[inaudible conversations] all right, so before we have the doctor, up to give what will be great keynote remarks, i want to start the morning off with having a conversation with you about something that is near and dear to me as one of those two represents a Success Story of the great specialized care system, spinal cord injury does the system of care. Before i get to exactly what the topic is, i want to ask a couple questions. What are some of the reasons why one becomes a clinician . Why do you choose to become even. Raise your hand if its money. A bunch of millionaires in here. Social status. Everybody respects about her. Job security. You always have people focus on getting better. If you are a healer, youve got some job security and its probably a combination of all of those. But again, from perspective of the statement, im willing to bet somewhere on the list of what brought you into your discipline was compassion. What is compassion . A feeling of deep sympathy for another whose stricken by this. What are we talking about . People of become disabled, diagnosed with disease with a strong desire to alleviate the suffering. It puts you in a position of the healer. As clinicians, you literally alleviate suffering. By show of hands, how many of you are va clinicians . Im a neo, we cannot doubt of the say you have compassion with each and every patient you touch, each and every one of them. Not a lot of hands. Should be more than that. If youre trying, at least you aspire to show compassion with each and every patient. Alright, so so tell me this. Then why are we in this position, where you enjoy the privilege of providing care for the nations, our heroes . Is your system now where they go away. Ill talk about an excellent nba has to make it more successful. Specifically spinal cord injury and disease system of care that is enduring that earthquake in testing its foundation. How do we get there . What happened . We could talk about phoenix. We could talk about toma, all the other major things. But im talking about what i see when i go to your individual facilities and i talked to the nurse says and leadership about making a Foundational Mission a priority. Im talking about when access to care is denied. You show it. I believe that. The question today, is that enough . I dont believe its enough. Not with what is going on today. Lets separate the power to heal from another critical aspect of care, that we consider important. Empathy. The psychological identification with vicarious experiencing or attitudes of another in this case, the veteran. Suffer trauma, suffer disease, trauma, exposure. This is what we are talking about. How is empathy different from compassion . Unlike passion come empathy is not about alleviating suffering. Its about something rarely if ever found, a military cultural competency you wont see outside of the va in many cases. It is your Competitive Edge talking about competing with other systems. That is the edge you have if you know what it really means. The question is, do we know what it really means to be empathetic what role does it play in your role as healers . That is the question we are going to test this morning. I want to do that by revisiting my journey, taking you on my journey. I want you to bear with me. Close your eyes for a moment and stretch. Close your eyes. I see you. Empathy. I want you to stretch your imagination. Open your eyes. That is how fast this happens. No warning. At this point, stop moving. You are quadriplegics. Stop moving. The side of the room, youre paralyzed. You are lucky. You could to move your arms and legs, but you cant move anything else. Bear with me. Your nose itches, you cant move. You cant. You are paralyzed. You have to accept it. Over here come you can wave your arms and stretch, but dont stretch her legs because you cant. You just have to accept it. I want you to take this journey with me for just a few minutes. Wife is sitting there nearly paralyzed right now as you are. After the accident he just suffered, not a chainsaw or lawnmower, the jaws of life. Your car is cut open mic you can. You smile twisted burnt metal and its going to haunt you for the rest of your life. Your body is extricated from the vehicle. The next thing you going completely unconscious is this. The first sound you hear when you wake up. This is what it sounds like to be maintained by a machine. You wake up to that sound. Thats what woke you up in fact. The next set of sounds will haunt you as you try to figure out what the heck happened while staring into the dark. Hospital sounds, missouri, cheerfulness, misery. A mix of everything. Youll be visited by a litany of people, people, doctors, nurses, social workers psychologists, nutritionists as he faced a mobility, sleeplessness, hunger, anxiety, depression and nonstop pain. And meanwhile, your marriage, kids, bills, classes, the thing you didnt get done all appears to freeze, but it doesnt. It simply moves on without you. And then on the preexisting conditions, all the choices you make that got you here, diet, oral hygiene, addictions, education model, trauma, exposure to combat, all of that now im foreseeably matters and has an impact. Now it matters. And then your own mind begins to play tricks on you. You shook your head come even though youre paralyzed. If you ever heard about the running dream bigger patients have . This is the dream were typically about 3 00 or 4 00 in the morning just as the sun is coming up during the middle of the dream sequence where you are in a wheelchair. You now understand what happened to you and your body starts to force you to think about what it was like before this happened to you. Youre moving along and suddenly take the first step, you stand up, take the first step, step, step, trot, trot are running as fast as you can and then you wake up. No matter how hard you try, you cant go back to sleep to get back into that body that knew what it felt like to run. This is your mind doing this to you. I want to talk a little bit about my first medical family conference in the way it went. By uncle bill is a vietnam veteran gunnery sergeant. When i became paralyzed, he was one that came on the conference, marine corps, drill and start your and he didnt want to see me this way. He said dr. , is my nephew ever going to walk again . Dr. . No. My thoughts are what . Thats it . That simple . What about the 3 that what began . Statistics. They might be one of the 3 . You are a doctor. You are not god. How do you know . How are you so certain that you can basically define my life in two letters, one word, no. Speaking of god, why me . What did i do . Does anybody even care . A completed rehab and tried to move on with my life, my new life and now im a veteran who is homeless. Now im an angry veteran. Now im not compliant. Im overweight, making poor dietary choices. Im a burden to you, a veteran being denied access. The veteran being denied the drug i need. Im a veteran and its a wheelchair fixed right now, a veteran who fears retaliation if i complain. Im an undesirable. I am a human being and i need your help. Please dont make me wait. Please dont make me wait a second longer. Does anyone care . I wonder if thats the last question he asked before he died alone. Hes not an abstraction to me. This is a person that i talked to, touched, got to know. I dont need to tell you what happened to him because it