1. Veteran Health Network CDR Bard, LCDR Campbell, MAJ Ford 5 June 2012 CDR Bard, LCDR Campbell, MAJ Ford 5 June 2012

2. Outline Backstory / Problem Abstract Network Network Operation Measure of Effectiveness Network Analysis Summary and Conclusion 2

3. U.S. Dept. of Veteran Affairs (VA) VA Mission: Fulfill Lincoln’s promise Serve and honor America’s Veterans 3 Lincoln’s Promise: “to care for him who shall have borne the battle, and for his widow, and his orphan”

4. VA 2011-2015 Strategic Plan Strategic Goals Access to Care Optimal Value 4 Mindful of President Lincoln’s promise

5. Veteran Health Administration (VHA) Largest integrated health care system in United States 152 medical centers 1400 community-based outpatient clinics 5 21 Veteran Integrated Service Networks (VISNs) Meets needs of 8.3 million Veterans each year

6. VA Sierra Pacific Network VISN-21 serves 1.2 million Veterans in northern and central California, northern Nevada, Hawaii, the Philippines, and Guam Consists of 40 sites across six Systems Each Health Care System is sub-network of larger VISN-21 network 6

7. Abstract of VISN-21 Examine three independent Health Care Systems VA Palo Alto VA Sierra Nevada VA Northern California Representative of urban, rural and hybrid areas 7

8. Community Terms Urban (Palo Alto): Consists of major population centers Rural (Sierra Nevada): Sparsely populated with a few small urban areas Hybrid (Northern CA): Consists of major population centers surrounded by rural areas 8

9. Nodes and Edges Nodes: SUPPLY - Veteran populations by county DEMAND - Treatment facilities Edges: Connect each county with network facility Cost is distance in miles 9

10. Simplified Graph 10 VeteransTreatment CLINICSCOUNTIES Treatment Demand

11. Abstract of VISN-21 11 1 2 3 4 5 6 7 8 9 Siskiyou County VA Northern California (Hybrid) Yreka

12. VA Northern California (Hybrid) 12 COUNTIESCLINICS

13. Network Analysis Purpose: Provide outpatient care to Veterans Data Tracked: Cumulative Distance Traveled Per Capita Distance Traveled (outputs) Patients Assigned to Clinics 13

14. Measures of Effectiveness Model allocates Veterans to treatment facilities Minimum-Cost Flow Modeling Minimize Veteran travel distance to treatment Objective Function: min  c ij y ij c ij : cost (distance) per unit flow y ij : number of veterans (flow) on arc 14

15. Assumptions All eligible Vets receive care from VA System One City per County for distance calculations No population distribution for veterans in county Community near geographic or population center Health Care Systems (HCS) operate independently Ability for interchange among HCSs for specialty care Not modeled for simplicity and tractability 15

16. Modeling Begin with an unconstrained model Add network design constraints and evaluate responses Patient limits Patient limits with buffers Facility closure or patient capacity reductions Open a new clinic Year 2030 veteran populations 16

17. Unconstrained Results 17 All patients go to nearest clinic Per Capita Distance: Urban: 13.69 miles Hybrid: 17.37 Rural: 30.02

18. Patient Limits 18 Capacities chosen to ensure no unmet demand Modeled as upper bound on Clinic – Treatment Arcs Urban / Suburban Outpatient Clinics Capacity: 30,000 (urban / hybrid) Capacity: 25,000 (rural) Rural Outpatient Clinics Capacity: 10,000 Hospitals Capacity: 75,000 (hybrid) Capacity: 50,000 (urban / rural)

19. Patient Limits Results 19 Per Capita Distance: Urban: 16.26 miles Hybrid: 22.36 Rural: 40.93 20 - 35% increase

20. Patient Limits with Buffers 20 1% buffer below capacity for all facilities Allow for patient transfers New sign-ups Recently moved Flexibility

21. Patient Limits with Buffers Results 21 Per Capita Distance: Urban: 16.32 miles Hybrid: 23.0 Rural: 41.25 Baseline Closest to Reality

22. Budget Cuts 22 All HCSs must close a clinic or reduce staffing to save costs Force a clinic closure in each region Reduce patient limits across the board to simulate staffing cuts Model chooses optimal clinic to close and redistributes patients

23. Closures Hybrid: Yreka, CA Rural: Winnemucca, NV Urban: Capitola, CA 23

24. Budget Cuts Results 24 Per Capita Distance (optimal): Urban: 16.99 miles Hybrid: 23.60 Rural: 41.25 Optimal Decision Urban: Staff Cuts (+0.67) Hybrid: Closure (+0.60) Rural: Closure (+1.50)

25. Budget Cut Takeaways 25 Can safely close one clinic in each network without disruption Two or more closures trigger unmet demand (untreated patients) Network is efficient but vulnerable Redundancy is expensive and not an efficient use of limited resources Maximum reductions in patient capacities (staff cuts) without disruption Urban: 10 percent – unmet demand Rural: 5 percent – unacceptable patient assignments Hybrid: 2.5 percent – unmet demand

26. Open New Clinic 26 Political Pressures Can’t close a clinic and displace vets Must open a new clinic in each network Modeled after VA’s Rural Outreach Program Opening new small clinics in rural, underserved areas Yreka (CA) and Winnemucca (NV) are examples Optimal choice from among three communities in each region

27. Urban Three possible locations Rancho Calaveras, CA Tracy, CA Hollister, CA 27

28. Hybrid Three possible locations Weaverville, CA Orland, CA Colusa, CA 28

29. Rural Three possible locations Austin, NV Fernley, NV Mammoth Lakes, CA 29

30. Open Clinic Results 30 Per Capita Distance: Urban: 16.06 miles Hybrid: 21.92 Rural: 49.72 Reduction from Baseline Urban: 0.26 (1.5%) Hybrid: 1.08 (4.7%) Rural: 1.53 (3.7%)

31. Open Clinic Takeaways 31 Not worthwhile in urban network Slight decrease in objective function No patient load decreases on full capacity clinics Effective in hybrid and rural networks Larger decreases in objective function Decreased patient loads at full clinics

32. 2030 32 What does the future hold? Veteran population projections by county from the VA for 2030 40% reduction from current level Fewer WWII, Korea, and Vietnam era vets Drafts vs. Volunteer Force Assumed all current clinics remain Not likely to be true Will VA system be folded into National Health Care System?

33. 2030 Results 33 Per Capita Distance: Urban: 14.88 miles Hybrid: 17.69 Rural: 32.2 Similar to Unconstrained model results Clinic capacities become inconsequential Future closures?

34. Conclusion Network satisfies strategic objective Network resilient to limited disruption Offers insight to VA network of networks Project results in alignment with VA practices Flexibility for future Veteran population 34

35. Future Work Add competing objective function(s) Minimize Veteran traveling distance Minimize cost per patient Minimize overhead costs Increase granularity Determine Optimum Staffing Levels Model to help VA meet strategic goals considering 35-40% decrease in Veteran population by 2030 35

36. QUESTIONS? 36

37. BACKUP 37

38. Patient Limits and Buffers Results 38

39. Budget Cuts Results 39

40. Open Clinic Results 40

41. 2030 Results 41