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					Loma Linda Healthcare System
Loma Linda, Calif.
Jan. 12, 2004
The Loma Linda Healthcare System is part of the Desert Pacific Healthcare Network. It
consists of one VA Medical Center located in Loma Linda and five Community-Based
Outpatient Clinics located in Corona, Palm Desert, Sun City, Upland and Victorville, all
in California. It has over 1,600 employees serving more than 40,000 veterans. The
medical center has 97 acute care beds and a 108-bed nursing home care unit. The hospital
provides a wide variety of services through inpatient, outpatient, and home care
programs. Its major healthcare services include medicine, surgery, behavioral medicine
and neurology. According to VAMC Director Dean Stordahl, Loma Linda patient
workload has more than doubled in the last six years.

2003 CARES Draft Plan Assessment: The VISN 22 Market Plan Summary for Loma
Linda (CA) VAMC calls for the expansion and improvement of research space achieved
mainly through new construction. The proposed CARES strategy is the construction of a
281,000 square foot Clinical and Research addition on the Loma Linda campus. Research
space in Building One is not contiguous and will be backfilled by adjacent administrative
and/or clinical services.

Funding: VAMC Loma Linda’s FY 2002 budget was $180 million. In FY 2003 it was
$219 million, a 22 percent increase. VAMC management stated that the increase would
allow the VAMC to increase its FTE ceiling level to 1,623 from 1,515 by Sept. 30, 2003,
to assist in meeting patient care needs and appropriate staffing levels. MCCF collections
for FY 2003 were $9,891,878 of an $8,768,971 goal or 13 percent over goal (they also
exceeded the “Exceptional” goal – a sort of overachievers’ goal, but not a requirement –
which was $9,891,878). They do not expect to meet their FY 2004 goal of $12,004,312.
In order to improve their future collection rates they have begun to hire additional
collection staff and to increase verification of insurance coverage for third party
payments. They will also begin utilizing Electronic Data Interface for all billings to
increase the timeliness of collections. They are also cross-training collection staff for
both first and third party collections to include contacting veterans to establish repayment
plans. They have not had to use capital investment dollars to supplement the medical care
budget. The major budget challenge at present is matching current fiscal year workload
growth to two fiscal years before capitation.

Enrollment and Access: Management states it has 336 CBOC patients at Palm Desert
awaiting a primary care appointment as of December 15, 2003. A new provider has been
added to the community clinic and a recent extension has been completed. At present, no
veterans are waiting beyond 30 days for a follow-up appointment. The Palm Desert
CBOC is nearing capacity. Six new exam rooms were completed November 2003, while
two additional providers were oriented in January 2004 – one for Palm Desert and one for
Sun City CBOC. All the CBOCs have implemented Advanced Open Access. Apparently
there is an electronic wait list that determines if any veterans are waiting beyond the 30-
day timeframe, which can be tracked from within the system. There are 1,086 Priority


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Group 8 veterans who have applied since the January 17, 2003 cutoff. The VAMC has
appointed a health benefits advisor to track these veterans via an electronic spreadsheet,
and to serve as a point of contact for these veterans and to handle all correspondence.
However, the enrollment coordinator handles all Priority Group 8 veterans’ appeals,
especially pertaining to hardship. Estimating a $30 fee lost for each veteran denied
treatment (a very conservative estimate) and with 1,086 veterans denied since January 17,
2003 the VAMC lost $32,580 – again a very conservative number.

Community Based Outpatient Clinics: There are five CBOCs currently operated by
VA or under contract. They are located in Corona, Palm Desert, Sun City, Upland and
Victorville.