is right. Heres the thing. He became disillusioned with the relationship he had with his providers in the va. Some have a dramatic brain injury. He was an opioid abuse her. There were reasons. An undesirable. He undesirable. You said you know what, im not doing this. I will pay for my care in the private sector. And now live with paralysis. Please move your legs, move them around. Move your arms, quadriplegics. You are doing it for me. Move your legs, stretch. Feels good, doesnt it . Now tell me, anybody who is a healer, ever deny access to care. Ever slow down in admission, ever put put something aside and make someone wait who never had that get that ive just given you. Or leave a better and isolation or put policy and process and rules before compassion. I know you are all people, you have to make a living forget to follow rules to keep your job and your professionals. Guess what. We are not professional patients. You dont give us our purpose. We give you your purpose. We are why you exist and im thankful that you exist. So in closing, we talked about this yesterday. There are forces out there that want to eliminate this specialized system of care pic again were not talking about expanding to the community and all the things that have to happen to give greater access to quit talking about this specific system of care. And they will move a step closer to be successful with every that we end up finding out about. Every one of those would be the reason. Your Competitive Edge in these times is to provide care with passion, but more importantly your ability to emphasize. I want to thank you this morning for empathizing with me. Thank you. [applause] do you want to do that after his talk . [inaudible conversations] good morning. My name is carl blake, associate director of Government Relations for paralyzed veterans of america and here in washington, d. C. Before introduce our keynote i want to say to sherman, im one of those 3 . 3 . Im a pva member who is fortunate to have been able to move my legs. But it rings very true listening to what sherman had to say because what you do matters to me as an actual user of the va Healthcare System so i thank you all for being here. You all make a huge difference for a lot of people like me and i really dont know what we would do without folks like you. So this morning im stalling a little bit. We are fortunate to be joined this morning by our keynote doctor baligh yehia. He is currently the deputy undersecretary for health, for Community Care. It probably goes without saying that he maybe has the toughest riddle to crack in washington, d. C. , right now, how to deliver on access that is continuing to grow while expanding that access into the trinity which is a complicated proposition, all the while his rather by a political minefield trying to solve this problem. I certainly dont envy what dr. Yehia has to deal with, even though we kind of cross paths, this i do with the political environment entirely. So its a complicated proposition. I asked him, i said whats the one thing you want these folks in this audience to know most . And he said they need to know that im a practicing the a physician. You will note he raised his hand when sherman asked the question. He has a vested interest in the system that we are talking about today. I think you probably have his bio. I couldnt do justice to the number of awards if received, his background. He received his m. D. From university of florida. He did his residency at Johns Hopkins and hes been at the university of pennsylvania medical system forced sometime that there is also a professor there while also practicing in the va and while navigating the political minefield that is Community Care policy with va at the national level. So please show a nice warm welcome for our keynote speaker this morning, dr. Baligh yehia. [applause] thank you all and hilly okay . All right. Thank you for having me today. Sherman and i have done a couple of conversations together that are on different panels. Im always inspired by what he has to say and i think its important for clinicians to be moved by talks like that because i think it shows that you are open and that you are there to do the right thing for patients. So thank you for your story. What i want to talk about today is really how we move [inaudible] we cant hear you. [inaudible conversations] [inaudible] i can use the podium mic. Can you guys hear me okay . All right. Lets start again. So today were going to talk a little bit about how to move towards a highperforming network. They have already limited me because the folks in november i like use my hands and i like to walk around some going to do my best to stay in front of this microphone. I think we should start where many Healthcare Organizations across the country are starting, which is how do you maximize value for our patients . For us its our commitment to that trend. Many of you have seen a slight slimmer to this which is really the aaa of healthcare, which is how can we get better health, better care and experiences and then better value for our patients. This is really a low bit of what many Healthcare Systems and plants and organizations across the country are striving to do in this environment, which is really maximizing the good expenses and care and positive outcomes of the want for our patients while at the same time being as efficient as possible in using our resources. When we think about how to maximize the Value Proposition for our veterans i think we really need to start with them and we need to think a little bit about where they are. We have veterans that live in every corner of the united states, literally in the smallest of cities or smallest accounts to the largest of cities. This is very unlike other Healthcare Systems or health plans, where they actually get to choose which market they enter into and then they compete for patients. We are very different. We need to provide healthcare to a population that can live anywhere. And so that fundamentally makes what we do different than entering into a market organically and say hey, we think is a good market to begin, we are going to try to attract patients to a. We had to go with the patients are, not other way around. Its important to note that we cant have the physical infrastructure in every single one of those locations. So it really starts, we really start to think about how do you create a network of providers across the country to take care of our veterans that live anywhere. We also need to the thing about this in the context of increasing demand for care. As many of you know we have an aging population, and with age comes more comorbidity conditions and other issues. You can see in this graph the number of appointments both inside and outside the va has been growing in recent years. Not only are we trying to make changes to develop a highperforming network, we are doing in the context of more individuals coming to us to receive their healthcare. We also need to think about the location, and so i am like many of yo you are the one of your patient is different and theres unique nuances about who they are as an individual of what their medical condition is. We have the same thing in different geographies. I just put up three different locations for you as an example. When we think about alaska or maybe some more of the front to states like montana you will see a