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

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

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

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

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

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

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

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

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

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

Community Provider Resources VA Community Provider Website VHA Provider Updates Newsletter VA Community Provider Webinar Series Update with latest Community Care Network, MISSION Act, etc. fact sheets, Post any Community Care programs and policy changes, Provide links to external websites of interest/use for providers https://www.va.gov/COMMUNITYCARE/providers/index.asp A monthly e-publication for community providers that delivers scheduled updates about programs, policies and changes. Subscribe at: https://public.govdelivery.com/accounts/USVHA/subscriber/new?topic_id=USVHA_1240 Office of Community Care Overview Series: An overview of Community Care Programs. Accredited Topics Series: Accredited webinars with VA experts presenting on health care-related topics. Register at: https://www.train.org/vha/welcome

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

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