewsFeb-2008.pdf (accessed September 7, 2012).

DoD/VA. 2010. Executive agreement for the Department of Defense-Department of Veterans Affairs Medical Facility Demonstration Project, Federal Health Care Center. April 23. http://tricare.mil/tma/congressionalinformation/downloads/2010310/111-288%20Section%201701(d)(1)%20FHCC%20EA.pdf (accessed September 6, 2012).

Fouse, S., and B. Faber. 2011. Patient Services Directorate. Presentation to the IOM Committee on Evaluation of the Lovell Federal Health Care Center Merger by Dr. Sarah Fouse and CDR Bridgette Faber, associate director and assistant director, Patient Services Directorate, Lovell FHCC, North Chicago, IL, June 29.

GAO (U.S. Government Accountability Office). 2012. VA/DoD health care: Costly information technology delays continue and evaluation plan lacking. GAO-12-669. Washington, DC: GAO. http://www.gao.gov/assets/600/591895.pdf (accessed September 7, 2012).

Harnly, M. J. 2005. A qualitative analysis of resource sharing agreements between Naval Hospital Great Lakes and North Chicago Veterans Affairs Medical Center: The iron triangle theory of healthcare integration. Master’s Thesis, Army-Baylor Program in Healthcare Administration, Fort Sam Houston, TX. http://www.dtic.mil/dtic/tr/fulltext/u2/a443921.pdf (accessed September 13, 2012).

Joint Commission. 2011. Improving America’s hospitals—The Joint Commission’s annual report on quality and safety 2011. http://www.jointcommission.org/2011_annual_report/ (accessed September 21, 2012).

Lovell FHCC (Captain James A. Lovell Federal Health Care Center). 2010a. Concept of operations. October 1. Provided by the Lovell FHCC.

Lovell FHCC. 2010b. Interim business plan for fiscal year 2011. Provided by the Lovell FHCC.

Lovell FHCC. 2010c. FHCC integrated benchmarks: Tech manual. Provided by the Lovell FHCC.

Lovell FHCC. 2012a. Organizational climate survey synopsis. January. Provided by the Lovell FHCC.

Lovell FHCC. 2012b. Business plan for fiscal year 2013 through 2015. Provided by the Lovell FHCC.

Shortell, S. M., R. R. Gillies, D. A. Anderson, K. M. Erickson, and J. B. Mitchell. 2000. Remaking health care in America: The evolution of organized delivery systems, 2nd Edition. San Francisco: Jossey-Bass.

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
×

VA. 2010a. Communications Department working side-by-side. The Great Lakes News (VISN 12 Newsletter), January. http://www.visn12.va.gov/docs/gln/Great_Lakes_News_2010_01.pdf (accessed September 7, 2012).

VA. 2010b. USS Osborne remains critical component in recruit dental readiness. The Great Lakes News (VISN 12 Newsletter), October. http://www.visn12.va.gov/docs/gln/Great_Lakes_News_2010_10.pdf (accessed September 7, 2012).

VA. 2011. FY 2011 performance and accountability report. November. http://www.va.gov/budget/report/ (accessed September 13, 2012).

VA/DoD. 2002. The Department of Veterans Affairs and the Department of Defense report on health care resource sharing, FY 2002. March 23. http://tricare.mil/tma/congressionalinformation/downloads/DoD%20VA%20Sharing%20signed%20Mar%2027%202003.pdf (accessed September 16, 2012).

VA/DoD. 2007. FY 2006 VA/DoD Joint Executive Council annual report. February. http://www.tricare.mil/DVPCO/downloads/VADoD2006.pdf (accessed June 8, 2012).

Woodson, J. 2011. Prepared statement by Jonathan Woodson, MD, Assistant Secretary of Defense (Health Affairs), regarding the Military Health System, overview before the Senate Armed Services Committee Personnel Subcommittee, May 4. http://armed-services.senate.gov/statemnt/2011/05%20May/Woodson%2005-04-11.pdf (accessed September 7, 2012).

Suggested Citation:"4 Initial Results of the Integration Demonstration." Institute of Medicine. 2012. Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions, and Recommendations. Washington, DC: The National Academies Press. doi: 10.17226/13482.
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The 2010 opening of the Captain James A. Lovell Federal Health Care Center (FHCC) created a joint entity between the Department of Defense (DoD) and the Department of Veterans Affairs (VA) that replaced two separate centers in North Chicago. VA and DoD leaders envisioned a state-of-the-art facility that would deliver health care to both DoD and VA beneficiaries from northern Illinois to southern Wisconsin, providing service members and veterans seamless access to an expanded array of medical services. Unprecedented for the military and the VA, the Lovell FHCC would integrate clinical and administrative services under a single line of authority.

The DoD asked the IOM to evaluate whether the Lovell FHCC has improved health care access, quality, and cost for the DoD and the VA, compared with operating separate facilities, and to examine whether patients and health care providers are satisfied with joint VA/DoD delivery of health care.

Evaluation of the Lovell Federal Health Care Center Merger: Findings, conclusions, and Recommendations finds that initial implementation of the Lovell FHCC has provided important lessons about how to integrate VA and DoD health care services and has identified remaining obstacles that the departments could overcome to make such mergers more effective and less costly to implement. The IOM recommends that the VA and the DoD develop a comprehensive evaluation plan to objectively judge its success or failure, with measurable criteria, that would provide essential knowledge for both the Lovell FHCC and future endeavors.

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