large proportion of the care is actually being delivered by partnerships. Or in alaska happens to be great partnerships with our dod facility and our Tribal Health partners in that state. So actually more care is delivered outside of our walls than inside of her walls. Rejected when you think about new york city where we have a lot of different clinics and different access points, and so more likely they will be treated by a va provider versus a committee provided. Its important to think about that as we think that moving towards the highperforming network. He can it be the same in every location. It has to very buy that geography and the population density of that trend it has to ver vary by that geography. It varies by specialty. For decades now there are sort of things weve been partnering for, freestanding dialysis clinic. We buy a lot of dental care. Most were all Maternity Care is done outside of the va wall. Community Nursing Homes and home health whereas there are certain things that are provided within a va facility such as Mental Health care services, geriatri geriatrics, rehab medicine, spinal cord energ injury. Not only do they vary geography also very by what type of care is purchased. So thats important because when you think about how do we design the right system and it is definitely the topic of discussion these days here in d. C. , is whats this right proportion of va Community Care and how can they work together. You need to think about all those different nuances. I3 you need to think about all those different nuances. I really am a person that doesnt think of this as all or none. I really given us two sides of the same coin. Va care and Community Care are linked and have been linked for decades and will talk about them in the sector. It just seems to happen right now theres a lot spotlight on Community Care but weve been in the business of partnership at va for decades upon decades. What do i mean by a highperforming network . I want to talk about the characteristics of that, that we are striving towards and then talk more about how do we get there throughout the rest of our time together. First, it means strengthening and growing our Foundational Services. You might have heard this term by the secretary or others. Every single Healthcare System across the country dhat excel in every single area. I think its important for us to invest in the services that are most important to veterans, that a most unique to the va and make sure that their stateoftheart and worldclass. Thats what foundational seundatices means is making sure that they care that cannot be provided of our walls is delivered with excellence to all the veterans that need it. At the same time it means identifying those seundatices tt are readily available in the community and delivered in a high quality, and partnering with the right people to help deliver that care to our veteran population. Agan, its hard to be 100 perfect in every single field. Most Healthcare Systems focus their efforts on developing certain excellence and we want to make sure that we do that as well. We also want to move towards a process of monitoring uality satisfaction and value. And again a lot of Healthcare Systems across the u. S. For their own entity can do that. We are now moving into this world of partnershusi and networks but we dont have the best clarity on what is the quality of our community partners, how are they using an organ healthcare . What is the veteran satisfaction with those providers . So we need to develop those competencies as a system so that we can make sure we provide our patients with information on not on the quality care in va which i think is well known, but also within our network of providers they might end up accessing or touching for one type of care or another. We also need to transition to seamless Electronic Exchange of health im sormation. Again this is that something thats unique to the department but its what all of medicine is trying to achieve. The more care that we have inside and outside the va, the more coordination that has to occur. And really the currency good coordination is information, making sure that our patients know who when where and why theyre going to a different provider, making sure as a va clinician i understand what tests are or what the care plan was if i referred some out and vice versa for the committee provider making sure they have the records that they need and that the patients they need so we dont duplicate tests, we dont order things that dont need to be ordered. Answer this idea of Health Information exchange has become even more critical in the world of highperforming network. We also need to start to evolve delan with the rest of the healthcare field to not only, i call it paying for volume or widget, thingt paying for value. Had we partner with those providers and really reward them for delivering the outcomes that we need. Thats going to be very importanems a lot of the healthcare field is now moving to something called valuebased payments. At the eight were starting to explore what those are not but i view this as part of our future of making sure that our partnerships are really centered around Value Proposition and not just n it ber of vol it e of vis that is being conducted. And then lastly we need to think about new care mccuels that support personalized and coordinated care. What i mean about care mccuels s really this concept that we have care that is received within our va facilities. Theres care that we might purchase on death of our veterans indic unity, and as many of you know about 8its of our veterans have another form of ind is tendent health insurae that they can use it anytime that they want. So when you think about these circles come inside va care, purchase care and then care that is accessed privately, how do you connect the dots . When a talk about care models its about how you connect the dots between those three different rings and making sure that a patient isnt being prescribed opioid in one place and another place, and that everyone understands that they are working on the same care plan. Like i said these are things that are challenges for the vhie thingt also challenges for amern medicine. Thats what i see an opportunity for us to not o like spinal cord injury and rehabilitation medicine and military and culgesral competent care, but also an area of coordination and how can we acgesally deliver care in a coordinated manner that is really, that the rest of healthcare is l ocking towards cracking that not. So now that a giggle a bit of where we want to get to i want to move toward hyper from network. I want to take us back and think about how has commi soee care if all and how im going to get to that in state. Delan, when i came to the va te office of Community Care was nonexistent. Ee years there, his office was formed. However, when you look back as a mention weve been doing partnerships since the 1940s. Again, its all concept that i i talked about before. With veterans that live in every corner of the united states. How do you service them, make sure they get the care that they need . Those partnerships really start to blossom with her academic teaching affiliates. Im a prime example of that. When i was in medical sch ocl or of florida, i trained at the gainesville north florida va. That was my first time on the medicine ward as a thirdyear medical student. I