Affiliations and Staffing: Postgraduate medical and dental education programs are
conducted with the Loma Linda University. In addition, the VAMC is also affiliated with
36 other educational institutions and provides training for a variety of allied health
specialists. Management has difficulty in hiring specialists in oncology, radiology,
cardiovascular and surgical. They presently employ fee/contract physicians in medicine,
surgical, behavioral health, compensation and pension examinations and the emergency
room. They have one physician under a J-1 visa in cardiology, who has been fulfilling all
contract obligations. They also have trouble recruiting and retaining FTEE for:
respiratory therapist, radiology technologist, ultrasound technologist, physical therapist,
nurse anesthetist, anesthesiologist, custom equipment repair, bio medical technician,
medical instruction technician, cytotechnician and nurses. Management hopes to receive
help in hiring from the new physicians’ salary bill before Congress. Physician pay has not
been addressed since 1991. However, they emphasized that rehabilitation and primary
care physicians are presently near the top of the salary range for the Loma Linda Inland
Empire region, and the salary bill might hurt future hiring of some non-specialist
physicians. Presently the VAMC offers relocation bonuses, special salary rates above
minimum and an education debt reduction program to encourage recruiting and retention.
In order to recruit needed psychiatric nursing professionals, Loma Linda reports that they
will need to increase the present salary pay scale.

Physical Plant: Loma Linda VAMC was opened in 1977 and has a number of plant
issues. The four boilers are beyond their scheduled economic life and are close to needing
replacement. One of the four chillers that are being used as standby is old and inefficient.
The Energy Management System computer and software are outdated. The elevator
control is old and troublesome. Both the Energy Management System and elevator
control system are scheduled for replacement with funding for both already in place. The
hospital is planning to build three new major operating rooms with accompanying minor
surgery rooms. They hope eventually to have their own radiation therapy facility to save
patients the long two-hour plus commute to the nearest VAMC, or receive therapy at
expensive local private facilities. The medical center is critically short of parking space
and hopes to arrange a special lease for five adjoining acres shortly.

Long Term Care, Mental Health and Homeless Services: The NHCU bed count has
actually increased slightly since the Millennium Health Care Bill from 106 to 108 beds,



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with 92 veterans in contract nursing home beds. The NHCU includes four hospice beds.
There is no Alzheimer’s unit at present. The homeless veterans program includes
outreach to homeless veterans; VA supported housing that can provide subsidized
housing (Section 8) and an eight-bed grant/per diem program with Frazee Community
Center. The program includes an outreach clinician, a VASH clinician plus one clerical
support person, and the coordinator. The Commission on Accreditation of Rehab
Facilities recently accredited the program. Loma Linda received six exemplary practice
notations and no recommendations. They recently established an agreement with US Vets
at March Air Force Base to assist with the treatment process and housing for homeless
veterans. The hospital treats many patients with dual diagnoses such as substance abuse
and psychiatric disorders. Patients are provided mental health intensive case management
using nurse practitioners.

Patient, Family and Employee Surveys: None available.




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Salem Veterans Affairs Medical Center
Salem, Va.
Feb. 3, 2004
The Salem VA Medical Center is a 288-bed, tertiary referral center and teaching hospital.
Salem serves veterans throughout the State of Virginia for psychiatric, medical, and
surgical care, and the medical center serves as a referral center for acute and long-term
psychiatric care. All beds are currently in service. Salem VAMC is located on a
sprawling campus just outside of Salem, Virginia. The area is largely rural, except for the
mid-sized city of Roanoke and the smaller cities of Salem and Blacksburg.

2003 CARES Draft Plan Assessment: The VISN 6 Northwest Executive Summary for
Salem VAMC calls for collaboration with the National Cemetery Administration
providing acreage for a possible new cemetery site. There are no Market Plans or VISN-
identified planning initiatives for VAMC Salem.

Funding: VAMC Salem’s FY 2002 budget was $130.5 million. In FY 2003 it was
$143.6 million, a 10 percent increase. MCCF collections in FY 2003 were $9.1 million of
a $12.1 million goal (75 percent). FY 2004 goal is $10.4 million. Management states this
represents a more reasonable goal based on historical collection rates. VAMC Salem’s
collection rates have increased an average of 27 percent per year since FY 2001. Based
on collections through December 2003, they are 39 percent ahead of the amount collected
through the same period last year. They expect this trend to continue through FY 2004
and the goal should be reached. VAMC management sees its major fiscal challenge as
meeting patient care levels, pharmacy expenses, facility maintenance and improvements,
new equipment needs and salary limitations for physicians. The VAMC Director stated
that annual continuing resolutions make planning difficult and the lag time between the
passage of a budget in Congress and receipt of new funding makes it difficult to make
timely job offers to prospective medical staff.

