Appendix C
Department of Veterans Affairs/Department of Defense Joint Ventures1:Brief Histories and Lessons Learned
The committee reviewed the current nine formal joint ventures that share resources in a variety of arrangements, and arrived at its summary of lessons learned across them by considering the information collected from a number of sources (see Chapter 5).
ALBUQUERQUE, NEW MEXICO: 377TH MEDICAL GROUP, KIRTLAND AIR FORCE BASE/NEW MEXICO VETERANS AFFAIRS HEALTH CARE SYSTEM
Brief History
The first formally designated Department of Defense (DoD)/Department of Veterans Affairs (VA) joint venture was established in 1987 between the Air Force’s 377th Medical Group (377th MDG) at Kirtland Air Force Base (Kirtland AFB) and the New Mexico Veterans Affairs Health Care System (NMVAHCS), located in Albuquerque, New Mexico. The Kirtland AFB Hospital and the Albuquerque VA Medical Center (VAMC), located two miles apart, had shared some services since at least the 1970s, for example, laboratory tests performed at no cost by the VA for DoD patients in the early part of that decade. With an eye toward achieving efficiency and cost savings, DoD and VA officials in Albuquerque have envisioned, created agreements for, and supported the increase of their shared services. The first
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1 The Lovell FHCC is no longer formally classified as a joint venture because it is considered to be a unique organizational arrangement.
formal sharing agreement was signed in March 1976. Under the agreement, the VA provided medical services and laboratory tests on a reimbursement basis. In the 1980s, the Air Force was faced with renovating its hospital at a cost of $26 million at the same time that the VA was planning the construction of a new Albuquerque VAMC. Rather than renovate the Air Force hospital, the VA agreed to include a 40-bed inpatient medical-surgical unit for the 377th MDG to staff and manage in the new VA facility, to be called the New Mexico Regional Federal Medical Center, which opened in 1987. The Air Force also agreed to manage the emergency room and, in 1989, constructed an ambulatory care center next to the hospital. The VA provided all ancillary services to the Air Force–staffed inpatient unit. The joint venture underwent a major change in 2002, when the Air Force, due to substantial reductions in personnel stationed at Kirtland, closed the inpatient unit and revised the interagency sharing agreement to allow the purchase of inpatient services from the VA (GAO, 1978; Simmons, 1989; VA/DoD, 2002).
In a recent development, the DoD invested $2.9 million for the renovation of its same-day-surgery unit, which was completed in 2011. As of the end of February 2012, the director of the joint venture indicated that the associated sharing agreement is pending review and approval by the Air Force Medical Support Agency, and the reopening was anticipated for March 2012.2 The sharing agreement will be between the 377th MDG and the NMVAHCS for the VA to occupy DoD ambulatory surgery space in exchange for providing 30 free surgeries a month for DoD beneficiaries (VA/DoD, 2011b).
Lessons Learned
Lessons learned at the Albuquerque joint venture include that successful agreements are worked out over time and through extensive planning efforts. Sharing agreements or joint ventures are unique to their locations and will not work unless the arrangement is cost effective for both partners. Leadership, personalities, and communications are important, and cultural issues must be overcome. Leadership needs to make strategic plans in the anticipation of accommodating the fluctuating availability of resources in an unpredictable environment. Sharing partners and their leaders must be committed, flexible, open-minded, and patient in their planning efforts, and they must look for opportunities to expand and modify arrangements as needed (Anderson, 1995; Baine, 1995; Carlton, 2000; Rogers, 2007; Spaulding and Catton, 2008; VA/DoD, 2011b).
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2 Personal communication with Patricia L. Ospino, M.B.A., Joint Venture Director, February 24, 2012.
EL PASO, TEXAS: WILLIAM BEAUMONT ARMY MEDICAL CENTER, FORT BLISS/EL PASO VETERANS AFFAIRS HEALTH CARE SYSTEM
Brief History
The William Beaumont Army Medical Center (WBAMC) and the El Paso Veterans Affairs Health Care System (EPVAHCS) have shared resources since the early 1970s. At that time, the VA canceled plans to build a hospital in El Paso when the Army agreed to provide inpatient care to VA beneficiaries in the WBAMC, which was then under construction. The El Paso DoD/VA joint venture started in 1987, when the VA needed to replace its outpatient clinic. A working group between the two organizations agreed to an arrangement in which the VA built its new, larger VA Eastside El Paso Clinic (VA Clinic) adjacent to the WBAMC. The clinic opened in 1995, and each floor is physically connected and has open access to the WBAMC. The Army provides inpatient care to VA beneficiaries in El Paso, who account for 26 percent of inpatient services provided at the WBAMC. VA staff share an 8-room ambulatory surgical suite and 16-bed recovery area on the fourth floor of the WBAMC with Army staff. The VA Clinic’s staff provides primary and behavioral health care, specialty services, dental services, and ambulatory surgery to veterans and has two ambulatory surgery suites available for use by the WBAMC. In 2008, the VA opened a 29,000-square-foot addition to the clinic for physical therapy, behavioral health, and podiatry programs. While the WBAMC underwent renovations to its post-anesthesia care unit (completed in 2009), the VA allowed Army staff to use the ambulatory surgery suite in the clinic. The Texas Tech University School of Medicine has a consortium agreement with the EPVAHCS and the WBAMC to train residents in internal medicine and psychiatry. The WBAMC’s graduate medical education program (GME) is open to VA medical residents (AMEDD, 2012; DoD/VA, 2002, 2008b; GAO, 2007; Hite, 2011; U.S. Senate, 1980; VA, 2012b; VA/DoD, 2002, 2006).
Because of Defense Base Realignment and Closure (BRAC) actions and other shifts of personnel, Fort Bliss is expanding substantially. By 2014, it is slated to be the third largest Army installation in the United States after Fort Bragg and Fort Hood. TRICARE Prime enrollment at the WBAMC is expected to double, to more than 110,000. In anticipation of this large increase in demand for health care, the Army began to plan for a major expansion of health care facilities, including a new $966 million hospital in a new location about 10 miles away in East El Paso. The new WBAMC hospital replacement project was awarded in 2009, ground was broken in 2011, and the inpatient facility is scheduled to open in 2016 (Wirtemburg and Ancker, 2008).
The VA wanted to relocate with the new Army facility and possibly share space for outpatient services—rather than build a separate ambulatory care facility—and also possibly jointly staff ambulatory surgery services. The VA is expecting its patient load to increase by nearly 5,000, to 41,000, and also wanted its clinic to be near the new access to the emergency room and specialty consultations at the new WBAMC, and to have continuity of care, sharing of ancillary services, and better GME opportunities. There was an effort to size the new inpatient facility to provide services for both DoD and VA beneficiaries, with the VA paying a proportionate share of the construction costs (approximately 25 percent), but differing construction planning and funding cycles made this approach impossible to achieve. In August 2012, Army Major Bryan Walrath, program manager for the U.S. Army Health Facility Planning Agency, reported that what will happen to the Beaumont facility is yet to be determined, indicating that “a big part of that question will be answered when it’s known if the Veterans Administration clinic, now located in a wing attached to Beaumont, will stay or eventually move to its own facility at the new hospital site” (Kolenc, 2012).
Lessons Learned
Lessons learned in El Paso include that open communication and information sharing are paramount to the success of a joint venture, and that trust and cooperation are key elements of the collaboration. There must be strong and committed leadership and a solid management structure, including middle management as well as subcommittees and work groups, sufficient to cohesively address important issues. DoD/VA team members (along with leadership as needed) should brainstorm together in a joint effort to resolve the major issues and creatively collaborate on plans and documentation. This kind of communication involves being specific about situations that arise to encourage more targeted discussions and practical solutions and to create a paper trail. By doing this, staff from both organizations will come to understand each other better and identify with the positive community effort they are undertaking. Staff should also commingle as much as possible to further their community identification. Unions should be part of the discussions from the beginning and as often as feasible (Perdue and Ancker, 2007, 2011; VA/DoD, 2006; Wirtemburg and Ancker, 2008).
HONOLULU, HAWAII: TRIPLER ARMY MEDICAL CENTER/VETERANS AFFAIRS PACIFIC ISLANDS/HEALTH CARE SYSTEM (SPARK M. MATSUNAGA MEDICAL CENTER)
Brief History
The Tripler Army Medical Center (TAMC) and the Veterans Affairs Pacific Island Health Care System (VAPIHCS) joint venture is unusual because it was established through a 1991 memorandum signed by Hawaii Senator Daniel Inouye and by Undersecretary of the Army John W. Shannon. It became an official joint venture in 1992. Its purpose was to provide a better and broader range of health care for beneficiaries and to promote the use of a single inpatient facility that would obviate the need for the VA to build one separately, thus reducing both construction costs and the expense associated with beneficiaries going out to the community to seek medical care. In this sharing arrangement, the TAMC hosts the VA, with VA staff providing outpatient, mental health, dental health, and nursing home care. The VAPIHCS arranges and pays for the care of veterans at the TAMC, in the local community, or at VA facilities in California as needed (AMEDD, 2011; Hite, 2011; Perlin, 2006).