remember being asked by my attending to place an iv in one of our veterans patients and can osem a third trear medical st genems you are actually interacting with patients to your sdecaer excited you are also very neundatous because i havent had that much practice and i was te t the ied. I remember sitting at the bedside of one of our veteran patients and he could tell that i was a litndue bit ner, i he said, you know, they call a doctor, dr. Yehia, dont worry, ough a lot worse. Give it a try. [laughing] and that really gave me a sense of call him and i was able to successfully place the ib up with the fluids that he needed. Thingt i think like me and manyf the doctors in this room and across the country, part of the reason why either is to get back because i would not be for him today without the care that i received and the teaching that i received from our veteran patients in places like in gainesville. So that academic teaching iliations i think is critical because we do train the workforce of america in, not only in medicine but in nursing and what i could, you name it. So then it started to grow even mors a we were working oneonone with the dod, then became more formalized. We then started a program called project hero followed by project arch we formalized relationships with Indian Health service and tringsal health partners. And not until the end of 2013 did a Large National contract called pccc out and shortly after that came the Choice Program. You can see theres been kind of an increase in the last couple of years really focusing on choice but choice is one of multiple programs that we access the committee. This idea of partnern busi, greater relationships to take your veteran patients is not new. So really what we need to figure out is how to recreate that network of how to make sure those pare lern busis work and d we make sure that we are referring out the right type of care in the right lortlations. What other point i will mention is, too much of a g ocd thing sometimes creates problems and thats a little bit of what happened hers a over time rather than sun city many of the several programs they just added on an added on and aaboued under so now in 2ed7 we have eight ways of doing kind of the same thing which is gradinpre soy partnerships withe entities, referring care and pu refhasing cars a and all of them have dt the fert criteria, different rules surrounding them to acttion lly create some proare we will talk a bit more about that and so how do we get to a state where we can consolidate and stream in all these different programs and make them work for our veterans. Of making a bit about the choice act. I think for many of you you miour vt be living and breathing this but it was really born in august oft ofed b4 to access toe department and provided various resources to Access Medical care for eligingsle veterans. The eliginot this program are numerous with the ones that we t outically talk about our 30 days. If youre waiting for or can be seen at the va and need to be ating moreoufe w than 30 days, geographic distance which is 4 memiles from a primary care pry,sician, unusual access a burden, if you have to go over mountans and last as or various other pry,sil structures, or you have the sort of medical condition that would prevent you from traveling to a va. The list goes on and on and on thingt thats a bit l eie the overview of the program theres a set of criteria for patients and then theres a set of eligingsility criteria for the types of providers we work with. There is a set amount of money to administer this program that was recently, a nive intlusionf dollars was placed in o couple weeks ago. The challenges of this program, i get a lot of town halls with veterans and Community Providers across the country, and for many of you that a resea refh as you might know of a concept called maturation where apartner you he a n it ber of dt the ferent ints you start hearing the same thing. It didnt take long for me to start hearing the same thing. This program has a lot of issues and we will talk about those. Some of those issues stem from the fact we were required by law to distringsute 9 million cards, choice cards, but not every one of those patients is eligiare for the prl traps as you can see those Eligibility Criteria are very limited. When you have a car that l octhe list a an insurance card to a veteran or any patient, they think thvie canupust go out and get care. That wasnt the case. We had a lot of education to do to er tcate folthe use the program. And a lot of homes along the way because people got care that wasnt authorized and it created problems. Also, we had 90 days to administer to stand at this program. I always like to compare to tricare which is really a prl tram that is somewhat similr in dod. Ee months. Days, ts ee years to stand at this program. Standing up a very Large National program in the short amount of time creates problems. Also puts us with an eight ball ous to achieve this timeline, one of the things they did was take this contract, the pccc contact and modify it to do the Choice Program for our contracting partners were not designed to run this race at that point. Thats up with the purpose, thats not what they signed up for initially. You can see the challenges. We had a patient time of your bread a lot of very confusing, we had our partners that would initially came to work with us on Something Different. Plus since then weve changed that lost six times which indeed another sense of how many different issues existed in that legislation that we needed ty, ai wabouress. While the program is better than when it was at the bly,inning, its not what we need to do. My sense is you cant keep improving on something that is hingsndamentally needs to be changed and so were looking for a brandnew way to approach him a dictator, a consolidation of all the two programs and a modernization not this rst a contintion tion of the stagess o of the current program. I think one of the things i learned ous getting trained as a clinician was really was to listen and thats one of the fame our team did is we actively listen to our stakeholders, our veterans, our dortltors, our vsos at her Community Providers and healthcare leaders, and heres what they told us. And again this gets to the concert i talked about of semantic saturation and i hear this in almost every scene setting that i sent around whether its a roundtaare townhall with our patients and their doctors and our community partners. We have way t oc many Eligibility Criteria. People are conhingsseng. Cannot access Community Care or not . How do i know course where do i find out. So we hear that a lot, theres some computer am i eligible or not . From a special from the Community Providers and rva staff. Theres multiple referrals and ossthorization requirements. Thvie vary by the program. For this path what you need to do, thouour vt this for or fillt these boxes. For this pathway you need to do something dt the ferent. Lack of standard care coordination, i see this again time and time again for every facility is doing Something Different and the care clinician processed also varies by prl traps in tersom of our two Major Network where different ways to partner with providers. Ouour v large contracts, summer three things called provider agreements. Ouour v ainiciliation agreements. Our Committee Partners might be working with