Enrollment and Access: Management states it has no patients waiting beyond thirty
days for primary care appointments or for follow-up appointments. Eighty-three percent
of its patients are enrolled in primary care. Sixty-seven percent of admissions in CY 2003
were through the emergency room. In order to insure maintenance of a zero wait list,
enrollment and scheduling of new primary care patients is centralized with a PCMM
coordinator. The veteran is then assigned to one of three primary care teams and consults
are entered for either the VAMC or a CBOC. Since January 2003 there have been 594
Priority Group 8 veterans denied enrollment. This information is kept on file and the
veterans are enrolled if they receive a service-connected disability or if income drops to
the established thresholds for Priority Group 7.

Community Based Outpatient Clinics: Salem VAMC has CBOCs in Danville and
Tazewell. The Danville CBOC operates two satellite clinics in Martinsville and Axton.
All CBOCs are contractor operated. A new CBOC in Lynchburg, Va., is on hold pending
the CARES process.



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Affiliations and Staffing: Salem has an active affiliation with the University of Virginia
School of Medicine for the training of residents, medical students, and fellows in seven
specialties. A new affiliation with the Edward Via Virginia College of Osteopathic
Medicine is being developed. In addition, 39 associated health-training programs are
offered in affiliation with 26 colleges and universities. An active research program
includes 16 investigators working on 45 approved projects. VAMC management states it
is increasingly difficult to recruit U.S. citizen physicians due to the disparity in salaries
between VA and the private sector. They currently employ 11 J-1 visa physicians. Fee-
for-service doctors are employed primarily in the ER and some are utilized in most
specialties. Two reservists, a psychologist and a gerontologist are currently deployed to
Iraq.

Physical Plant: VAMC Salem was opened in 1938 and has been extensively renovated,
however concerns about the steam distribution system, roofs, exterior paint, and air
conditioning and indoor air quality remain. Salem typically receives $1.5 million per year
in funding for infrastructure and physical plant improvements but says it is difficult to
obtain funding for minor construction projects above the $500,000 threshold and uses
funds for temporary labor to contract for extensive local construction projects. Salem
operates a 23-bed hotel on campus for visitors. With the numbers of female veterans
returning from combat duty in Afghanistan and Iraq, a serious need exists in the area of
women’s mental health patient safety and privacy.

Long Term Care, Mental Health and Homeless Services: A 90-bed ECRC reflects
emphasis on wellness, preservation of function and rehabilitation. This bed count is the
same as before the implementation of the Millennium Act. Salem provides contract Adult
Day Care, hospice and home health care. There are currently five patients in community
contract nursing homes. They provide NHCU care and inpatient respite in-house. They
do not operate a dedicated Alzheimer’s unit, but have a nationally recognized memory
disorder unit with 25 authorized beds. The need for an enhanced geriatric assessment
program is needed. MH services have expanded significantly at Salem over the past five
years, adding additional staff including psych nurses, two psychiatrists and two
psychologists. New funding has been received to add longer stay SA residential rehab
beds, staff a memory disorder clinic, MH intensive case management, a military sexual
trauma unit, outpatient depression primary care medicine, and a telepsychiatry link to an
isolated region of rural Virginia. Salem runs an HCHV program for homeless veterans
who utilize the medical center. Homeless outreach is actively conducted in the area by a
full-time outreach clinician and Salem has a per-diem contract with the Roanoke Valley
Veterans Council Housing Corporation.

Patient, Family and Employee Surveys: Five each of inpatients, outpatients and family
members were interviewed. The average inpatient traveled 25 miles to VAMC Salem and
was transported by a family member who traveled 28 miles on average. Inpatients were
positive about the quality of care and food (there were no negative comments).
Outpatients traveled 80 miles on average and waited 30 minutes to be seen for a specialty
care appointment. They were also positive about the quality of care. Employees
interviewed commuted an average of 20 minutes. They were motivated by the people



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with whom they work and serve, citing the work environment and people as the most
satisfying parts of their jobs and enjoy working with veterans and colleagues. Negatives
include inconsistencies in methods of operation and swings shifts for nursing, an issue
even with non-nursing personnel raised on behalf of nurses. One suggested resolution to
perceived problem is to “put nursing under nursing,” which the Director indicated is
going to happen.


