VA Community Clinics:

Networks' Efforts to Improve Veterans' Access to Primary Care Vary

HEHS-98-116: Published: Jun 15, 1998. Publicly Released: Jun 15, 1998.

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Pursuant to a congressional request, GAO provided information on the Veterans Health Administration's (VHA) use of community-based clinics to improve veterans' access to primary care, focusing on: (1) VHA's planning process for new community-based clinics; (2) networks' implementation of VHA's planning guidelines; and (3) VHA and network oversight of clinic operations.

GAO noted that: (1) VHA has strengthened the process that networks are to use when establishing new community-based clinics, thereby addressing several of GAO's recommendations; (2) VHA provided more detailed guidance, including a 30-minute travel standard and an expectation that clinics be established primarily to benefit current users rather than attract new users; (3) VHA developed a more structured planning process, including the development of network business plans covering a 5-year period, and established a task force in accordance with VHA's guidelines; (4) VHA's long-range goal is to increase the number of community-based clinics; (5) to that end, VHA has approved 198 clinics, and network business plans show that 402 additional clinics are to be established between 1998 and 2002; (6) the plans, however, do not address the percentage of current users who have reasonable access, or what percentage of those without reasonable access are targeted to receive enhanced access through the establishment of new clinics; (7) as a result, VHA's network business plans cannot be used to determine on a systemwide basis how well networks are using clinics to equalize veterans' access to primary care; (8) based on the limited information that networks can provide, it appears that the geographic accessibility of VHA primary care currently varies widely among networks and that while networks' efforts should reduce this variation, thousands of the VHA's 3.4 million current users will likely continue to have inequitable access for many years; (9) moreover, it appears that networks are planning to improve access for thousands of lower priority new users over the next two years, while thousands of higher priority current users are waiting considerably longer periods of time for reasonable access; (10) networks, which have primary responsibility for monitoring community-based clinic performance, have developed evaluation plans for proposed clinics, as VHA requires; (11) to date, few clinics have operated for more than 12 months; (12) as a result, most evaluation plans have not been implemented; and (13) network evaluation plans, however, vary widely, with few containing a common set of criteria or indicators that appear necessary to effectively assess clinic evaluations to monitor performance within or among networks.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to establish minimum criteria that all networks are to use annually for evaluating new clinics' performance.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: A VA workgroup has recommended performance measures for monitoring CBOC performance. Networks, however, are not required to use them annually.

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to require networks to plan and propose new community-based clinics in a manner that ensures that veterans with highest statutory priorities achieve reasonable access as quickly as possible, consistent with the requirements of the Veteran Health Care Reform Act of 1996.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: VA has taken one of two steps necessary to assure that veterans have reasonable access. VA has done an analysis that shows areas where high priority veterans could benefit. However, VA has not directed the networks to use the information to locate clinics and instead allows networks wide latitude in deciding where to locate clinics.

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to require networks to include in their business plans the percentage of: (1) current users, by priority status, who have reasonable access; (2) the remaining current users (without reasonable access), by priority status, who are targeted to receive improved access through the establishment of community clinics by 2002; and (3) current users, by priority status, who will not have reasonable access by 2002.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Not Implemented

    Comments: The VHA policy for Planning and Activating Community Based Outpatient Clinics (CBOCs) requires that a detailed description of the target market analysis and proposed workload projections for the CBOCs be included in each new CBOC proposal from the VISN. VA has also prepared a report which analyzes veterans access to care by priority status. However, VA has not projected the number of veterans who will receive improved access by establishment of community clinics through 2002, nor the number of veterans who will not have reasonable access by 2002. Nor has VA required these projections to be included in network business plans.

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to set a national target level of performance that focuses each network on a goal of providing reasonable geographic access to VHA primary care for the highest percentage of current users practical by 2002.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Not Implemented

    Comments: VA believes that its current efforts to improve access have proven successful because new community clinics have provided more veterans than ever before reasonable access to VHA primary care. VHA asserts that a national target is unnecessary and unwarranted because of this success.

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to require networks to annually report their evaluation results to the Capital Budgeting and Oversight Service, a unit within VA, and others for their use in reviewing proposals for new clinics and other purposes.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: A VA workgroup has completed a CBOC evaluation which has been shared with all networks and facilities to assist in their evaluation of local CBOC operations. In addition, networks assess CBOCs on a continuing basis to make changes such as expanding clinic staff, hours of operation or contract provisions. However, VA has not provided guidance on using the workgroup evaluation to evaluate proposals for new clinics.

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