TAMC’s E-Wing inpatient ward, staffed by VA personnel, was established in 1994, was renovated in 1999, and became the site of the VA’s Regional Office Center and the VAPIHCS administrative services in 2000. In 1997, the VA Day Hospital Program was relocated to the campus adjacent to the VA-staffed psychiatric ward. A new parking facility and the Center for Aging were completed in 2000. That same year, the VAPIHCS Spark M. Matsunaga VA Ambulatory Care Center, located adjacent to the TAMC campus, opened and began to provide primary care services, including mental health, specialty services, radiology, and optometry. The VA’s Post-Traumatic Stress Disorder Recovery Rehabilitation Program residential program relocated to the fifth floor of the TAMC after moving from Hilo in 2006. The first telehealth initiative began in 2009, as did the opening of the VA Dialysis Unit managed by VA staff for the use of both VA and DoD beneficiaries. A Joint Sleep Studies Unit was completed in 2010 (AMEDD, 2011; Committee on Veterans’ Affairs, U.S. Senate, 2002; DoD, 2010; Hite, 2011; Pacific Region Health Systems, 2011; Perlin, 2006).
Lessons Learned
The Hawaii joint venture offers a number of lessons learned. Good leadership from both partners that creates a cooperative atmosphere based on mutual trust and from staff who address issues on an ongoing basis is needed. Sharing equally and reaching consensus despite differences between
the organizations are important, with the underpinning of well-documented agreements and understandings. It is important for both organizations to be dedicated to the common joint venture mission, to work hard and envision success, and to further progress by developing new initiatives created by working groups and multidisciplinary teams. To accomplish the joint venture goals, open and honest communication is paramount, as is creative thinking to find solutions. Patients need to be the focus (patient-centered care) while saving money in the federal health care system at the same time (Horner and Holes, 2007, 2008; Horner et al., 2006).
Potential Contributions to Other Joint Ventures and Sharing Locations
The Hawaii joint venture has provided potentially useful electronic sharing technology models for other joint venture and sharing agreement arrangements. Its pilot project graphic user interface (GUI), or Janus, is a promising technological collaborative development with Pacific Telehealth & Technology Hui that was begun in 2003. In 2011, it was announced that Janus would be used as part of the VA’s joint electronic health record to access records and radiological imagery, including laboratory and pharmacy, allowing clinicians to view data from the two systems, and that the single GUI for the Veterans Health Information Systems and Technology Architecture (VistA) and the Armed Forces Health Longitudinal Technology Application (AHLTA) was being tested in the Tripler Army Medical Center in Honolulu. Future capabilities for Janus II are being developed through collaboration with the same company and will include intranet capabilities and radiology imaging sharing. In 2008, document management and referral management tools with four modules—bi-directional enhanced document referral (eDR) system, Charge Master Billing System, Joint Analytic Repository, and VistA Fee/IPAC Interface (a patch that allows the VA to pay the DoD within the VistA system)—were tested and implemented. A 2010–2012 joint venture objective is to follow up on the implementation of the eDR system and make it more efficient as an evaluation tool. If this effort is successful, it will lead to national implementation of the system at all joint venture sites as part of Joint Marketing Opportunities efforts (Brewin, 2011; Horner and Holes, 2007, 2009; Kyte and Camara, 2006; Perera, 2011; VA/DoD, 2007, 2008b, 2009a).
FAIRFIELD, CALIFORNIA: 60TH MEDICAL GROUP, DAVID GRANT MEDICAL CENTER, TRAVIS AIR FORCE BASE/NORTHERN CALIFORNIA VETERANS AFFAIRS HEALTH CARE SYSTEM
Brief History
The 1988 and the 1995 BRAC actions led to changes in the Mather and the McClellan Air Force Bases, located in Sacramento and McClellan, California, respectively. Mather became the Sacramento VA Medical Center and McClellan became a VA outpatient clinic with a DoD satellite clinic. With these developments as a backdrop, the 235-bed VA hospital in Martinez, California, closed in 1991 because of concerns that it was not safe in the event of earthquakes. A replacement clinic was built and opened in November 1992. It was regarded as a desirable VA prototype because veterans were provided a number of outpatient services they had not had before, including surgery and state-of-the-art technology. In 1994, the Air Force and its David Grant Medical Center (DGMC)/60th Medical Group (60 MDG), located at Travis Air Force Base (Travis AFB), and the Northern California Veterans Affairs Health Care System (NCVAHCS) formed a joint venture that allowed the VA to provide health care services to veterans in space allocated to them at the DGMC. This sharing agreement allowed veterans to use the emergency room, receive inpatient care, access radiation therapy, and receive specified diagnostic services. The medical/surgical unit at the DGMC (No. 5150) was operated by VA staff, while there was joint staffing at the inpatient psychiatric unit. In 1996, the VA proposed the construction of a new VA hospital, a VA outpatient clinic, and renovation to its DGMC space, but Congress decided that building a smaller outpatient clinic at Travis AFB and working through contractual arrangements would be sufficient for the VA’s needs. The sharing agreement between the DoD and the VA was renewed in 2008; the current joint venture services include the above, as well as dialysis, inpatient mental health, laboratory, radiology, and pharmacy (DGMC/VANCHCS, 2006; GAO, 1996a,b, 1998, 2004; Hite, 2011; Mosher et al., 2009; Scharenbrock and Carlson, 2010; Wilder and Kelly, 2011).
The key locations for the services of this joint venture are the DGMC and the VA Fairfield Outpatient Clinic, which opened in 2001, in Fairfield, California. This is a good location because it is situated at a midpoint on the I-80 corridor between East Bay and Sacramento with the VA Medical Center located in Sacramento, and the outpatient clinics in Alameda and McClellan. The VA’s Sacramento site is the location of the McClellan 60 MDG satellite clinic that provides services for DoD beneficiaries. The joint venture educational partnership is with the University of California, Davis, which is located near the DGMC (Allen and Carlson, 2009;
DGMC/VANCHCS, 2006, 2011; DoD, 2001; VA/DoD, 2000; Wilder and Kelly, 2011).
Lessons Learned
The need to have strong leadership, a single joint venture business office, an “operations guide,” and an organizational chart on which to base the hiring of personnel are all offered as lessons that have been learned through this joint venture experience (DGMC/VANCHCS, 2011).
In 2011, current leadership from the Air Force and the VA discussed lessons they have learned from this joint venture. They said that a major factor in determining how well a model might work in a given location should be in the assessment of the degree of mutual dependence. Before even entering into collaboration projects, it is important to research the availability of extant federal facilities (Wilder and Kelly, 2011).
With the establishment of a joint venture, they stressed the importance of the partners meeting regularly and developing a joint strategic plan, including those to address information technology issues. Joint venture management personnel also need to work closely with veterans groups to establish trust, including sharing Joint Incentive Fund proposals with them and asking for comments (Wilder and Kelly, 2011).
When it comes to operations, both partners need to “stand at orientation” to mitigate cultural issues and promote high standards. Staff who are dedicated to the joint venture will create a smoother operation, so it is important to communicate common goals effectively, from the leadership level to personnel attending to day-to-day clinical care. This can be accomplished by shared strategic planning sessions (established between the Air Force and the VA in 2006 for the Northern California joint venture) to cement the partnership. In this case, a 3- to 5-year plan has been created on the premise of mutual dependency with mutual benefits and efforts to “understand each other’s culture” (Wilder and Kelly, 2011).
Effective planning for construction projects and health facilities is important. For example, Travis AFB can bring in the VA as part of the planning process, such as the joint musculoskeletal rehabilitation facility (Wilder and Kelly, 2011).
As for the potential for a merger in Northern California, the leadership indicated that they felt it would be plausible, but that there would need to be a unified operational mechanism for supervision rather than two separate entities, e.g., VA employees and the military. However, a single chain of command and one physical “pot of money” would be better than “shuffling the money back and forth” (Wilder and Kelly, 2011).
LAS VEGAS, NEVADA: 99TH MEDICAL GROUP, NELLIS AIR FORCE BASE/VETERANS AFFAIRS SOUTHERN NEVADA HEALTHCARE SYSTEM
Brief History
The joint venture between Nellis Air Force Base’s 99th Medical Group (99th MDG) and the Veterans Affairs Southern Nevada Healthcare System (VASNHS) started operations in 1994 with the opening of a new hospital on the base to replace the outdated hospital constructed in 1965. Dedicated as the Mike O’Callaghan Federal Hospital (MOFH) in 1996, the new facility marked the first hospital construction project jointly funded and planned as an “operational joint venture” by the Air Force and the VA, although the two organizations had shared resources well before then. Currently, the MOFH has 114 beds (62 DoD and 52 VA). This arrangement promotes the sharing of costs between the two organizations and the opportunity for veterans to have access to services in Las Vegas, which they had not had previously. Inpatient, limited outpatient, some parts of intensive care and the step-down unit, psychiatric, and emergency room services are shared. Staffing is complex, with some degree of integration. Planning for a new, collocated Las Vegas VAMC began in 2003 and the center opened in August 2012, with the capacity of 90 inpatient beds (22 mental health unit, 48 medical/surgical, and 20 intensive care unit), and launching with an operational outpatient mental health clinic. From August through December 2012, there will be a phased opening of other services, including the provision of “23 dental exam chairs; 13 surgical, 14 radiology, and 6 audiometric sound suites,” and featuring “a telehealth unit, with bidirectional just-in-time communication capability with its outlying clinics” (VA, 2012d). With the opening of the center, sharing agreements will be enhanced, allowing Air Force patient access to clinical services currently not available at the MOFH (Collins, 2011; Hite, 2011; Irwin and Drew, 2008; MOFH, 2006; Nellis Air Force Base, 2012; Nicholson, 2005a,b; Roadman, 1999; Simmons, 1989; VA, 2006, 2007b; VA/DoD, 2002).