Los Angeles Veterans Affairs Medical Center
Los Angeles, Calif.
Jan. 13, 2004
The Greater Los Angeles Healthcare System has 953 employees and a budget of
approximately $400 million. It is a tertiary and teaching hospital that provides a full
range of patient care services. In January 2004 it had a total of 981 beds in use out of a
total number of 1,103 authorized beds GLA provides comprehensive services including
primary care, tertiary care, and long-term care in areas of medicine, psychiatry, physical
medicine and rehabilitation, neurology, oncology, dentistry, geriatric extended care,
infectious disease, and radiology. GLA oversees a large transitional care program
providing medical care in a therapeutic, institutional environment helping veteran
patients reenter a community setting. GLA has many consolidated services in the western
US, especially for VISNs 21 and 22. Those services include consolidated laundry,
consolidated pharmacy, radiation therapy, central dental laboratory, prosthetics treatment
center, fast neutron beam therapy, behavioral improvement, refractory programs,
substance abuse programs, hospice program, open-heart center, regional acute psychiatric
treatment ward, and DoD sharing agreements.

2003 CARES Draft Plan Assessment: The VISN 22 Market Plan Summary for the Los
Angeles VAMC calls for demolition of vacated buildings on the north side of the West
Los Angeles campus with all care (except for long term care) consolidated on the south
side of the campus as part of a new clinical addition on the south side. This move would
be in addition to a collocation project with VBA: moving the VA Regional Office from
high-priced space in a West LA office building to new quarters in a brand new structure
with the VAMC. This will be accomplished through an Enhanced Use Lease project. A
range of outpatient mental health programs and support staff would also be located within
this new clinical addition to accommodate the increasing workload. The north side of the
campus, freed up by the move of clinical services to the new south campus structure,
would see its many, older buildings demolished and the construction of a State Nursing
Home, along with expansion of the Los Angeles National Cemetery onto 20 acres on the
north campus in order to build a columbarium. An additional $64.4 million is also
projected for seismic upgrades to the West LA campus. There are also plans for a
130,000 sq. ft. replacement for the VAMC’s nursing home facility.

Funding: GLA’s FY 2002 budget was $358 million. In FY 2003 it was $438 million, a
22 percent increase. The budget increase allowed the VAMC to maintain levels of service
and staffing levels, though enrollment was restricted because of the Jan. 17, 2003 cut off.


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MCCF collections in FY 2003 were $12,228,047 of a $13,323,258 goal or 8 percent short
of the goal. The FY 2004 goal is $14,323,258. Management is uncertain as to whether it
will meet that goal. To help improve collection rates management has added new
staffing, acquired new software, and focused on customer service. Major budgetary
challenges are considered to be: obtaining competitive pay for highly trained staff,
assuring adequate funding to maintain the considerable infrastructure within the 368 acre
“campus,” and to procure and maintain medical equipment. Keeping the later up-to-date
in the present technological environment is a huge challenge. Maintaining and expanding
the staff required to operate the new equipment is a challenge as well.

Enrollment and Access: Management states that at present there are no veterans waiting
beyond 30 days for their first primary care appointment. It is less clear about the wait for
follow-up appointments since management simply refers to “clinical need” as the
criterion. Some 80 percent of patients are enrolled in primary care. According to
management, a wait for primary care is avoided thusly: “Veterans present for services,
their eligibility is established, and we enroll and/or schedule their appointments
immediately.” Some 2,195 Priority Group 8 veterans have applied since Jan. 17, 2003.
There was no estimate available for lost income.

