1. VA Care and the New Normal in Military City, USA: Innovative Collaborations with DOD and Community Julianne Flynn, MD South Texas Veterans Health Care System Col Evan M. Renz, MD Brooke Army Medical Center Michael J. Eppinger, MD South Texas Veterans Health Care System William E. Jones, III, MD South Texas Veterans Health Care System

2. Disclosures The presenters have no financial relationships to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS. Neither PESG,AMSUS, nor any accrediting organization support or endorse any product or service mentioned in this activity. PESG and AMSUS staff has no financial interest to disclose. Commercial support was not received for this activity. The views expressed in this presentation are solely our own and do not necessarily reflect the official policy or position of the Air Force, Army, Department of Defense, Veterans Administration, or the U.S. Government.

3. Learning Objectives: At the conclusion of this activity, the participant will be able to: 1. Understand the MyVA initiatives, to include Strategic Partnerships 2. Define compelling reasons for DOD-VA collaborative efforts 3. Describe various approaches to and models of DOD-VA collaboration

4. Outline: 1. Brief Background on STVHCS 2. Overview of collaborative efforts 3. DOD-VA Collaborative Partnership: SAMMC perspective 4. DOD-VA Collaborative Partnership: CT surgery program 5. DOD-VA Collaborative Partnership: Radiation Oncology program 6. Wrap up and Questions

5. STVHCS OVERVIEW Audie L. Murphy Campus Kerrville Campus Community Based Outpatient Clinics (CBOCs) 4 VA staffed7 contract clinics Over 85,000 unique Veterans FY15 outpatient visits: 1,107,463 FY15 operating budget: $678 Million Over 3,500 employees 10 th most complex VA

6. STVHCS Service Area

7. STVHCS Scope of Services Scope of ServicesALMKerrCBOCs Acute Medical Primary Care Specialty Care limited Geriatric Care Long-term Care Palliative Care Mental Health Surgical Care Spinal Cord Injury Center Bone Marrow Transplant Polytrauma Rehabilitation

8. 1.) Improving the Veteran experience 2.) Improving the employee experience so they can better serve Veterans 3.) Improving internal support services 4.) Establishing a culture of continuous improvement and 5.) Enhancing strategic partnerships It’s an opportunity for building a better VA!

9. Strategic Partnerships 138 active affiliation agreements Proximity to University of Texas Health Science Center at San Antonio (UTHSCSA) and University Hospital 3 rd highest number of physician – resident slots (216) Local Growth of Collaboration with DOD - Why? We have patients, interesting pathology Readiness Ease of transition for AD and veteran patients Military culture competence

10. STVHCS - 59 MDW and BAMC Sharing 59 MDW Agreements Blood Bank ETO Sterilization Hyperbaric Services Medical Services North Central Federal Clinic Radiation Oncology Surgical Services Surgical Supervision BAMC Agreements ENT Services for VA Beneficiaries ETO Sterilization General Medicine Services for VA Beneficiaries Iplementation of the VA/DoD Disability Evaluation System Pilot at BAMC STVHCS Support for the Center of the Intrepid Surgical Services for VA Beneficiaries at BAMC Surgical Services Support for VA Beneficiaries

11. STVHCS TriCare Collections Active Duty EncountersActive Duty UniquesTriCare Collections FY15 5,937 4,300 $7,821,026.67 FY14 5,717 4,255 $10,215,454.38 FY13 4,917 3,914 $8,034,683.51 FY12 2,904 2,555 $2,701,609.72 FY11 1,763 1,551 $516,174.99 FY10 $314,658.88

12. DOD-VA Collaborative Partnership: BAMC perspective Col Evan M. Renz, MD Brooke Army Medical Center

13. DOD-VA Collaborative Partnership: CT surgery program Michael J. Eppinger, MD South Texas Veterans Health Care System

14. VA Cardiothoracic Surgery VA has 41 cardiothoracic programs arranged in 5 regions Of these, 6 are mechanical circulatory assist device programs, and 5 are heart txp programs Variety of models for staffing Most are aligned with university programs

15. VA Cardiothoracic Surgery Audie Murphy VA Cardiothoracic Surgery 130-150 hearts/year 50 thoracic cases 50 miscellaneous

16. VA Cardiothoracic Surgery Cardiothoracic Surgery Coverage Previously covered by UTHSCSA Faculty and fellows saw clinic and performed cases at VA VA paid UTHSCSA for services provided Support for program provided by VA Nursing, PA, Perfusion