us under more than one way and thats also hard for them. To them there seeing our veteran patients. Some of the behind the scene complicates it there is variaare pay the reconstruction. S it mer actress set in law of what the payment rates are. Others are more varied and creates concision when to our partners ac the va different prl trasom have dt the ferent r. Until recently th choice prograb as a secondary payer for certain conditions which means that veterans have to pay cautious upfront or toaster than awer other prl traps so it created, taking it created that confusion. Lastly, customer service. Who do you call come how to make sure theyre picking up the phones and theame questions . This is a highlevel summary of many of the things that i heard ous partners and from you and others like you across the count mu. Fer that that that that that with that. We really tried to think of what is the veterans explained to the committee care process . Without of different engineers and design thinkers, we really mapped out the steps that a veteran takes as they go from the va to the community and back. This is really what we been striving towards at the office of committee care since the beginning. Our goal is to deliver one program that is easy to understand, simple to administer, and that meets the needs of veterans and their families, Community Providers and va staff. So i start all of our meetings and work with that in mind. That is our goal, all the different projects and things we do stem from that. Really theres six touch points were identified along that better journey through Community Care. One is eligibility. We really want to focus on providing easytounderstand eligibility information to all of our stakeholders. The second is referrals. We want to provide veterans time access to a committee provider of their choice. When we think about care coordination i really think this is the secret sauce for success. If we can make care clinician work, i think we can make a hyper from network work and we can serve as a model for the rest of the industry, which is coordinating care through Seamless Exchange of information. When we think about the Community Care network we want to make sure we have a Robust Network that provides access to highquality Community Providers both inside and outside the va. Provider payment, to born for us to be good partners for providers and that means paying timely and accurately. If we cannot be good partners for our doctors in the committee, why would they work with us and why would they take care of our veterans . I think thats a very important piece to ensure that we provide those services that are needed to our patients. And then lastly, customer service, which is providing quick resolution of questions and inquiries to our various stakeholders. So thats wher what we started e start with a veteran at the center and the journey, and any other component that if that was very important is how do you come if you want to create any lasting changes it really needs to come from the ground up. While we set the direction, we really needed the help of frontline staff to do that. We establish what i call tiger teams or portfolio teams that really touched on each one of those different important parts of the veterans journey. People came out of the woodwork. All you had to do was ask. We put out a call into two once to help us solve this problem and work on making this Program Better . Nurses, doctors, administrators, schedulers, all kinds of folks. Not only did they raise their hands of the volunteered to go in detail to our team for three months at a time where they were away from the job focusing specifically on creating solutions. We have been doing what i call sprints for the last year and half, just working on different projects that could move the needle in each one of those key areas that are veterans told us were important to them. So involving that frontline staff i think its really important to creating that change. Its funny, the big ideas and the big changes that weve been making, whether its on a contract perspective, rolling out new i. T. Projects or care models is not from folks here. They are folks from the frontlines saying i have a better way doing this, let me share with you. If youre open to listening, its amazing what you can do. So heres a little bit of whats happened. Because of some of these different changes that weve been making, there has been a dramatic increase in choice authorizations over the last couple of years. In the first year of the program there was only about just a a little less than 300,000 authorizations. Now we have more than 3. 8 million authorizations that have been sent since the start of the program with dramatic growth this year and last year. An authorization is really an episode of care. It could lead to multiple appointments. You might authorize someone for five or six pt appointments and it would count as one authorization. Behind that number are millions of appointments. We have been working to increase our Provider Network and make sure we have the top quality providers that can help service veterans. When we first started in the first year we had about 175,000 different entities across the country. These are hospitals, clinics. Now we have almost half a million. And really focusing not just on find out anyone who needs him to want to sign up a really signing at the right folks in the right places and making sure they are the ones that are delivering excellent quality care. Again come just to tell you all a bit about how we been working with her contracting partners as i described before, one of the ways we administered the Choice Program is too large a National Contract weve modified those contracts or than 80 times to make them work better for our patients and for you and for our Community Providers. It shows you the fact went to modify it so much that they were not designed originally to run this race, which is why right now we have an open procurement down the street to really help us develop a new Network Moving forward and were excited about that. One of the things i also learned again taking a play from the tricare playbook was collaboration. When you collaborate, the best way to do it is really to be in that same room as someone. So we have right now at 74 74 different locations across the country where we have embedded our contracting staff with our va employees in the office of committee care to help improve that process. Thats been very successful and we hope to continue to do that. The last one is really i mentioned about care coronation and the exchange of information we have more than doubled the number of partners that we work with to the electronic Health Information exchanges. These exchanges are set up on a community level. They are not set up by va but the participates. And now we are part, we can now Exchange Information for 1. 