Community Based Outpatient Clinics: GLA operates 10 CBOCs and none at present
are at or near capacity. To avoid delays GLA consolidates appointments, moves patients
to other facilities if patient prefers and attempts to recruit more staff where needed.
CBOCs are located at: Gardena, East Los Angeles Valley, Lancaster, Lompoc, Pasadena,
Oxnard, San Luis Obispo, Santa Paula and a satellite clinic at Patriotic Hall in downtown
Los Angeles.

Affiliations and Staffing: GLA maintains academic affiliations with the University of
California, Los Angeles, and 45 other universities, colleges and vocational schools in 17
different medical, nursing, paramedical and administrative programs. Budget limitations
and difficulties in hiring and retaining qualified staff have resulted in reduced nursing
coverage and closed nursing home wards. This has reduced the number of patients who
can be admitted to the NHCU. Physician salaries are not competitive with the
community, most notably radiation therapy and anesthesiology. Nurses and technologists
in general are hard to recruit. At present there are no physicians at the medical center
with J-1 visas. To help with recruitment, the VAMC pays moving costs and recruitment
bonuses. Finally, GLA’s mental health department is seeking a permanent Chief of
Psychiatry.

Physical Plant: A number of improvements and upgrades are slated for West LA’s main
hospital tower, including some urgently needed seismic work (the seismic work will take
the lion’s share of the $25 million appropriated for GLA). GLA sits on 368 acres
adjoining the communities of Beverly Hills and Bel Air; it represents some of the most
valuable real estate in the nation. Because of community pressure, the choice of uses for
this real estate is limited beyond the current array of buildings including two theatres and
even oil well (income from which unfortunately mostly goes to the Bureau of Mines).
Other sharing and enhanced use projects include renting out space for a school bus



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parking lot, renting out additional space for parking of cars through a local car dealership,
renting a baseball field to a local college, renting land to a private elementary school, and
sharing buildings for homeless veterans shelters with community organizations. To
address the need for additional space in the main hospital building, West LA is planning
to build a new structure that would accommodate administrative services that are
presently housed in the main building and provide space for the VA Regional Office,
now housed in an expensive nearby office tower.

Long Term Care, Mental Health and Homeless Services: GLA has the largest mental
health program in VA with almost 20,000 veterans served in 2002, an increase of 61
percent over five years. However, the number of veterans served as inpatients declined 44
percent from 1,974 to 1,131. This is part of a national trend de-emphasizing inpatient
care, particularly in mental health. At GLA there has been a major emphasis on mental
health services at the CBOCs: Santa Barbara, Bakersfield, East Los Angeles, Antelope
Valley, Lompoc and Oxnard. Direct referrals are available to veterans using the
Pasadena, San Luis Obispo, Santa Paula and Ventura CBOCs. An Alzheimer unit is
planned for the California State Home Project. At present GLA has a palliative care
section whose beds are integrated with other sections. It is managed on a consultative
basis. Budget limitations and the aforementioned difficulties in hiring and retaining
qualified staff have resulted in reduced nursing coverage, and the closing of some nursing
home wards. This has reduced the number of patients admitted to the nursing home.

Patient, Family and Employee Surveys: None available.


VA Long Beach Healthcare System
Long Beach, Calif.
Jan. 14, 2004
The VA Long Beach Healthcare System is part of the Desert Pacific Healthcare Network
including facilities in Las Vegas, Loma Linda, San Diego, and the Greater Los Angeles
area. The VA Long Beach Healthcare System is a teaching hospital providing a full range
of patient services. There are a total of 327 operating beds in the facility as compared to
426 authorized overall. Comprehensive health care is provided through primary care,
tertiary care, and long-term care in areas of medicine, surgery, psychiatry, physical
medicine and rehabilitation, neurology, oncology, dentistry, spinal cord injury, geriatrics,
and extended care. The VA Long Beach Healthcare System currently is comprised of the
Anaheim Vet Center, four community clinics, located in Anaheim, Santa Ana, Villages at
Cabrillo in Long Beach, and Whittier-Santa Fe Spring, and the main 100-acre campus
adjacent to California State University, Long Beach.