17. DoD Cardiothoracic Surgery Wilford Hall Medical Center and Brooke Army Medical Center For years, busy CT surgery programs at both facilities Volume substantially decreased over time due to shift to Tricare After BRAC plan in 2005, programs merged in September 2006 into one combined program at BAMC

18. DOD-VA Collaborative Partnership: CT surgery program Jan 2013, DoD began coverage of CT surgery at VA Sharing agreement 2 DoD surgeons working at VA, WOC status PA/Perfusion services to augment staff at VA Increases case load for DoD staff Cardiac rehab availability for postop VA patients Full-time Chief of CT surgery hired Oct 2014

19. DOD-VA Collaborative Partnership: CT surgery program Outcomes Tracked closely by National Surgery Office of VA VASQIP (VA Surgical Quality Improvement Program) used to track volume, outcomes including mortality, morbidity, readmissions, length of stay, etc. Information available on national, VISN, and local levels Provides comparison based on observed/expected Most recent 12 month data shows mortality of 0.78% vs. expected of 2.65% for O/E ration of 0.3 BAMC outcomes tracked using STS database

20. DOD-VA Collaborative Partnership: CT surgery program Ongoing – Future Purchased Impella LVAD Short-term left ventricular support device High risk cardiac interventions, acute support in emergencies, elective high risk operations Increase capacity to ensure capture of beneficiary population, keep wait times low Maintain readiness of DoD partners Cost-effective use of available resources; responsible management of taxpayer dollars

21. DOD-VA Collaborative Partnership: Radiation Oncology William E. Jones, III, MD South Texas Veterans Health Care System

22. Radiation Oncology Services Highly technical services provided by a comprehensive team Requiring: Specialized equipment QA Policies & Procedures Highly trained staff Extensive support staff

23. Radiation Oncology Team DosimetryNursingPhysicianTherapistsPhysicist

24. Radiation Oncology Services – VA San Antonio Advantages of Contracting Services Minimal investment No staff requirement Avoid direct liability for complex services Disadvantages of Contracting Services Patient care at outside facility Data security - PHI Complicated coordination of care Quality assurance Costs

25. 2010 Radiation Oncology Contracting Expenditures for 1A Facilities Million Dollars

26. VA & DOD Sharing of Resources Defense Base Closure and Realignment Commission led to DOD consolidation of radiation oncology services at SAMMC Availability of equipment at Wilford Hall Medical Center on Lackland AFB Excellent opportunity for VA to transition care in house DOD provides equipment, space, and support services VA to provide staff and implement policies and procedures for clinical care

27. Mutually Beneficial DOD Equipment utilization Less unoccupied space Biomedical support staff continue to enjoy expanded training Continue to support the soldier after leaving the service VA Quality assurance Timely care Coordination of care Cost savings

28. MOU – Memorandum of understanding Sharing agreement between VA & DOD VA pays fixed and variable costs Space Biomedical support Maintain hardware/ software support contracts Pays for routine medical supplies provided by the DOD VA provides staffing

29. Accomplishment s 791 Veterans treated 16,890 treatments delivered safely First VA patient treated April 2012

30. Accomplishment s 791 Veterans treated 16,890 treatments delivered safely ACR Accreditation achieved June 2014 Excellent treatment metrics Palliative sim to treat < 5 days Prostate < 15 days Head & Neck 11-12 days First VA patient treated April 2012

31. Cost Savings

32. 3 rd Party Insurance Payments to VA Fiscal YearAmount Paid by Insurance 2012 $1,623,980.39 2013 $1,986,880.07 2014 $2,764,800.41 2015 $2,936,501.88

33. Anesthetic and Perioperative Implications of Radiation Therapy - A Primer for Anesthesiologists, Intensivists and Pain Physicians Grand Rounds – August 4, 2015 Department of Anesthesia and Operative Services, San Antonio Military Medical Center Elizabeth Maani, MD Department of Radiation Oncology South Texas VA Health Care System

34. Collaborative Projects Grand Rounds at SAMMC Poster presentation

35. Collaborative Projects Grand Rounds at SAMMC Poster presentation Prosthodontics JLV – Joint Legacy Viewer

37. Collaborative Projects Grand Rounds at SAMMC Poster presentation Prosthodontics JLV – Joint Legacy Viewer Tumor Boards w/ SAMMC ENT Thoracic 59 th MDW Chaplain Services

38. Challenges VA patient access to military facility Aging equipment Wilford Hall Demolition Hiring and retaining staff – collaboration helps

39. VA Care and the New Normal in Military City, USA: Innovative Collaborations with DOD and Community Questions?

40. Obtaining CME/CE Credit If you would like to receive continuing education credit for this activity, please visit: http://amsus.cds.pesgce.com