Inside Oversight

Adam Roy:
Hello and welcome back to another episode of Inside Oversight, a podcast of the Veterans Affairs Office of the Inspector General.
This is your host, Adam Roy.
Today we’ll focus on the VA OIG report, Care in the Community Healthcare Inspection of VA Midwest Health Care Network or VISN 23, published on May 19, 2022. The OIG Care in the Community healthcare inspection program examines key clinical and administrative processes that are associated with providing quality VA care and community, or non-VA, care. These inspections are one element of the OIG’s overall oversight efforts to ensure that veterans receive high-quality and timely healthcare services.
Joining me to talk about this report and care in the community healthcare inspections is Katharine Foster, the director of community care within the Office of Healthcare Inspections.
Katharine, thank you being here. Why don’t you introduce yourself and share with the listeners your role in the VA OIG and how long you’ve been part of the OIG family.
Katharine Foster:
Thank you for the opportunity to talk about the report, Adam. I’m a director in the Care in the Community Program, and I oversee the work done by teams of healthcare inspectors. I’ve been with the OIG for twelve years now. And prior to that, I worked as a nurse in VHA and community hospitals.
Adam Roy:
That’s great. Thanks for being here. According to the VA website, VHA uses community-based outpatient clinics across the country to make access to health care easier. And I’m quoting here, “these clinics provide the most common outpatient services, including health and wellness visits, without the hassle of visiting a larger medical center.”
I understand the VA OIG conducts oversight of these clinics. So, let’s share with the listener the kinds of services these clinics provide, some details about our inspection program, and give a few examples of what we look at when we inspect a clinic.
Katharine Foster:
A Community Based Outpatient Clinic, or CBOC, is an outpatient site of healthcare services located geographically away from a VHA medical facility. VHA utilizes CBOCs to make VA health care more accessible to veterans. CBOCs provide common outpatient services without necessitating a visit to a larger medical center, and care available at CBOCs includes services in primary care, specialty care, mental health care, or in any combination.
The Care in the Community inspection program provides oversight in the care provided in Veterans Health Administration community-based outpatient clinics and by contracted non-VA care providers.