The Mike O’Callaghan Federal Hospital
Before 1994, VA beneficiaries did not have access to VA inpatient services in Las Vegas and they had to travel to facilities in Southern California for their care. Alternatively, DoD beneficiaries had more limited access to specialized providers prior to 1994 than after the establishment of the joint venture. In fiscal year (FY) 1990, the Air Force contributed $58 million and the VA $7 million to build the MOFH. After its 1994 opening, some operational difficulties arose, one of which was not having a system to adequately
address disputes. A high-level Air Force and VA team was brought in to help resolve issues. In 1999, complications came about because of cost accounting issues, bringing to light the need for joint venture partners to have interoperable information systems. In 2002, more serious concerns about inefficiency thought to be brought about by insufficient sharing efforts between the Air Force and the VA were reported. Over time, both limited space and the MOFH concerns about the availability of beneficiary services needed to be addressed. In response, a new VA medical campus complex was proposed, approved, and subsequently funded (DoD/VA, 2002; GAO, 2004; Principi, 1999; VA/DoD, 1995).
Collocated VA Medical Campus Complex
In 2003, the VA sought a permanent location for an ambulatory care center in Las Vegas, intended to meet the needs of both the VA and the DoD, and a recommendation to build a new hospital there was made in 2004. The location was within a few miles of the MOFH facility. FY 2006 Capital Asset Realignment for Enhanced Services funding supported this construction project for a total estimated cost of $600.4 million (Collins, 2011; Ensign, 2007; MOFH, 2006, 2007; Nicholson, 2005a,b; Panangala, 2005; VA, 2003, 2007a, 2008). The state-of-the-art VA medical center opened on August 6, 2012. At the dedication, Colonel John DeGoes, the 9th Medical Group commander, commented that “this is not a divorce” and that the joint venture “will continue in Las Vegas long into the future” with “two outstanding medical centers, separated by only four miles” (Sanders, 2012).
Lessons Learned
Lessons learned in Las Vegas include that it is important to establish trust between the partners, and leadership, as well as an effective executive council, sets the tone. A joint venture is a partnership in which a single set of standards should be set forth. Both partners need to maintain consistent and open dialogue to reach their common goals and successfully share resources for the benefit of each of the populations represented. Key concerns and other issues should be recorded in formal minutes, and focusing on insignificant issues should be avoided. There should be flexibility in hiring, particularly for emergency room operations, personnel should be jointly trained from the outset, and dual credential/privileging workarounds between the DoD and the VA personnel should be created. In a few specific operational areas, the reimbursement methodology needs to be sufficient; computing technology should be adequate for unique joint venture needs; and equipment such as a patient lift system can minimize patient and staff
injuries. Staff should also chronicle clinical experiences so that lessons learned can be shared for the benefit of patients and staff (e.g., that fall patients need to be actively monitored and that the early detection of MRSA [methicillin-resistant Staphylococcus aureus] minimizes internal nosocomial infection and reduces the patient’s stay) (Benjamin and Feistman, 2008; DoD/VA, 2008a; Mietzner and Gerrard, 2009; VA/DOD, 2011a).
ANCHORAGE, ALASKA: 3RD MEDICAL GROUP, ELMENDORF AIR FORCE BASE/ALASKA VETERANS AFFAIRS HEALTH CARE SYSTEM
Brief History
Challenges in providing health care services to VA and DoD beneficiaries in Alaska include accessibility (long distances, rugged terrain, severe weather, a limited road system, air evacuation often needed for patient transportation); transportation costs associated with the availability of medical services and clinicians (particularly specialty); the size of the populations served (e.g., sparse in some of the more remote locations); and the opportunity for military clinicians to maintain and improve their skills through the opportunity to consistently work with patients from a broad-based population (Alaska Joint Venture, 2006).
In 1986, the Alaska Veterans Affairs Health Care System and the Air Force initiated a collaborative effort to provide inpatient services to both VA and DoD beneficiaries in a jointly planned, funded, and staffed hospital located on the Elmendorf AFB near Anchorage, Alaska. (The base has been named Joint Base Elmendorf-Richardson since 2010, when Elmendorf AFB and the Army’s Fort Richardson were combined under the BRAC action in 2005.) The existing Air Force hospital at Elmendorf needed to be renovated and expanded to serve DoD beneficiaries. VA patients were being treated in area private hospitals because there was no VA inpatient facility. In 1992, after review of the original concept of operations (ConOps) that had been developed 2 years earlier (and was revised in 1998), the Air Force and the VA agreed to build a new hospital together and operate it jointly through a set of sharing agreements. The purposes of the joint venture were to use federal construction dollars more cost effectively, provide inpatient services directly to VA patients at lower cost, reduce per patient operating costs, and increase access and quality of care for both sets of beneficiaries (Alaska Joint Venture, 2006; GAO, 2004).
The project became a formal VA/DoD joint venture in 1999, and additional opportunities to collaborate for the mutual benefit of agencies and their beneficiaries have been identified and pursued since that time. Most significantly, in May 2010, the VA opened a new outpatient clinic located
on an 11-acre parcel of Air Force land outside the Muldoon entrance to Elmendorf AFB. It includes a connecting walkway to the Elmendorf hospital, located outside the Air Force security checkpoint, to provide easier access for VA patients. Currently, there are shared arrangements for services at the joint venture hospital on Elmendorf AFB and at the VA outpatient clinic next door, as well as purchased care (or fee-based) arrangements with community hospitals. Primary, specialty, and mental health outpatient care are offered. The Army also hosts the VA’s Fairbanks community-based outpatient clinic (CBOC), located in the Bassett Army Community Hospital at Fort Wainwright, under a VA/DoD interagency sharing agreement. The University of Alaska Anchorage, the University of Washington, and the Alaska Family Practice Residency Program are academic partners (Pendergrass, 2010; VA, 2012a).
Lessons Learned
The Alaska joint venture has yielded a number of important lessons. Both partners should be able to gain from the joint venture experience and to collaborate in a positive way toward the achievement of their separate and unified goals through joint strategic planning efforts. Staff from both organizations should approach the partnership as one team that works toward providing the best care for its collective beneficiaries, and these efforts must be consistent. There must be a commitment from the senior leaders, joint venture coordinators, and other organizational staff to establish good working relationships, including maintaining ongoing and systematic organizational communication within and outside of the collaboration. In the financial area, sound business practices must be established, resources must be shared fairly, and reimbursements must be fair and equitable. A joint business office should be set up, through which processes are thoroughly tracked and audit process are implemented to verify accuracy. In addition, it is important to have a VA or a DoD counterpart communicate these processes so everyone will be informed of all key changes. The importance of having a paper trail and maintaining documentation appropriately has also been pointed out. In this joint venture, another important lesson is that the Air Force staff need to be up-to-date in their clinical education and practice (Alaska DoD/VA Joint Venture Hospital, 2011; Anderson and Kurzejeski, 2007; Blair and Cecil, 2007; Spector and Cecil, 2008).
KEY WEST, FLORIDA: NAVAL BRANCH HEALTH CLINIC KEY WEST/MIAMI VETERANS AFFAIRS HEALTH CARE SYSTEM COMMUNITY BASED OUTPATIENT CLINIC KEY WEST
Brief History
The Naval Branch Health Clinic Key West (NBHC Key West [Jacksonville Naval Hospital]) and the Miami Veterans Affairs Healthcare System Community Based Outpatient Clinic Key West (VA CBOC Key West), in Monroe County, became the first Navy-VA joint venture in January 2000. Prior to that time, however, the DoD and the VA had developed sharing agreements for mutually beneficial services and they had shared facilities. The Naval Hospital Key West (NHKW) was commissioned in 1942, and it became the Naval Regional Medical Center (NRMC) in 1979. One year earlier, the General Accounting Office (GAO; former name for the current Government Accountability Office) had reported that the inpatient and outpatient medical services at the NHKW were underutilized and, further, that VA beneficiaries did not have health care services in the local area, which led to increased medical services costs. The VA entered into a sharing agreement with the Navy in 1986 to bring a mental health clinic into the NRMC. The following year, the NRMC facility was condemned, and the care for Navy patients was transferred to the Florida Keys Memorial Hospital. The VA mental health clinic was moved into the local community, but it returned to the newly renovated Navy clinic in 1994. In 1997, the original NRMC building was demolished and a new clinic was constructed, starting from 1998–1999 until early 2000, when the 60,000-square-foot NBHC Key West opened along with the VA CBOC Key West that shared space within the facility. In 2004, the medical and dental operations of the Naval Branch Medical Clinic integrated under the NBHC Key West brand (Cleckley and Ramirez, 2009; DoD/VA, 2006; GAO, 1978, 2000, 2004; Robinson, 2011).