2003 CARES Draft Plan Assessment: The VISN 22 Market Plan for the Long Beach
Healthcare System calls for the renovation of 64,000 square feet of the Long Beach
location to expand and improve the Long Beach Nursing Home. $39 million will be spent
for urgently needed seismic improvements to the facility. Also in the works are a new 24-



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bed Blind Rehabilitation Center and the conversion of 30 acute SCI beds to long term
care SCI beds.

Funding: VA Long Beach’s FY 2002 budget was $171 million. In FY 2003 it was $192
million, a 12 percent increase. The 2003 budget allowed Long Beach to maintain the
previous year’s level of services, open enrollment and staffing level. The MCCF goal for
FY 2003 was $9.7 million, whereas collections exceeded that by 10 percent at $10.7
million. The MCCF collection goal for FY 2004 is approximately $11.3 million, which
management thinks they will exceed or come very close to exceeding. To improve
collections, management has contracted out collection of receivables for third party
follow up with the insurance companies, activated an electronic payment account for
more expeditious reimbursement for federal receivables, established payroll deductions
for employee debts, use EDI software to expedite claims and reimbursements, use
QudraMed coding/billing, which helps in coding, and decreased unfilled receivables from
$4 million to $250,000. Management sees its major fiscal challenge to be the chronic
delay in the Congressional appropriations for the fiscal year, the complex new
appropriations process and the restrictions, need for additional funds for ADP equipment,
need for additional funds for construction projects, and the ever-rising cost of drugs.

Enrollment and Access: Management states that it has no patients waiting beyond thirty
days for primary care appointments, or follow up appointments. Virtually all patients are
enrolled in primary care. Veterans are enrolled at the time they come in to the facility,
without delay. They are planning to implement Open Access appointments that will
“eliminate delays in scheduling in all primary care clinics.” They do not have figures on
the numbers of Priority 8 veterans who have attempted to enroll since the January 17,
2003 cutoff.

Community Based Outpatient Clinics: Long Beach has four CBOCs, only one of
which is contracted. At present two of these are close to capacity. The monitor patient
visits and panel size to appropriately assign staff. Waits and delays are minimized.
Mental Health services are also available at CBOCs: psychology, social work and
psychiatry. It would appear that patient access requires that a fifth CBOC be established
in the southern Orange County area.

Affiliations and Staffing: Long Beach’s medical school affiliations include the
University of California Irvine School of Medicine, California State University Long
Beach School of Nursing, University of California Los Angeles School of Nursing, Long
Beach City College School of Nursing and School of Radiology, and Bryman College.
Due to the high pay scale in southern California, the Long Beach VA finds itself priced
out of the labor market in many areas. FTEE that are difficult to recruit and retain include
diagnostic radiologic technologist, ultrasound technologist, nuclear medicine
technologist, radiological therapeutic technologist, radiation therapy physicist,
occupational therapist, nursing assistants, speech pathologists, RN (critical care), RN
clinical nurse specialist, RN (spinal cord injury), and police officers. As hiring incentives,
the medical center offers a recruitment bonus and retention allowances, when necessary,
an all-new salary structure for RN’s, placement of new employs above the normal



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starting pay amount. There are no J-1 Visa holders among the medical center’s
physicians. The following specialties are contracted out: radiologist, anesthesiologist,
urologist, oncologist, and emergency room physician.

Physical Plant: Long Beach reports $100 million is needed for seismic upgrades.
Management is looking for additional major construction on the Long Beach campus to
accommodate patient care areas, rehabilitation and surgery to compensate for the loss of
Building 122. The domestic hot water system is over 25 years old, and must be replaced
in stages. Repair and replacement is needed for two elevated domestic water towers,
valves, and various roads have been requested. Seismic deficient buildings are planned
for demolition or upgrade. Due to the demolition of building 122 there is a shortage of
space. Security considerations: increase of police services and addition of
decontamination capabilities.