2 million veterans that we were not able to before. Which allows those committee provided and the va to t. A. P. Into that Electronic Health exchange and make sure that we know whats been done by whats to be done. Thats all a bit of where we came from where what weve been doing, just want to focus a little bit on tomorrow which is where we want to go. As you can see we have multiple programs, all of them create a level of confusion, Administrative Burden and bureaucracy. What does the future look like . This is really the opportune time of the next couple of months the department and partnership with congress and our colleagues will really be discussing this question of how to recreate this highperforming network and consolidate and modernize our Community Care program while at the same time strengthening va . I have a couple just thoughts. We want to move from administrative Eligibility Criteria like those 30 days and 40 miles which i always tell folks there was nothing in medical school that taught me thats how you think about access to care. There was nothing about, if youre less than 30 or more than 30 or if you live this far away or that far away. We need to move from these administrative, arbitrary criteria to clinicallybased criteria. When i talk about clinicallybased it really, really means having a conversation between a patient and the doctor do understand where the right place to get care is, when is the best time to get that care and how should that care be delivered. We really want to move from excessive bureaucracy and confusion to making something that is simple, easytouse with more choices. As you can imagine, just by the fact of having all these different programs, by nature you are trading bureaucracy and administrative hurdles. We want to get to one program and we do that is really like taking the best of each of the different programs and kind of combining them together. And when i talk about making eligibility clear, making the referral process simple, that creates efficiencies in the system and make it more userfriendly for everyone. We need to go from minimal care coordination to robust care coordination. I cant harp on this enough. The more care that we purchase outside or that we partner with, the better we have. I think we do a good job especially in this area a spinal cord injury and cancer care, in our primary care and we are coordinating very well within our system and our team. Now we need to figure out how to take this concept and figure out how to chordate as part of a network. Those are different skill sets and will require a different tool but i think its important for us to do that so that we can really have the whole picture and provide the best care for our patients. And lastly, again, its very important we need to move from lack of timely payments and the data prostitute something that is timely and contemporary. Pushing towards a valuebased models, pushing towards citizens and partnerships that can help us process our bills more accurately and timely so we can build the network that we need to build for our va staff and for our veterans. Its all about the veteran provider relationship, thats what i think is very important to me is when i think about the Choice Program today. Theres a lot that it got in the way of veteran provider relations, those criteria which are arbitrary piccolo bit at the different handoffs we had to do with our third party. Its really not allowed that relationship to thrive as it should be. And so as we move into what the new program could look like, i think we have to keep that in mind, that that provider relationship with the key. Its not only heating and therapeutic in nature but its also provides the most, that dyad is really where that knowledgebase provides of whats needed for that patient and how can we support that. And then lastly i will end on this comes with how do veterans benefit. What we hope to get to in the future is really that improve care coordination with the consistent point of contact. We want to make sure that not only do our patients that are doctors have access to the seamless information. We actually hope to create something new which is really a robust convenient clear clinics so someone has the sniffles or paper cut or needs to get something and cant get to it quickly, they can access some of these walking types of care. We really want, we really want of the best in class in our va Foundational Services and also partner with highs quality provided to create that network. I think its important transparency for our veteran patients on the type of care that we do as well as the type of care that in the community. And then you tools to help us navigate the system, whether its scheduling or coordinating care. So lastly, where do we go from here . I think the time is now. This is literally the opportunity that we have to get this right. A couple months ago they gave us about 2. 1 billion to the Choice Program. That will carry us a number of months into the future but definitely not for the rest of the year. I think while we have that time. Its really imperative on us to work with our partners and congress to help us consolidate and modernize all these different programs and get it right so that we dont keep kicking the can down the road. And getting the right to be really means strengthening the va, building a highperforming network that is coventry, cracking the not on Seamless Exchange of information and care coordination. And if we can get those three pieces right, i think we can end up in a better place than we are today. So with that i will and and im happy to take any questions. Again i want to thank you all for your service and for the work that you do every single day. Its great to be and i want to thank carl and sherman and the rest of the team for having me. The event excellent partners and this is not, this is hard. Judges would also mention that the folks, the brain trust over your thats working on trying to get this right, if it was simply wouldve been done already. And so i look forward to learning from you more through your questions today to see how you can help us shape the future for va Community Care. Thank you. [applause] so what we would like free to do, if you have a question, you have the mic stand, come straightforward and you can ask your question. Dr. Yehia has been generous with his time. He still has about 20 minute so he has agreed to take any questions. I asked that its harder he didnt talk about politics. Its really hard. So if you like to come to the mic stand. Thank you very much for your talk this morning. Im michael, chief of spinal cord injury at the augustine va. Since the consolidation of the Choice Program just weeks ago with the elimination of choice first and basically rolling everything in, we have had a terrible time, and absolutely unbelievable challenge. Because for this population there is a distinct and very important differentiation between the Choice Program as you described here, seeing an provider, a specialist, a physical therapist in community, seeing a primary care doctor close to home. In this population we are highly specialized area, and the providers in the community dont know how to take care of our patients. So thats the first piece. So we are very dependent on the beneficiary travel program, which may not be part of choice but needs to be maintained at all costs for our population. The second piece is the care in the community to us means homecare. The Homecare Services, have been eliminated in many situations in our center because it comes out of hospitalbased dollars. And so it takes not quite an act of congress but an act of the director to approve unskilled and skilled homecare for people with disabilities who are dependent on that. As a result they end up having to stay in the hospital. We cant even get them into a nursing home if they are not eligible for a va