The NBHC Key West and the VA CBOC Key West are both outpatient clinics, and neither offers inpatient or emergency services. The VA CBOC Key West occupies 10 percent of the 57,000-square-foot NBHC Key West facility, and the Navy pharmacy is located adjacent to the NBHC Key West. The NBHC Key West serves active duty military, their families, and other eligible beneficiaries, and offers some specialty services, but refers others out of the network. The VA CBOC Key West offers primary medical and mental health, physical therapy, dermatology, social work, and psychiatry services. The Key West joint venture partners also collaborate with the Naval Air Station Key West (NAS Key West) personnel in the areas of safety and security (Hite, 2011; NBHC, 2012; VA, 2012c).
Lessons Learned
Lessons learned from Key West include that DoD and VA leadership should communicate daily, including electronically, and meet quarterly. The strategic goals of each of the organizations should be understood by the other. Therefore, deliberations that affect the success of joint venture operations and have an impact on the clinics should be open to promote a team effort to try to meet the needs of both partners and to find resolutions to both common and unique problems. Further, communication it should be promoted on all levels of the DoD/VA interdisciplinary team, and it should include holding frequent staff meetings; providing joint training in all areas of mutual concern (e.g., clinical, safety, emergency preparedness) to achieve continuity of care for patients and to create a safe environment for both staff and patients; looking at ways to share resources; and having joint staff celebrations and recognizing the achievements of employees. In the area of staffing, departments need to consult with each other in the areas of credentialing and privileging to address any issues that may arise (Cleckley and Ramirez, 2008, 2009; DoD/VA, 2006; Hardin and Ramirez, 2007; Miavez et al., 2011).
PENSACOLA, FLORIDA, AND BILOXI, MISSISSIPPI: NAVAL HOSPITAL PENSACOLA JOINT AMBULATORY CARE CENTER/VETERANS AFFAIRS GULF COAST VETERANS HEALTH CARE SYSTEM, BILOXI CAMPUS
Brief History
Keesler Air Force Base (Keesler AFB), the 81st Medical Group (81st MDG)/Veterans Affairs Gulf Coast Veterans Health Care System (VAGCVHCS; also called the Veterans Affairs Gulf Coast Health Care System) were identified in FY 2005 as potential DoD/VA sharing agreement partners after the advent of Hurricane Katrina that led to a perceived need for the sharing of services in the Biloxi area. In 2008, these organizations were identified as a center of excellence (CoE) joint sharing site by the Joint Executive Committee, and they entered into a master sharing agreement based on a two-hospital model set up to eliminate duplication of clinical subspecialties. There are five coequal partners in this joint venture: (1) the VAGCVHCS; (2) Keesler AFB’s 81st MDG; (3) the Naval Hospital Pensacola (NHP), the location of the Joint Ambulatory Care Center (JACC); (4) Eglin Air Force Base’s 96th Medical Group; and (5) Tyndall Air Force Base’s 325th Medical Group. Collaboration has taken place since 1996, through sharing agreements between the Navy hospital and the VA-Gulf Coast, with Navy staff treating VA patients through various arrange-
ments for inpatient, emergency, and associated outpatient and ancillary care. The VA has provided laundry services for the Navy since 2000. Since 2001, some VA patients officially had been allowed to receive inpatient and surgical care if space was available; that same year, the VA requested increased services, for example, VA-approved inpatient admissions (Cornum and Wisnieski, 2010; Duren, 2005, 2008; GAO, 2004; Johnson et al., 2009; VA, 2011b,d; VA/DoD, 2008a, 2009b; Wyman, 2010).
The management structure of CoEs differs from other joint ventures. This DoD/VA sharing agreement involves integrated services and buildings that are not located in close proximity to one another, which sets it apart from other CoEs as well. The 81st MDG medical facility is one of the largest in the Air Force (Keesler Air Force Base, 2011). The Biloxi location is the main facility for operations, with CBOCs in Mobile, Alabama; Eglin, Florida; Pensacola, Florida; and Panama City, Florida (Irwin and Drew, 2008; Keesler Air Force Base, 2011; VA, 2011a).
The JACC, a CBOC located adjacent to the NHP, opened in 2008. Double the size of the facility it replaced, the JACC was the result of a 2002 joint recommendation by the NHP and the Biloxi VAGCHCS. In 2008, renovations began to build a VA-specified inpatient ward in the hospital. The open-access Naval Branch Health Clinic (NBHC Corry Station; also referred to as the CWO3 Gary R. Schuetz Memorial Medical Clinic at Corry Station), one of the hospital’s branch health clinics, is located at the JACC but serves active duty personnel only. Joint Navy and VA clinic spaces for VA and DoD inpatient, outpatient, emergency, dental, rehabilitative medicine, and physical therapy services are available for the use of beneficiaries in the coastal counties of Alabama, Mississippi, and Florida. Academic outreach includes a residency training program accredited by the GME program through the NHP (Duren, 2005, 2008; Johnson et al., 2009; NBHC Corry Station/JACC, 2011; Robinson, 2011; VA, 2011d).
Lessons Learned
Pensacola has reported that success depends on using the strengths and separate services offered by each of the partners effectively. The partners should have equal standing at the management level, and exercising independent facility management and frequent communication are important. Sharing initiatives should be mutually beneficial, with both high-quality and coordinated patient care programs and financial benefits for each of the partners, and the missions of each should be accommodated in the streamlined construction of the initiatives. Each of the partners should be comfortable with the pace of starting or expanding sharing initiatives, and neither the staff nor the patients should feel rushed into arrangements. On the other hand, however, it has been the experience of this joint venture
that the implementation of initiatives can be inordinately slowed down by the contracting process (Cornum and Wisnieski, 2010; Morro et al., 2009).
Biloxi’s lessons learned include that it is important for the partners to move at a pace that is comfortable for them, that operations are undertaken when it is appropriate both for their patients and their staff, and that the contracting process itself may prolong implementation of sharing initiatives. The local environment should guide the governance structure that is created, it should be included in the operations plan, and it must encompass all elements of the joint venture, including personnel management, which must comply with the rules and regulations appropriate for the individual partners. A joint market opportunities work group that meets frequently should be created to establish best practices and to identify systemic issues to be addressed by management, particularly at the outset of the joint venture. Strategic planning summits should be held annually and should include all functional experts and the senior leadership. Communication is a key element, and it should take place at all management levels and should extend to unions. The sharing initiatives should be of benefit to all partners financially and meet their unique missions, and they should provide services that are accessible to all patients. Each partner should be allowed to do what it does best, that is, take the lead in those particular areas (Cornum and Wisnieski, 2010; Irwin and Drew, 2008; Robb and Sepich, 2008; VA, 2011c).
CHARLESTON AND BEAUFORT, SOUTH CAROLINA: RALPH A. JOHNSON VETERANS AFFAIRS MEDICAL CENTER; NAVAL HEALTH CLINIC CHARLESTON; 628TH MEDICAL GROUP, JOINT BASE CHARLESTON/NAVAL WEAPONS STATION; NAVAL HOSPITAL BEAUFORT
Brief History
A unique and robust collaboration among the VA and the Navy and the Air Force of the DoD has been established with the most recent joint venture in Charleston-Beaufort, which has developed over time based on a complex history of sharing activities among (1) the Ralph H. Johnson Veterans Affairs Medical Center (RHJVAMC) and the Naval Health Clinic Charleston (NHCC), including the new Captain John G. Feder Joint Ambulatory Care Clinic, the location of the NHCC and the RHJVAMC CBOC (VA/DoD, 2010) in Goose Creek, South Carolina, which opened in September 2010 at a site on the Naval Weapons Station Charleston (NWSC); (2) the Air Force 628th Medical Group (628th MDG), Joint Base Charleston (JBC)/NWSC (the former Air Force 437th Medical Group [437th MDG])/Charleston Air Force Base, the host unit until its inactivation in this role in
January 2010 [Joint Base Charleston, 2010]); and (3) the Naval Hospital Beaufort (NHB) in Beaufort, South Carolina (Hite, 2011; VA/DoD, 2010).
Becoming official in October 2011, this complex joint venture is operating under a 5-year ConOps. There are sharing agreements between the VA and the DoD to provide joint care in outpatient cardiology, orthopedics, optometry, and phlebotomy, as well as shared access to a mobile magnetic resonance imaging unit. The RHJVAMC provides care at its JACC CBOC for VA beneficiaries. The naval organizations serve DoD beneficiaries (Hite, 2011; VA/DoD, 2010).