Long Term Care, Mental Health and Homeless Services: The medical center’s level
of long-term/extended care has remained the same since enactment of the Millennium
Bill of 1999 at 105 beds. There are 58 veterans in contract nursing homes as well. Mental
health care has continued to stress outpatient over inpatient, including an emphasis of the
“team approach,” with representatives from psychiatry, psychology, social work, nursing
and pharmacy. Each team covers a panel of patients who are seen in both inpatient and
outpatient settings. All patients covered by the teams have a primary psychiatrist. The
mental health intensive case management program has been actively implemented as well
as a geropsychiatry inpatient unit for elderly patients in need of acute inpatient
stabilization. Long Beach has a very active health care for homeless veterans program. At
present the facility has 15 hospice beds but no Alzheimer’s unit. Long Beach also has 152
grant and per diem beds through its relationship with the US Vets and Villages at
Cabrillo.

Patient, Family and Employee Surveys: None available.


VA San Diego Healthcare System
San Diego, Calif.
Jan. 15, 2004
The VA San Diego Healthcare System is part of the Desert Pacific Healthcare Network.
It provides services to more than 238,000 veterans in the San Diego and Imperial Valley
regions of southern California. The Healthcare System consists of the major medical
center on La Jolla Village Drive in San Diego; six CBOCs located in Chula Vista,
Escondido, Imperial Valley, Mission, Valley, Wave and Vista, and two Vet Centers
located in San Diego and Vista. Medical, surgical, mental health, geriatric, spinal cord
injury, and advanced rehabilitation services are provided. With an operating budget of
$253 million, the healthcare system has 242 authorized beds with 238 presently in use,
including skilled nursing beds. The system also operates several regional referral
programs including cardiovascular surgery, and spinal cord injury.



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2003 CARES Draft Plan Assessment: The VISN 22 Market Plan Summary for San
Diego calls for new construction of 260,000 sq. ft. for the San Diego campus and
renovation of another 16,000 sq ft. Seismic retrofitting is funded at $49.1 million for San
Diego. CARES also calls for closer collaboration with Balboa Naval Hospital in San
Diego.

Funding: San Diego’s FY 2002 budget was $253 million. In FY 2003 it was $277
million, a 9 percent increase. Management stated that despite the modest increase in
funding they still experience delays in hiring caused by a shortage of applicants,
especially for complex jobs such as nursing and IT. VA salaries are simply “not
competitive in this market.” MCCF collections in FY 2003 were $9,562,160 million of a
$9,020,492 goal or 6 percent over. The FY 2004 goal is $12,004,312. Management feels
that it is unlikely that they will meet their new goal. To improve its collections,
management has contracted with an outside vendor to help with follow-up on open
receivables. They have not had to use capital investment to supplement their medical care
budget. Budgetary challenges are seen as: “the need to selectively increase hiring.” There
is a need for additional FTEE to meet performance goals and to insure that there are not
long waiting times for elective operations and there are adequate beds for admissions.
The biggest complaint that management has is, as elsewhere, the belated budget process
and the continuing resolutions that hinder the medical center’s planning and spending
decisions.

Enrollment and Access: Management states that it has no patients waiting beyond thirty
days for their first primary care appointments. There are no veterans waiting beyond
thirty days for a follow-up appointment. Some 51 percent of patients are enrolled to
receive primary care. Approximately 875 Priority Group 8 veterans have applied since
the Jan. 17, 2003 cutoff. This information is kept on file electronically and as hard copy.

Community Based Outpatient Clinics: San Diego operates six CBOCs. VA staff
operates four CBOCs. Only the Vista location is nearing capacity. However, there is an
intake physician available and patients can be seen within 30 days. Patients are then set
up for another appointment as necessary. Management is presently negotiating for
additional lease space in Vista to obviate the capacity concerns.

