1. How can healthcare networks develop policy autonomy within an environment shaped by external mandates? Carla L. Cassidy, CRNP, MSN Director, Evidence-Based Clinical Practice Guideline Program Quality Standards and Programs (10A4B) Washington, DC Evidence-Based Guidelines Affecting Policy, Practice and Stakeholders (E-GAPPS) December 10, 2012

2. I have no current affiliation or financial arrangement with any grantor or commercial interest that might have direct interest in the subject matter of this CE program. Disclosure Statement The views expressed in the presentation are those of the presenter and do not necessarily reflect the official policy or position of the Department of Veterans Affairs, Department of Defense, or the U.S. Government.

3. About the Veterans Health Administration Veterans Health Administration has 8.6M enrollees, serves 6.2M Veterans/year in 152 hospitals, 817 clinics, 300 community living centers – Affiliations with 124 medical schools $54 Billion health care budget Older, sicker, poorer than U.S. pop. – Half are over 65 yrs, 8.3% female 24% racial and ethnic minorities – Likely to grow as minorities make up 1/3 active duty military National healthcare system – Responsible for Veterans in every corner of the US VHA addresses social as well as medical issues

4. VHA’s vision will continue to be the benchmark of excellence and value in health care and benefits by providing exemplary services that are both patient ‐ centered and evidence ‐ based. This care will be delivered by engaged, collaborative teams in an integrated environment that supports learning, discovery and continuous improvement. It will emphasize prevention and population health and contribute to the Nation’s well ‐ being through education, research and service in national emergencies. Veterans Health Administration Mission & Vision VHA’s mission is to honor America's Veterans by providing exceptional health care that improves their health and well-being.

5. Current VA/DoD Guidelines (December, 2012) Chronic Condition Related Asthma Chronic Heart Failure (CHF) Chronic Kidney Disease (CKD) Chronic Obstructive Pulmonary Disease (COPD) Diabetes Mellitus (DM) Dyslipidemia (LIPIDS) Hypertension (HTN) Ischemic Heart Disease (IHD) Obesity and Overweight (OBE) Tobacco Use (MTU) Mental Health Related Bipolar Disorder (BD) Major Depressive Disorder (MDD) Post Traumatic Stress Disorder (PTSD) Substance Use Disorder (SUD) Military Related Biological, Radiation, Chemical, and Blast/Explosion Induced Illnesses Medically Unexplained Symptoms (MUS) Post-Deployment Health (PDH) Pain Related Pain Lower Back Pain (LBP) Opioid Therapy for Chronic Pain (OT) Post-Operative Pain (POP) Rehabilitation Related Concussion/mTBI Lower Limb Amputation Stroke Rehabilitation Women's Health Pregnancy

6. External Influences on Guideline Development Federal Government −Congress −OMB Veteran Service Group −Professional /Advocacy organizations −Federal Advisory Committees External Agencies −NCQA −The Joint Commission

7. Federal Government Congress Last year congress initiated process of over 100 bills that affect veteran care: −Women Veteran health Care Improvement Act −Rural Veteran health Care Improvement Act −Homeless Care −Camp LeJeune Omnibus Act Tribal Government Relations

8. Veteran Advocacy Groups −World War I −World War II −Korean War −Vietnam War Veteran Family Organizations Women Advocacy Groups Veteran Service Groups

9. External Influences The Joint Commission NCQA CMS

10. Implications Office of Management and Budget Constraints Research Congressional Mandates Global Conflicts