The RHJVAMC opened in 1966. In November 2010, operations moved to Goose Creek, South Carolina, to the JACC facility where the VA shares clinic space with the DoD’s NHCC. This consolidation occurred after H.R. 1720 mandated a study that included considering whether a joint-care venture with the Medical University of South Carolina (MUSC) in new facilities for both organizations would be feasible. The RHJVAMC provides primary, secondary, and tertiary care for veterans in South Carolina and Georgia, and supports veteran centers in North Charleston, South Carolina, and in Savannah, Georgia. Additional CBOCs are in Beaufort, Goose Creek, and Myrtle Beach, South Carolina, and in Savannah and Hinesville, Georgia (Hite, 2011; Perlin, 2007; U.S. Congress, 2003; VA, 2002, 2012e). MUSC residents, student trainees, and trainees from several allied health positions rotate through RHJVAMC house staff positions, and this “unique partnership … maintains the nation’s only mutually supported research facility, housing collaborative biomedical research with an FY 11 VA and non-VA funding level of about $18 million … and over $10 million in funding from the VA” (MUSC, 2012).
DoD TRICARE Prime and 628th MDG enrollees receive primary, outpatient, pharmacy, laboratory, and ancillary care services at the JACC. Satellite clinics include the Naval Weapons Station Branch Medical, the Naval Nuclear Power Training Command, the Dental, the Medical Readiness/Wellness, and the Optometry Clinics, located at the NWSC (Charleston Joint Venture, 2009; Joint Base Charleston, 2010; Militarynewcomers.com, 2012; VA/DoD, 2010).
The 628th MDG offers outpatient primary care that includes physical therapy and mental health at the Charleston AFB/Joint Base Charleston facility.
The NHB provides inpatient and outpatient services at two branch health clinics, the Marine Corps Air Station at Beaufort and the Marine Corps Recruit Depot at Parris Island (Beaufort SC, 2012; Hite, 2011).
Lessons Learned
In 2006, the GAO issued a report on the VA’s experiences in trying to forge partnerships with medical affiliates, specifically, in Denver and Charleston. Although the VA did not support the proposal for a joint venture in Denver, the partnership between the VA and the MUSC in Charleston was still being studied at that time and no final decision had yet been made. The GAO indicated that the Charleston and the Denver experiences yielded the following lessons: “criteria at the departmental level help provide clarity and consistency in evaluation approach; a communications strategy helps avoid misinformation and confusion; leadership support facilitates negotiations; and extensive collaboration assists negotiations” (GAO, 2006, Highlights). In 2011, the following lessons learned about what is needed for or what should be considered when undertaking a joint venture included “exclusionary fiscal processes/seamless flow of money; service footprint with measurable metrics; joint basing considerations; information technology interoperability; and deployment and staffing turnover impact” (Joint Venture Review, 2011, p. 15).
REFERENCES
Alaska DoD (Department of Defense)/VA (Department of Veterans Affairs) Joint Venture Hospital. 2011. Alaska DoD/VA Joint Venture Hospital. 2011 VA/DoD Joint Venture Conference, October. http://www.tricare.mil/DVPCO/CJVC2011.cfm [Elmendorf Joint Venture] (accessed November 29, 2011).
Alaska Joint Venture. 2006. Alaska joint venture. Presentation at 2006 Joint Venture Conference, February. www.tricare.mil/DVPCO/bummed/Navy%20JV%20Conf.Feb06.ppt (accessed October 28, 2011).
Allen, M., and K. C. Carlson. 2009. David Grant USAF Medical Center, VA Northern California Health Care System. Presentation by Col. Mark Allen, David Grant USAF Medical Center, and Ms. K. C. Carlson, VA Northern California Health Care System. http://www.tricare.mil/DVPCO/SharingConf.cfm (June 4, 2009, Breakout 7B—Joint Venture Update, Northern California VAHCS/Travis AFF) (accessed December 6, 2011).
AMEDD (U.S. Army Medical Department). 2011. Current AMEDD/VA joint ventures: Tripler Army Medical Center/VA Pacific Island Health Care System (VAPIHCS). http://vadodrs.amedd.army.mil/JV/JointVentures.html (accessed November 3, 2011).
AMEDD. 2012. William Beaumont Army Medical Center. http://www.wbamc.amedd.army.mil/ (accessed February 10, 2012).
Anderson, D., and A. Kurzejeski. 2007. Alaska VA/3MDG demonstration project: Presentation by Dan Anderson, 3rd Medical Group JV Coordinator, and Adam Kurzejeski, Alaska VA JV Coordinator. 2007 Joint Venture Conference, March 6. http://www.tricare.mil/DVPCO/el-paso/Elmendorf%20Demo%20Update.ppt (accessed October 28, 2011).
Anderson, G. K. 1995. Statement of Maj. Gen. George K. Anderson, USAF, MC, Deputy Assistant Secretary of Defense, Health Services Operations and Readiness, Department of Defense. Hearing on VA/DoD Sharing before the Committee on Hospitals and Health Care, Committee on Veterans’ Affairs, House of Representatives, October 18. http://democrats.veterans.house.gov/hearings/schedule104/transcript104/sn104-12.htm (accessed January 17, 2012).
Baine, D. P. 1995. Statement of David P. Baine, Director, Health Care Delivery and Quality Issues, Health, Education, and Human Services Division, GAO. Hearing on VA/DoD Sharing before the Committee on Hospitals and Health Care, Committee on Veterans’ Affairs, House of Representatives, October 18. http://democrats.veterans.house.gov/hearings/schedule104/transcript104/sn104-12.htm (accessed January 17, 2012).
Beaufort, SC. 2012. Naval Hospital Beaufort. http://www.beaufortsc.org/military/navalhospital-beaufort.stml (accessed January 26, 2012).
Benjamin, C., and A. M. Feistman. 2008. The Mike O’Callaghan Federal Hospital: 99th Medical Group and VA Southern Nevada Healthcare System. Presentation by Chris Benjamin, Col, USAF, and Ann Marie Feistman, FACHE. 2008 VA/DoD JV Conference. http://www.tricare.mil/DVPCO/Hawaii/2008%20JV%20Conf%20-%20Las%20Vegas%20JV%20MOFH%20(99MDG-VASNHCS).ppt (accessed January 5, 2012).
Blair, H., and B. Cecil. 2007. Alaska VA/3MDG joint venture. Presentation by Hal Blair, Associate Director, Alaska VA, and COL Billy Cecil, Deputy Commander, 3rd Medical Group. 2007 Joint Venture Conference, March 6. http://www.tricare.mil/DVPCO/el-paso/Elmendorf%20JV%20Update.ppt (accessed October 28, 2011).
Brewin, B. 2011. Joint health record graphical interface contest. May 26. http://whatsbrewin.nextgov.com/2011/05/joint_health_record_graphical_interface_contest.php (accessed November 8, 2011).
Carlton, P. K. 2000. Statement of Lt. Gen Paul K. Carlton, Jr., Surgeon General, United States Air Force. VA/DoD health care sharing. Hearing before the Subcommittee on Health of the Committee on Veterans’ Affairs, House of Representatives, May 17. Serial No. 106-39. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=106_house_hearings&docid=f:66495.pdf (accessed January 17, 2012).
Charleston Joint Venture. 2009. Success stories on sharing: Joint clinics (Charleston, SC). Power of VHA DOD Sharing Conference, June 3. http://www.tricare.mil/DVPCO/downloads/20090625/Breakout5aSuccessStoriesJointClinicsCharleston.ppt (accessed January 26, 2012).
Cleckley, J., and H. Ramirez. 2008. Key West VA/DoD joint venture: Naval Medical Clinic Key West/Miami VA Health Care System. Lieutenant Janiese Cleckley, BHC Key West, and Dr. Hector Ramirez, VA Miami, 2008 Joint Venture Conference. http://www.tricare.mil/DVPCO/Hawaii/2008%20JV%20Conf%20-%20Key%20West%20JV%20(NBHCKWMVAHCS).ppt (accessed February 16, 2012).
Cleckley, J., and H. Ramirez. 2009. Naval Branch Health Clinic & VA Outpatient Clinic Key West, FL. Presentation by LT Janiese Cleckley, NBHC Key West, and Dr. Hector Ramirez, VA Key West. 2009 Joint Venture Conference. http://www.tricare.mil/DVPCO/downloads/20090625/Breakout3dJVUpdateKeyWest.ppt (accessed February 16, 2012).
Collins, C. 2011. VA medical centers: Bigger and better. December 25. Defensemedianetwork. http://www.defensemedianetwork.com/stories/va-medical-centers-bigger-and-better/ (accessed July 5, 2012).
Committee on Veterans’ Affairs, U.S. Senate. 2002. The fiscal year 2003 budget for veterans’ programs. Hearing before the Committee on Veterans’ Affairs, United States Senate, S. Hrg. 107-744, February 14. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=107_senate_hearings&docid=f:82502.wais.pdf (accessed November 3, 2011).
Cornum, K., and T. Wisnieski. 2010. Biloxi/Keesler joint venture site. Presentation by Brig. Gen. Kory Cornum and Mr. Thomas Wisnieski, MPA, FACHE. 2010 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/lvjvc.cfm (accessed November 11, 2011).
DGMC (David Grant USAF Medical Center)/VANCHCS (Veterans Affairs Northern California Health Care System). 2006. David Grant Medical Center, VA Northern California Health Care System: Joint venture overview. Presentation at the 2006 VA/DoD Joint Venture Conference. www.tricare.mil/DVPCO/bummed/DavidGrant.ppt (accessed December 6, 2011).