Affiliations and Staffing: The San Diego Healthcare System has affiliations with the
University of California, San Diego School of Medicine, and provides training for 809
medical interns, residents and fellows, as well as 64 other teaching affiliations for
nursing, pharmacy, dental and dietetics. San Diego also has one of the largest research
programs in the VA with a budget of over $47.2 million (FY 2002), 220 principal
investigators and more than 965 projects. The healthcare system is also home to several
specialty research programs including health sciences research and development, mental
illness rehabilitation, education, and clinical centers, the research center for AIDS and
HIV, and the San Diego Center for Patient Safety. San Diego’s most critical challenge in
physician recruitment is the current VA physician salary structure. They are not able to
offer salaries that are competitive with the salaries offered in the community, however,
strong affiliations with local universities counteracts this to some extent for physicians



                                            11
interested in academic pursuits. The pay issue is particularly problematic in some
specialties such as radiology, anesthesiology, and some surgical and medical
subspecialties in which local salaries are close to double that which VA is able to offer.
San Diego has had recent serious difficulties (lasting two years or more) recruiting a
hepatologist, neurosurgeon, and a chief for the spinal cord injury unit. San Diego
currently contracts for urgent care physicians. They have two contract outpatient clinics
in Escondido and Brawley. They periodically use a locum tenens contract for primary
care providers when new enrollments push waiting times for first appointments beyond
30 days. They have some physicians providing periodic fee basis care during extended
absences or for vacation coverage. Hiring incentives include: specialty pay schedules for
urgent care, ICU and OR. They have also employee referral bonuses and are launching
recruitment and retention bonuses for SCI staff. They are “using the full flexibilities
afforded to us through appointments above the minimum for Title 38 employees.”
Recruitment of nurses continues to be difficult, reflecting the national nursing shortage.
At San Diego the shortage is particularly acute with RN vacancies in the operating room,
urgent care center, and general medical/surgery areas. They are currently 2 percent to 5
percent below the local labor market in pay, but the turnover rate at San Diego is 11.6
percent, well below the national average of 15.8 percent.

Physical Plant: The plant is over 35-years-old and much of the piping, air conditioning,
electrical and other systems are in need of upgrade or replacement. Building 1 has serious
seismic and structural issues including exposed asbestos. In addition to the outmoded
configuration there is a shortage of useful space including lack of patient privacy in many
four-patient rooms, outdated outpatient clinics and lack of capacity in subspecialty
clinics. There are 242 authorized beds in the facility of which 238 are operational. They
have not had to close any inpatient beds. The emergency room is open 24 hours each day.
The medical center is located on 26 acres of government-owned land. Much of this land
is used for parking and is owned by the University of California, not VA. Next year UC
will build a bridge across Interstate 5 to connect its separated campuses and will need VA
to sacrifice 150 parking spaces which, added to the 100 spaces it is already short, will
make a deficit of 250 spaces. As a result they will need to build a parking structure to
make up the deficit.

Long Term Care, Mental Health and Homeless Services: In the last five years San
Diego has seen significant changes including a psychiatric primary care clinic, combining
service for both mental health and medical problems of a mild to moderate degree. The
mental health intensive case management program was begun last year for veterans with
severe and chronic mental illnesses. The post combat stress disorder program has been
allocated additional FTEE to allow an annual 20 percent plus in veterans treated. Nurse
practitioners have been added to outpatient services. Policies and procedures were revised
to allow enhanced admissions to VA San Diego. Mental health services were added to the
Vista CBOC. A methadone program was begun this year. Mental health care has shifted
from primarily an inpatient program to an outpatient program over the last several years.
Mental health professionals in San Diego question how much longer that can continue as
patients’ mental conditions tend to deteriorate as they age, and ever-larger numbers of
veterans in the vicinity seek care. Presently (December 2003) there are 75 veterans in



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contract nursing homes, more than before passage of the Millenium Bill. Finally there is
no Alzheimer’s unit, though patients are admitted with dementia for respite program
stays. There is no hospice program per se but there is a palliative care program for four to
eight patients at a time. There is a hoptel operated as well. There is also a homeless
program made up of homeless chronically mentally ill, VA supported housing, per diem
program, and critical time intervention. The program is Certified Accredited
Rehabilitation Facility certified.

Patient, Family and Employee Surveys: Three outpatients were interviewed. The
patients lived between seven and 43 miles from the medical center. Remarks concerning
quality of care: “not treated all that well,” treated “wonderfully,” and treated “well.”
Getting an appointment when needed: “not too good,” “very easy,” and “no problem.”




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