contract. And so by lumping the Homecare Services in with the provider services, two different animals, we have been, this whole problem has been created for us. So, is it mikey said . Okay, mike, at the end of this, come back and talk with me and kristen so we can help clarify some of it. So the Homecare Services are not stop t. When we got the new Community Care dollars of the Choice Program, many of the Homecare Services that were being provided for through things call provider agreements. So we pushed out a lot of resources to the field in the last couple of weeks to do that, so you should be seeing, you should be able to access those in the what you need to access the if youre having issues with that lets talk and we can figure how we can help you because its not because of a lack of resources. We have plenty of resources to be able to deliver those homecare resources with that new infusion of dollars. Your other point was about really the committee providers and the type of care that they deliver. Like many of you may be you might a practice both insanity and outside the fee. And i think, im not one to kind of, to paint them with the same picture. I think theres a ton of Community Providers that are delivering excellent care. Our goal when we talk about building this highperforming network is to do two things. Number one is to strengthen those va services so hopefully they exist, so you dont need to refer to a community provided because we can provide the inhouse, timely and stateoftheart. So thats the first point of like what i mean by highperforming network is for certain things like spinal cord injury and he shouldnt even really need to be referring out. We need to make sure that they are there to support our patients. At the same time there are things we think are provide as high called in the community and maybe dont require that expertise as much in military and cultural competency, like the quick exam, a colonoscopy, just for an example. Then how do it didnt buy those high make sure that theyre in our network . The last thing i will say is i think its part of our job to educate and provide resources. One of the things with done is we started 30 much like a Free Training Program for Community Providers where they can get free cme credits. We have a four course cme program on military cultural competency, free of charge. They can go to a website, get the certificate and they can get that. We also have a lot of opioid Mental Health care and others. Even in some areas we are providing services, if theres a committee provider that has a question, they can actually reach out to some folks in the va to get that answer. We are not where we need to be, but i think thats going to be, as we start to really refine what that network looks like, i hope that we have more and more providers that have completed those sort of training working with us in a collaborative manner. Ill take it a step even further. We want to reward and incentivize those providers to do that. So when i talk about valuebased payments come right now we are paying for volume. When you think about a lot of health plans, it might be incentivizing, minimizing the use of some care and thats how they become a preferred status. We want the complete opposite of what you make sure that our providers and the communities that are delivering high quality care are investing in taking care of veterans and learning about veterans, they might need to get a little bit plusup in how we work with them contractually. So thats what we want to get to the we are definitely not there yet but i think, i hope that over time you will start to see more of that. Im from the minneapolis va, spinal cord center. Followup question regarding the homecare. In our facility we havent had a problem with authorization for homecare. We dont have a problem with having agencies that have been contracted. Our problem is the workforce. So we can make referrals but the agencies dont have staff and with excess hospitalizations, premature nursing home placement and, in fact, deaths because we cant organize that. What can the va do to improve the workforce, not the contracting, but the workforce for homecare, particularly for the highest need kind of patience who need daily or twice daily intensive homecare like spinal cord injury . I think thats a great question and i dont know if i have the whole answer there, but you bring up this very important point, which va is part of the fabric of the american Healthcare System. So theres certain macro forces above all that we also face. A lot of our stakeholders may not know that and always try to make a distinction between was a deep issue and was an american medicine issue. That workforce issue is an american medicine issue. We have such a dearth of Mental Health provide provider especian certain areas, primary care providers to get sounds like a minneapolis, home health agencies, it probably is not religious in minneapolis va but maybe the university of minnesota and others that are experiencing this issue. We are part of that and we train such a large group of clinicians. One of the things were trying to do in this new proposal is really focusing on graduate medical education. The original choice act there was some resources that were provided to help va train more residents. We hope to do something similar in the future, asking to do something similar in the future where we would be able to cover the cost of our residency for payback time in the va with their completed. Very similar to what the public Health Service does for the dod does pick so i hope that we can start to contribute somewhat to that issue by Training Clinicians and then bringing them back to those shortage areas to practice. And as you know many folks that actually complete the Residency Training team to stay in that area. Hopefully they will stay and continue serving our veteran population and others. Thats a tough one and i think we need to be working with others in the american medicine spectrum to address that. So i would like to continue our homecare discussion, since thats a huge part of whats going on with the choice. I am from the denver va. We are currently a spinal cord injury spokes site. By next year are supposed to be a hub the site. What are Homecare Department has now done is gone to medicare criteria to authorize all homecare. And i will tell you that the majority of my spinal cord injury patients are not homebound. They are young, active, healthy men, for the most part. They work fulltime in many cases. They require assistance in their home in order to be able to get up in the morning, get dressed, get out to work on time. And that does not meet medicare criteria. So we have battled with our Homecare Department on making the exceptions for our spinal cord injury patients. And that includes our ms patients as well, and we get pushback. And dislikes no, the a requires medicare criteria. All right, this doesnt jibe it is if you go to medicare criteria, which many of our veterans would qualify for, medicaid does not have that same home band homebound require that it were kind to work with them in order to get some of those changes. But like our colleague has just said recently, homecare should not be a part of this Provider Network. It should be funded in a very separate way. Because it is utilized very carefully. In my facility, my department probably uses 90 of