DGMC/VANCHCS. 2011. David Grant USAF Medical Center, VA Northern California Health Care System: Joint venture review. Presentation at 2011 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/CJVC2011.cfm (David Grant Joint Venture) (accessed December 6, 2011).
DoD. 2001. Department of Defense appropriations for fiscal year 2002. Hearings before the Subcommittee on Defense of the Committee on Appropriations, United States Senate, H.R. 338, S. Hrg. 107-233, February 28. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2002_sapp_def_1&docid=f:70712.pdf (accessed December 5, 2011).
DoD. 2010. Department of Defense appropriations for fiscal year 2011. Hearings before the Committee on Appropriations, United States Senate, S. 3800. http://www.gpo.gov/fdsys/pkg/CHRG-111shrg54962/pdf/CHRG-111shrg54962.pdf (accessed January 5, 2012).
DoD/VA. 2002. Department of Defense and Department of Veterans Affairs health resources sharing: Staff report to the House Committee on Veterans’ Affairs, February 25. Pp. 123–140 in Health care sharing by the Department of Defense and the Department of Veterans Affairs’ hearing before the Health Subcommittee of the Committee on Veterans’Affairs and the Military Personnel Subcommittee of the Committee on Armed Services, House of Representatives, March 7. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=107_house_hearings&docid=f:80528.pdf (accessed February 9, 2012).
DoD/VA. 2006. Navy Branch Health Clinic & VA Outpatient Clinic, Key West, FL. Presentation. 2006 Joint Venture Conference. www.tricare.mil/DVPCO/bummed/KeyWest.ppt (accessed February 16, 2012).
DoD/VA. 2008a. Department of Defense (DoD)/Veterans Affairs (VA) Joint Market Opportunities Work Group update. C&CS Communications and Customer Service Conference. http://tricare.mil/conferences/ccs2008/breakout.cfm (accessed August 30, 2012).
DoD/VA. 2008b (July). Fiscal year 2003 National Defense Authorization Act. Department of Defense and Department of Veterans Affairs Demonstration Projects. Final report. Washington, DC: DoD/VA.
Duren, R. 2005. Ground broken on new day in VA/DoD ‘joint’ health care. Naval Hospital Pensacola Public Affairs, May 11. http://www.navy.mil/search/display.asp?story_id=18277 (accessed November 10, 2011).
Duren, R. 2008. Military Medicine teams with VA to open joint out-patient facility. Naval Hospital Pensacola Public Affairs, September 19. http://www.globalsecurity.org/military/library/news/2008/09/mil-080919-nns03.htm (accessed November 10, 2011).
Ensign, J. 2007. Prepared statement of Hon. John Ensign, U.S. Senator from Nevada. Hearing on construction and lease authorization needs of the Department of Veterans Affairs. Hearing Before the Committee on Veterans’ Affairs, United States Senate, S. Hrg. 109-561, April 6. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_senate_hearings&docid=f:28176.pdf (accessed January 5, 2012).
GAO (U.S. General Accounting Office). 1978 (June 14). Legislation needed to encourage better use of federal medical resources and remove obstacles to interagency sharing. Report to the Congress of the United States by the comptroller general. HRD-78-54. Washington, DC: GAO. http://archive.gao.gov/f0902a/106271.pdf (accessed February 16, 2012).
GAO. 1996a. VA health care: Travis Hospital construction project is not justified. Report to the Chairman, Subcommittee on VA, HUD, and Independent Agencies, Committee on Appropriations, U.S. Senate. GAO/HEHS-9-198. Washington, DC: GAO. http://www.gao.gov/archive/1996/he96198.pdf (accessed December 5, 2011).
GAO. 1996b. VA health care: Travis Hospital construction project is not justified. Summary and matters for congressional consideration. Washington, DC: GAO. GAO/HEHS-9-198. http://www.gao.gov/products/157398 (accessed December 5, 2011).
GAO. 1998. VA hospitals: Issues and challenges for the future. GAO/HEHS-8-32. Washington, DC: GAO. http://www.gao.gov/archive/1998/he98032.pdf (accessed December 5, 2011).
GAO. 2000. VA and Defense health care: Evolving health care systems require rethinking of resource sharing strategies. Washington, DC: GAO. http://www.gao.gov/archive/2000/he00052.pdf (accessed February 16, 2012).
GAO (Government Accountability Office). 2004. VA and DOD health care: Resource sharing at selected sites. Report to the chairman, Subcommittee on Oversight and Investigations, Committee on Veterans’ Affairs, House of Representatives. GAO-04-792. Washington, DC: GAO. http://www.gao.gov/new.items/d04792.pdf (accessed January 27, 2012).
GAO. 2006. VA health care: Experiences in Denver and Charleston offer lessons for future partnerships with medical affiliates. GAO-06-472. Washington, DC: GAO. http://www.gao.gov/new.items/d06472.pdf (accessed January 27, 2012).
GAO. 2007. VA health care: VA should better monitor implementation and impact of capital asset alignment decisions. Washington, DC: GAO. http://www.gao.gov/new.items/d07408.pdf (accessed February 6, 2012).
Hardin, D., and H. Ramirez. 2007. Navy Branch Health Clinic/VA Outpatient Clinic, Key West, FL. Presentation by LCDR Dawn Hardin, BHC Key West, and Dr. Hector Ramirez, VA Key West. 2007 Joint Venture Conference. http://www.tricare.mil/DVPCO/el-paso/Key%20West%20VA%20Joint%20Venture%20Conference%202007.ppt (accessed February 16, 2012).
Hite, R. 2011. Personal communication with Robert Hite, Program Manager, Policy, Reports and Analysis, DoD VA Program Coordination Office, Office of the Assistant Secretary of Defense (Health Affairs), October 25.
Horner, B., and J. Holes. 2007. Tripler joint venture update. Presentation by Ms. Brenda Horner and Mr. John Holes. 2007 Joint Venture Conference, March 6. http://www.tricare.mil/DVPCO/el-paso/Tripler%20JV%20Conference%202007%20v3.ppt (accessed November 7, 2011).
Horner, B., and J. Holes. 2008. Tripler Army Medical Center and VA Pacific Islands Health Care System. Presentation by Brenda J. Horner and John E. Holes. 2008 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/Hawaii/2008%20JV%20Conf%20-%20Hawaii%20JV%20(TAMC-VAPIHCS).ppt (accessed November 7, 2011).
Horner, B., and J. Holes. 2009. Hawaii collaboration. Presentation by Ms. Brenda Horner, Tripler Army Medical Center, and Mr. John E. Holes, VA Pacific Islands Health Care System. Power of DoD/VA Sharing Conference, June 3.
Horner, B., E. Camara, and R. Girton. 2006. DoD/VA joint venture: Joint Venture Incentive Fund proposals. Presentation by project managers Brenda Horner (TAMC) and Dr. Enrico Camara and Dr. Richard Girton (VAPIHCS). 2006 Joint Venture Conference, February. www.tricare.mil/DVPCO/bummed/Tripler.ppt (accessed November 7, 2011).
Irwin, D., and K. Drew. 2008. Elements of a joint venture. Presentation by Ms. Debra Irwin, Chief, DoD/VA Resource Sharing, Air Force Surgeon General’s Office, and Ms. Kendra Drew, Director, VA/DoD Medical Sharing Office, Veterans Health Administration. 2008 Joint Venture Conference. http://www.tricare.mil/DVPCO/Hawaii/2008%20JV%20Conf%20-%20Elements%20of%20a%20JV.ppt (accessed December 7, 2011).
Johnson, J. R., R. Lockhart, and D. E. Stoops. 2009. Gulf Coast Joint Ambulatory Care Clinic (JACC). Success stories on sharing: Joint clinics. Presentation by Mr. J. Ronald Johnson, FACHE, Mr. Ralph Lockart, and Mr Dennis E. Stoops. VA/DoD Sharing Conference, June 2–4. http://www.tricare.mil/DVPCO/SharingConf.cfm (accessed November 11, 2011).
Joint Base Charleston. 2010. Joint basing takes pivotal step with activation of 628 ABW. http://www.charleston.af.mil/news/story.asp?id=123184751 (accessed February 6, 2012).
Joint Venture Review. 2011. Charleston-Beaufort: Joint venture review: Naval Health Clinic Charleston; Ralph H. Johnson Veterans Affairs Medical Center; 628 Medical Group, Joint Base Charleston; Naval Hospital Beaufort. 2011 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/CJVC2011.cfm [Charleston Joint Venture] (accessed January 26, 2012).
Keesler Air Force Base. 2011. 81st Medical Group. http://www.keesler.af.mil/library/factsheets/factsheet.asp?id=4972 (accessed December 14, 2011).
Kolenc, V. 2012. The new Beaumont Army Medical Center: Contractors can benefit from Fort Bliss’ $1B project. El Paso Times, August 13. http://www.elpasotimes.com/ci_21298898/contractors-can-benefit-from-fort-bliss-1b-project (accessed September 5, 2012).
Kyte, R., and E. Camara. 2006. DoD/VA joint venture: Joint venture demonstration project. Presentation by project managers Rosemary Kyte (TAMC) and Dr. Enrico Camara (VAPIHCS). 2006 Joint Venture Conference, February. www.tricare.mil/DVPCO/bummed/Tripler.ppt (accessed November 7, 2011).