Adam Roy:
This report focused on VISN 23? Share with the listener the concept of a VISN. What’s it?
Katharine Foster:
A Veterans Integrated Service Network, or VISN, is a regional system of VHA healthcare facilities which covers a geographic area defined by patterns of patient care referrals, numbers of veterans, or boundaries such as state borders. VHA established 18 VISNs to meet regional healthcare needs and provide greater access to care. Under the VISN model, care is provided at VA medical centers and CBOCs and through non-VA providers. VISN leaders are responsible for oversight of the care provided by its associated healthcare systems, CBOCs, and contracted providers.
Adam Roy:
What geographical areas are covered by VISN 23?
Katharine Foster:
VISN 23, named the VA Midwest Health Care Network, includes sites in Iowa, Minnesota, Nebraska, North Dakota, South Dakota, and parts of Illinois, Kansas, Missouri, Wisconsin, and Wyoming. VISN 23 serves over 440,000 enrolled veterans receiving care through nine hospitals, and 63 CBOCs or outreach clinics.
Adam Roy:
Wow, that is quite a reach. How do veterans get appointments with community providers or CBOCs?
Katharine Foster:
Appointment scheduling can occur in various ways, depending on VHA facility operations and patient preference, including scheduling by VHA Office of Community Care staff, the patient, the community provider, third-party administrator staff, or any combination of these.
Adam Roy:
Let’s get into the report a little bit. Your team focused on four areas of clinical care. Can you explain this to the listener-
Katharine Foster:
We focused on processes in these following four areas of clinical operations: care coordination for veterans with congestive heart failure, diagnostic evaluations after positive screenings for depression or alcohol misuse, quality of care for veterans performing home dialysis, and mammography exams by community providers, including communication of the results.
Adam Roy:
Before we talk about the report specifics, share with me the nuts and bolts of how your team goes into these inspections. How many people on the team? Do you go onsite or complete inspections virtually, possibly due to the pandemic? Were your site visits unannounced or scheduled? And also what records and/or data does the team look at ensuring it complies with VHA requirements?
Katharine Foster:
A team usually consists of four or five inspectors. We typically visit in person; however, due to the pandemic, we did conduct a virtual review for VISN 23. Our VISN was unannounced.
We reviewed a random sample of patients who received care provided by VHA clinicians within the VISN or by VA-contracted (non-VA) providers for each of the four areas of focus. We reviewed documentation in the patients’ electronic health records, and we reviewed relevant VISN administrative and performance measure data. Following that, we interviewed VISN leaders and program managers and discussed their oversight processes. We validated electronic health record review findings with them and inquired about reasons when there was noncompliance with requirements.
Adam Roy:
Earlier, you mentioned congestive heart failure as an area you looked at. Why did you choose to look at this specific medical condition, and what did you find?
Katharine Foster:
Congestive heart failure, or CHF, is a chronic disease that is rarely cured but can be treated, and it is projected to affect more than eight million people in the United States by 2030. With this condition noted as a leading cause of VHA hospital admissions, VA established evidence-based guidelines, which may allow veterans to experience longer lives with better quality of life.
We evaluated elements of care coordination for veterans with CHF including making contacts following a VHA inpatient stay, reconciling any medication changes before and after visits, and providing patient education. VISN 23 CBOC providers delivered care that generally met the requirements, and we made no recommendations.
Adam Roy:
Your team also looked at the evaluation of patients for depression or alcohol use disorder. Did the OIG have any recommendations for these areas?
Katharine Foster:
No, Adam, we did not make recommendations for either of these areas. We found that CBOC primary care providers conducted diagnostic evaluations of patients at risk for depression or alcohol misuse, and any referrals for specialty care by VA or non-VA providers were scheduled within the required time frame.
Adam Roy:
Some good news here. So far, everything we’ve talked about in the report did not result in OIG publishing recommendations. But that wasn’t the case home dialysis care. Let’s talk about that now.
Katharine Foster:
Sure. We made two recommendations for oversight of home dialysis, one for home visits and another for monitoring quality of care provided by non-VA dialysis providers who are contracted by VA for this care.
Adam Roy:
Why are home visits such an important part of home dialysis care?
Katharine Foster:
A unique aspect of home dialysis is just what it sounds like – the veteran is performing their own dialysis at home, without assistance by medical clinicians. Home visits are essential to ensuring safety within the patient’s home environment and to gauge the patient’s ability to safely perform home dialysis. A home visit is usually performed prior to the patient being accepted into the home dialysis program, and then at least annually to check on the home environment and assess the patient’s adjustment to home dialysis. VHA dialysis staff are not required to make the visits themselves, which may be difficult due to distance, but they are required to ensure that home visits occur. VHA requires these home visits as components of support services in their home dialysis programs.
Adam Roy:
The second recommendation in this report is “The VISN 23 Director ensures the implementation and sustainment of quality monitoring of contracted clinical services for home dialysis.” What circumstances led to your team making this recommendation?
Katharine Foster:
On one hand, if a VHA medical facility does not have a home dialysis program, VA must offer veterans access to home dialysis care managed by a non-VA provider who is contracted for the service. The non-VA provider is then responsible for providing support for home dialysis, including reviewing dialysis data submitted by the patient, writing medical orders, and ensuring home visits, and VA is responsible for monitoring the contracted clinical services.
On the other hand, VHA does not require non-VA dialysis providers to submit documentation of their ongoing care. This was a decision made at a level higher than the VISN. The VHA National Program Director for Kidney Disease explained to us that the requirements for non-VA dialysis providers were established by the Centers for Medicare and Medicaid Services, CMS, and that VHA does not require medical documentation from non-VA dialysis providers.
To assess how VHA monitors the quality of contracted home dialysis services without receiving documentation of the care for review, we focused on dialysis-related complications, such as infections, that might reflect quality of care, and which we identified in records from non-VA emergency department visits or admissions to non-VA hospitals. These records were incorporated into patient’s electronic health records, and we found the complications during our medical record reviews. We also interviewed patients who performed their dialysis at home and were managed by non-VA dialysis providers. We asked them about their experiences, about home visits for example, and compared those with the level of care that would have been provided by VA.
We found that VA providers who manage home dialysis were not aware of the complications we identified, and it raised concerns for us about VA’s ability to monitor care for their patients who were referred to contracted non-VA providers. Without the ability to monitor and reassess a patient’s care through community providers’ medical documentation, the VA provider cannot be assured that the patient is receiving adequate, safe, and timely care. That led us to recommend the implementation and sustainment of quality monitoring of contracted clinical services for home dialysis.
The VISN leaders also explained to us that the CMS would provide oversight of the non-VA providers’ care, so again they were not aware of their obligation to oversee this contracted care for their patients.
Adam Roy:
Okay, that makes sense—appreciate that. In reference to recommendation 1—which is the VISN 23 director ensures implementation of sustainment of initial and annual home visits for patients accepted into the home dialysis program—what was the VISN’s response, and what actions will it take?
Katharine Foster:
The VISN leaders developed and implemented a standard operating procedure specifying the requirements for home visits with a checklist for tracking visits for both current and future home dialysis patients.
Adam Roy:
And how will VISN 23 address the second recommendation that we talked about earlier? What is their plan for that?
Katharine Foster:
The VISN implemented a process to audit medical records for home visits by the non-VA providers. They've made this an ongoing performance monitor for reporting to their VISN leaders and its contracting officials.
Adam Roy:
Changing topics a little bit, the last area of focus for this report is mammography care and communication of results. What did your inspection find here?
Katharine Foster:
When mammograms are not available at VHA, facility providers refer patients to non-VA providers for mammography. The non-VA providers are required to send a written report of the results back to the provider who ordered the mammogram within 30 days of the exam. This isn’t unique to VHA, by the way, it’s a requirement in federal legislation that applies to all mammography providers.
For 19 percent of mammogram referrals to non-VA providers, VISN 23’s ordering providers did not receive results in writing within 30 calendar days after the date of the procedure. Without timely results, VA providers could not fulfill their obligations to communicate and plan with the patient. Even when the results are normal, the waiting can be anxiety-provoking for patients.
Adam Roy:
Absolutely. And what was that final recommendation in the report, related to this?
Katharine Foster:
We recommended that the VISN 23 director ensures that VA providers receive mammography reports from non-VA providers within the established acceptable timeframe.
And VISN 23 leaders developed a plan to more closely monitor receipt of mammography exam results. The OIG will continue to follow up on this and the other recommendations.
Adam Roy:
Absolutely. Katherine, that was well done, and really broke down quite a detailed and complicated report. I hope the listeners got a good summary of what your team found. Thank you for spending some time and sharing the impactful work of the Care in the Community Healthcare Inspection Program. Is there anything else you want to add before we wrap up Katharine?
Katharine Foster
Community care is becoming such an important focus for VHA, and we're really happy to work with them in improving processes wherever possible for our veteran patients. And thank you for having me on today, Adam.
Adam Roy:
Thank you. Listeners, learn more about this report by visiting our website, selecting the publications tab, and searching for VISN 23 under the reports tab. That’s V-I-S-N 23. Find the report summary or download the full report.
That’s it for this episode of Inside Oversight. I encourage you to check out other episodes wherever you listen to podcasts. Thanks for tuning in.

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