all healthcare authorized services because its a longterm. And so its not a shortterm you just had your hip replaced, you need si six to eight weeks of homecare. And so i think this needs to be looked at from a very different criteria on that community side. In addition to that, one of my frustrations with homecare, i never ever see the homecare notes. And when it asked for the homecare notes, my Homecare Department tells me they dont exist because the homecare people are not required to send in their notes in between. I can get the 485 and see what theyre supposed to be doing, but i have no reasonable expectation to know that that 485 is being carried out from one 45 to the next it would be really nice if there was an expectation that is like the committee provides, those homecare agencies were required to submit those notes to us so that we knew things were being carried out correctly. Ive had a patient on Speech Therapy that the Homecare Company is building as for, for four years billing. And thats not appropriate. Until i started asking for those notes and asking, and by the way, he was being seen for swallowing issues which he did not have, but thats what the documentation indicated. You know, so here we have four years of payments they Homecare Agency for a high level therapist that the patient didnt need and should never have been authorized. But because we dont have that followup, you know, i mean, its technically fraud because the patient didnt need that service, but i have no way of documenting that. So having some of those pieces in place. Sure. It sounds like we need a work group on home health. I have a couple volunteers it sounds like. [laughing] [applause] a few things i will say, nationally we dont come we havent set any sort of standards whether its medicare, medicaid so thats probably more local. One of the things im realizing is what i call standard episodes of care. We do this for many, especially for facilities that dont have a lot of specialty services. We tried to create a bundle, a package of Different Things that would be required for that. Perfect example is like for a Knee Replacement for a hip replacement where you bundle the things that patient needs. They need to see companies and imaging studies, they need to see the orthopod, they need a a surgical they need to do tt after. I could definitely see a standard episodes for spinal cord or injuries specific events different for homecare thats different in the homecare for after you had a surgery. I think theres a way to address that. Right now we are rolling out a number of these standard episodes over time. I think i would need you guys expertise to help us determine what would be appropriate, and you might have more than one depending on different conditions. Once we put those into the system they could be used anymore standardized fashion across the different facilities. I think thats solvable. It varies from one place to another. In some locations they are authorizing a tank, and others a little bit. We can work on that. I think for the records peace, this is what i was harping very strongly on exchange of information and care coronation because it is so critical. We have a couple new tools that we are just deploying. One sounds simple but its been making a big change and may be your team needs to access it, is literally secure email. Before a few months ago we couldnt really Exchange Information securely, encrypted, back and forth between Community Providers. Now we have a tool that does that. It can be part of your outlook. So we have deployed that to the committee carrots team and now were going to more broadly across the va. And so Community Care team. There should be nothing that stops you from communicating with the Home Health Agency and given those records. I think that we can provide in a way that it is up to a fax machine by three security electronic email. So again maybe we can touch base after and i can share with you a little bit about that. Denver is one of the sites that some of those resources, so we just need to connect the dots. Im from the boston va. Weve heard this morning the system of care and the va really is very strong system that provides the full spectrum all the way from acute and initial care to longterm care. But the one gap that is existing is assisted living. Im hoping that there are opportunities to explore with the community, partnership with the va to provide assisted Living Options for veterans who are aging with spinal cord injury but dont have to choose between living at home and being institutionalized. Looks to me like a Business Model. If i have an als patient and we dont do Clinical Care, we do the Business Model and theyve communicated with the provider, were lacking the clinical piece, that can help navigate. Clinical. When somebody is feeling theyre doing a great job beefing up the Clinical Care program, its not meeting the needs of veterans facetoface. Im glad you brought that up. Its a Clinical Care model and not a Clinical Care coordination model. When i first came to for Community Care. There was never a clinician leading this office. It was actually called the business office. Because they were transacting dollars back and forth to buy care. I think its a Clinical Program. Thats why im standing in front of you as a clinician leading this program. Its a Clinical Program and we need to think of it as such. Were talking about coordinating care. Were talking about the local office of Community Care really serves as that department when no services are available. When you have no radiation oncology, like everything else, theres a marriage between the business and clinical and some of the work were doing is working to align the local office of Community Care under more clinical type leadership, and weve created what we call our operating model that has nurses in there working with primary care providers or the care team. I hope that it evolves, you know, theres many good things about i hope we take the very good things about pacs and with the care coordination model like that. Im so glad you brought that up. Because its not we dont want it to be transactional. Its not did you fill out the right paper work, you received the records back from the doctor. Who do you need to contact them to let them know that it came back. We are an only in thele early stages of the culture, and we welcome your ideas, i think thats important. Unfortunately, im the bearer of bad news, she runs a tight schedule and im not going to mess up her schedule. If you have any questions for the doctor, forward any questions to her and well make sure to get it to him and his staff. I can promise theyre responsive to whatever we direct towards them. I think we owe him a round of applause for his time near. [applaus [applause] well, you can see were having some technical issues with our signal from the veterans with spinal cord injuries event hosted by the paralyzed veterans of america organization. Theyre about to take a short break and we expect to hear from doctors talking suicide by veterans with spinal card injuries. More to come on cspan2. Well, unfortunately, were having some technical challenges with our signal from the paralyzed Veterans Forum happening in suburban maryland this morning. Were correcting the problem and hope to go to live coverage. Were recording the event live on site and hope to have it later. Co