Miavez, J., H. Ramirez, and D. Eaton. 2011. Naval Branch Health Clinic Key West & VA Outpatient Clinic Key West. Presentation by CAPT Julie Miavez, OIC, NBHC Key West, Dr. Hector Ramirez, ACOS, Ambulatory Care VA Miami, and Dr. Douglas Eaton, CMO, VA Key West. 2011 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/CJVC2011.cfm [Key West Joint Venture] (accessed February 16, 2012).
Mietzner, D., and D. Gerrard. 2009. The Mike O’Callaghan Federal Hospital. Presentation by Col. David Mietzner and Dan Gerrard. 2009 Joint Venture Conference. http://www.tricare.mil/DVPCO/downloads/20090625/Breakout7bJVUpdateMikeOCallaghanFedHospitalNV.ppt (accessed January 6, 2012).
Militarynewcomers.com. 2012. Naval Weapons Station Charleston. Health care. http://www.militarynewcomers.com/NWSCHARLESTON/resources/05_health.html (accessed January 26, 2012).
MOFH (Mike O’Callaghan Federal Hospital). 2006. The Mike O’Callaghan Federal Hospital. Presentation at 2006 Joint Venture Conference, February. www.tricare.mil/DVPCO/bummed/Nevada.ppt (accessed January 5, 2012).
MOFH. 2007. Presentation on Mike O’Callaghan Federal Hospital (MOFH), March 2007, Nellis AFB, NV. 2007 Joint Venture Conference, March. http://www.tricare.mil/DVPCO/el-paso/Nellis%20Joint%20Venture%20Slides%202007c.ppt (accessed January 5, 2012).
Morro, M., D. Wyman, and K. Fogarty. 2009. Gulf Coast joint VA/DoD healthcare network “center(s) of excellence.” Presentation by CAPT Maryalice Morro, BG Daniel Wyman, and Ms. Kathleen Fogarty. VA/DoD Sharing Conference, June 2–4. http://www.tricare.mil/DVPCO/SharingConf.cfm (accessed November 11, 2011).
Mosher, P., J. Majerle, and L. Kelly. 2009. Success stories on sharing: Clinical applications (hemodialysis & neurosurgery). Presentation by Peter Mosher, DGMC, John Majerle, VANCHCS, and Laura Kelly, VISN 21. The Power of DoD/VA Sharing Conference, June 4. http://www.tricare.mil/DVPCO/downloads/20090625/Breakout6aSuccessStoriesClinicalApplicationsNeurosurgeryDialysisClinicsFairfieldCA.ppt (accessed December 7, 2011).
MUSC (Medical University of South Carolina). 2012. Ralph H. Johnson Veteran’s Administration Medical Center. http://academicdepartments.musc.edu/research/ord/collab_proposal/institutional_boilerplate/clinical/va.html (accessed September 5, 2012).
NBHC (Naval Branch Health Clinic). 2012. Key West Branch Health Clinic. http://www.med.navy.mil/sites/NavalHospitalJAX/AboutUs/Pages/Keywest.aspx (accessed February 16, 2012).
NBHC Corry Station/JACC. 2011. Corry Station. http://www.med.navy.mil/sites/pcola/NavyBranchHealthClinics/CorryStation/Pages/default.aspx (accessed November 9, 2011).
Nellis Air Force Base. 2012. Medical services. http://www.nellis.af.mil/library/factsheets/factsheet.asp?id=4073 (accessed January 8, 2012).
Nicholson, R. J. 2005a. Prepared statement of Hon. James Nicholson, Secretary, Department of Veterans Affairs. Proposed fiscal year 2006 budget for Department of Veterans Affairs programs. Hearing before the Committee on Veterans’ Affairs, United States Senate, S. Hrg. 109-72, February 15. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_senate_hearings&docid=f:22412.pdf (accessed January 3, 2012).
Nicholson, R. J. 2005b. Statement of the Honorable R. James Nicholson, Secretary, Department of Veterans Affairs. Department of Veterans Affairs budget request for FY 2006. Hearing before the Committee on Veterans’ Affairs, House of Representatives, February 16. Serial No. 109-1. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_house_hearings&docid=f:20426.pdf (accessed January 5, 2012).
Pacific Region Health Systems. 2011. http://virtual.mybaseguide.com/military/army/tripler/#page68I (accessed November 3, 2011).
Panangala, S. V. 2005. Veterans health care issues in the 109th Congress. CRS report for Congress, June 24. Order Code RL32961. Washington, DC: Congressional Research Service. http://www.policyarchive.org/handle/10207/bitstreams/2477.pdf (accessed January 3, 2012).
Pendergrass, S. 2010. Statement of Dr. Susan Pendergrass, Director, VA Northwest Network (VISN 20), Veterans Health Administration, Department of Veterans Affairs, before the Committee on Veterans’ Affairs, United States Senate, Field Hearing in Fairbanks, Alaska. http://veterans.senate.gov/hearings.cfm?action=release.display&release_id=73308297-1724-4e95-b725-84a067127c9d (accessed November 29, 2011).
Perdue, R., and M. Ancker. 2007. ELPVAHCS-WBAMC update. Presentation by Ray Perdue and Mary Ancker. 2007 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/el-paso/El%20Paso%20JV%20Update%202007.ppt (accessed February 9, 2012).
Perdue, R., and M. Ancker. 2011. El Paso joint venture update. Presentation by Ray Perdue and Mary Ancker. 2011VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/El-Paso.cfm [El Paso Joint Venture Update] (accessed February 9, 2012).
Perlin, J. B. 2006. Testimony of Hon. Jonathan B. Perlin, MD, PhD, Under Secretary for Health, Department of Veterans Affairs. Field hearing on the state of VA care in Hawaii: Part II. Hearing before the Committee on Veterans’ Affairs, United States Senate, S. Hrg. 109-376, January 11. Washington, DC: U.S. Government Printing Office. http://ftp.resource.org/gpo.gov/hearings/109s/27351.txt (accessed January 5, 2012).
Perlin, J. B. 2007. Statement of Jonathan B. Perlin, MD, PhD, MSHA, FACP, Under Secretary for Health, Department of Veterans Affairs. Department of Veterans Affairs collaboration opportunities with affiliated medical institutions and the DOD. Hearing before the Committee on Veterans’ Affairs, House of Representatives, March 8, 2006. Serial No. 109-37. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_house_hearings&docid=f:26675.pdf (accessed January 27, 2012).
Perera, D. 2011. iEHR will be in place 4 to 6 years from now, says Baker. Fierce Government, May 31. http://www.fiercegovernmentit.com/story/iehr-will-be-place-4-6-years-now-saysbaker/2011-05-31 (accessed November 8, 2011).
Principi, A. J. 1999. Verbal testimony of Anthony J. Principi. To receive the report of the Congressional Commission on Servicemembers and Veterans Transition Assistance. Hearing before the Committee on Veterans’ Affairs, House of Representatives, February 23. Serial No. 106-2. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=106_house_hearings&docid=f:56375.pdf (accessed January 3, 2012).
Roadman, C., II. 1999. Statement of Lt. Gen. Charles Roadman, II, Surgeon General, United States Air Force. Department of the Air Force presentation on the Defense Health Program to the Committee on Armed Services Subcommittee on Personnel, United States Senate, March 11. http://armed-services.senate.gov/statemnt/1999/990311cr.pdf (accessed January 17, 2012).
Robb, D. J., and C. Sepich. 2008. Gulf Coast joint VA/DoD healthcare network “center(s) of excellence.” Presentation by BG Douglas J. Robb, Commander, 81st Medical Group, Keesler AFB, and Mr. Charles Sepich, Director, VA Gulf Coast Veterans Healthcare System. 2008 VA/DoD Joint Venture Conference, March 4–6. http://www.tricare.mil/DVPCO/Hawaii/2008%20JV%20Conf%20-%20Gulf%20Coast%20Healthcare%20Network.ppt (accessed December 13, 2011).
Robinson, A. M., Jr. 2011. Prepared statement of Vice Admiral Adam M. Robinson, Jr. Defense Health Program FY12 budget. Hearing before the Subcommittee on Defense of the Senate Committee on Appropriations, April 6. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2012_sapp_def_3&docid=f:99104433.pdf (accessed January 27, 2012).
Rogers, B. 2007. Albuquerque joint venture. Presentation by Ben Rogers, CHE, NMVAHCS Joint Venture Director. 2007 Joint Venture Conference, March 8. http://www.tricare.mil/DVPCO/el-paso/JV%20ConfAlbuquerque.ppt (accessed January 17, 2012).
Sanders, J. 2012. VA medical center opens, keeps strong ties to Mike O’Callaghan. 99th Air Base Wing Public Affairs, Nellis Air Force Base. http://www.nellis.af.mil/news/story.asp?id=123315628 (accessed September 5, 2012).
Scharenbrock, C., and K. C. Carlson. 2010. Joint venture partnership successes, VANCHCS & Tribal Entities, DGMC & VANCHCS. Presentation by Dr. Christopher Scharenbrock, David Grant USAF Medical Center, and K. C. Carlson, VA Northern California Health Care System, January.
Simmons, J. 1989. Integrating federal health care resources at the local level. Hospital & Health Services Administration 34(1):113–122.
Spaulding, S., and K. L. Catton. 2008. Albuquerque joint venture. Presentation by Scott Spaulding, 377th Medical Group, and Kara L. Catton, New Mexico VAHCS. 2008 VA/DoD Joint Venture Conference, March. http://www.tricare.mil/DVPCO/Hawaii/2008%20JV%20Conf%20-%20Albuquerque%20JV%20(377MDG-NMVAHCS).ppt (accessed January 17, 2012).
Spector, A., and B. Cecil. 2008. Alaska. Presentation by Mr. Alex Spector, VA Director, and Colonel Billy Cecil, 3MDG Deputy Commander. 2008 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/Hawaii/2008%20JV%20Conf%20-%20Alaska%20JV%20(3MDG-VAHCS).ppt (accessed October 31, 2011).
U.S. Congress. 2003. H.R. 1720, to authorize the Secretary of Veterans Affairs to carry out construction projects for the purpose of improving, renovating, establishing, and updating patient care facilities at Department of Veterans Affairs medical centers, to provide by law for the establishment and functions of the Office of Research Oversight in the Veterans Health Administration of the Department of Veterans Affairs, and for other purposes. http://www.gpo.gov/fdsys/pkg/BILLS-108hr1720rfs/pdf/BILLS-108hr1720rfs.pdf (accessed January 27, 2012).
U.S. Senate. 1980. Hearing before the Committee on Governmental Affairs, United States Senate, Ninety-sixth Congress, Second Session, on S. 2958, Federal Interagency Medical Resources Sharing and Coordination Act of 1980, July 30. http://babel.hathitrust.org/cgi/pt?id=mdp.39015083099906 (accessed February 23, 2012).
VA. 2002. Health care sharing by the Department of Veterans Affairs and Department of Defense. Staff report to the House Committee on Veterans’ Affairs, February 25. Hearing before the Health Subcommittee of the Committee on Veterans’Affairs and the Military Personnel Subcommittee of the Committee on Armed Services, House of Representatives, March 7. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=107_house_hearings&docid=f:80528.pdf (accessed January 27, 2012).
VA. 2003. Departments of Veterans Affairs and Housing and Urban Development, and independent agencies appropriations for fiscal year 2004. Hearings before the Subcommittee of the Committee on Appropriations, March 13. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2004_sapp_va_1&docid=f:1910401.pdf (accessed January 3, 2012).
VA. 2006. Hearing on construction and lease authorization needs of the Department of Veterans Affairs. Hearing before the Committee on Veterans’ Affairs, United States Senate, S. Hrg. 109-561, April 6. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_senate_hearings&docid=f:28176.pdf (accessed January 5, 2012).
VA. 2007a. The VA’s budget request for fiscal year 2007. Hearing before the Committee on Veterans’ Affairs, House of Representatives, February 8. Serial No. 109-30. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_house_hearings&docid=f:26103.pdf (accessed January 5, 2012).
VA. 2007b. VA handbook 0311. Appendix C (p. C-3). November 8. http://www1.va.gov/vapubs/viewPublication.asp?Pub_ID=381&FType=2 (accessed January 5, 2012).
VA. 2008. VA FY 2008 Congressional budget submission, Vol. III, Construction. http://www.va.gov/budget/products.asp [FY 2008 Budget Submission] (accessed January 6, 2012).
VA. 2011a. VA Gulf Coast Veterans Health Care System. http://www.biloxi.va.gov/about/ (accessed December 14, 2011).
VA. 2011b. VA Gulf Coast: Joint venture review. 2011 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/CJVC2011.cfm [Keesler Joint Venture] (accessed November 11, 2011).
VA. 2011c. VA Gulf Coast: Joint venture review. 2011 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/CJVC2011.cfm [Keesler Joint Venture] (accessed November 11, 2011).
VA. 2011d. VA Gulf Coast Veterans Health Care System. http://www.biloxi.va.gov/visitors/Pensacola.asp (accessed November 9, 2011).
VA. 2012a. Alaska VA Healthcare System, Fairbanks, Alaska, Community-Based Outpatient Clinic. http://www.alaska.va.gov/visitors/fairbanks.asp (accessed April 27, 2012).
VA. 2012b. El Paso VA Health Care System. http://www2.va.gov/directory/guide/facility.asp?ID=46 (accessed February 10, 2012).
VA. 2012c. Miami VA Healthcare System: Locations. Key West Outpatient Clinic. http://www.miami.va.gov/locations/KeyWest.asp (accessed February 16, 2012).
VA. 2012d. New VA medical center with state-of-the-art mental unit to open in Las Vegas. http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2363 (accessed September 27, 2012).
VA. 2012e. Ralph H. Johnson VA Medical Center. About this facility. http://www.charleston.va.gov/about (accessed January 26, 2012).
VA/DoD. 1995. Hearing on VA/DoD sharing before the Subcommittee on Hospitals and Health Care, Committee on Veterans’ Affairs, House of Representatives, October 18. http://democrats.veterans.house.gov/hearings/schedule104/transcript104/sn104-12.htm (accessed January 3, 2012).
VA/DoD. 2000. VA/DoD health care sharing. Hearing before the Subcommittee on Health of the Committee on Veterans’ Affairs, House of Representatives, May 17. Serial No. 106-39. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=106_house_hearings&docid=f:66495.pdf (accessed December 5, 2011).
VA/DoD. 2002. Department of Veterans Affairs and Department of Defense health resources sharing: Staff report. Committee on Veterans’ Affairs, U.S. House of Representatives, February 25. Washington, DC: U.S. Government Printing Office. http://veterans.house.gov/sites/republicans.veterans.house.gov/files/documents/vadodsha.pdf (accessed February 9, 2012).
VA/DoD. 2006. VA/DoD joint venture: Wm Beaumont Army Medical Center and El Paso VA Health Care System. Presentation at 2006 Joint Venture Conference, February. www.tricare.mil/DVPCO/bummed/ElPaso.ppt (accessed February 9, 2012).
VA/DoD. 2007. VA/DoD Joint Executive Council FY 2006 annual report. February. http://www.tricare.mil/DVPCO/downloads/VADoD2006.pdf (accessed November 7, 2011).
VA/DoD. 2008a. VA/DoD Joint Executive Council fiscal year 2007 annual report. February. http://www.tricare.mil/DVPCO/downloads/VA%20DoD%202007%20Annual%20Report%20FINAL%203-14-08.pdf (accessed December 13, 2011).
VA/DoD. 2008b. VA/DoD Joint Executive Council FY 2008 annual report, including 2009–2011 joint strategic plan. http://www.tricare.mil/DVPCO/downloads/VA%20DoD%20Joint%20Executive%20Council%20Annual%20Report.pdf (accessed November 8, 2011).
VA/DoD. 2009a. VA/DoD Joint Executive Committee FY 2009 annual report: Joint strategic plan 2010–2012. http://prhome.defense.gov/docs/2009%20VA%20DoD%20Joint%20Executive%20Council%20Annual%20Report%20and%20Joint%20Strategic%20Plan.pdf (accessed November 8, 2011).
VA/DoD. 2009b. VA/DoD Joint Executive Council FY 2008 annual report, including 2009–2011 joint strategic plan.
VA/DoD. 2010. VA/DoD Joint Executive Council annual report for FY 2010. http://www.tricare.mil/DVPCO/downloads/2010%20JEC%20Annual%20Report%20to%20Congress%20(signed).pdf (accessed January 27, 2012).
VA/DoD. 2011a. Mike O’Callaghan Federal Hospital briefing. 2011 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/CJVC2011.cfm [Las Vegas Joint Venture] (accessed January 3, 2012).
VA/DoD. 2011b. New Mexico VA Health Care System, 377th Medical Group, Kirtland AFB, Albuquerque, NM. 2011 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/CJVC2011.cfm [Albuquerque Joint Venture] (accessed January 17, 2012).
Wilder, D., and L. Kelly. 2011. Personal communication and discussion with the IOM Committee on Evaluation of the Lovell Federal Health Care Center Merger. Conference call with Lt. Col. Doreen Wilder, David Grant USAF Medical Center, Travis Air Force Base, California, and Laura Kelly, VA Northern California Health Care System, in public session during the committee’s fourth meeting. Irvine, California, November 17–18.
Wirtemburg, D., and M. Ancker. 2008. El Paso joint venture: Wm. Beaumont Army Medical Center and El Paso VA Health Care System. Presentation by Dane Wirtemburg, ELP-VAHCS, and Mary Ancker, WBAMC. Annual 2008 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/Hawaii.cfm [El Paso Joint Venture] (accessed February 9, 2012).
Wyman, D. 2010. Gulf Coast sharing success. Presentation by Brig Gen Daniel Wyman, 81 Medical Group, Keesler AFB. 2010 Military Health System Conference, January 26. http://www.health.mil/Libraries/2010_MHS_Conference_Presentations_-_Jan_26/T06_D_Wyman.pdf (accessed December 13, 2011).
