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Report File
Title Full
Care in the Community Deficiencies and Ineffective VISN Oversight at the VA Maryland Health Care System in Baltimore
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Report Number
24-02031-171
Report Description

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess the impact of additional staffing on patient access to care in the community through the VA Maryland Health Care System (system) in Baltimore.


The OIG found that high consult volume contributed to system staff’s inability to schedule and complete community care consults timely and consistently coordinate community care, despite staff and system leaders taking some corrective actions to address deficiencies. The OIG also found that Care in the Community nurse care coordinators did not use care coordination plan notes for every consult or routinely document note addendums as required by the Veterans Health Administration. 


The OIG concluded that Veterans Integrated System Network leaders were aware of challenges in Care in the Community, but did not help system leaders improve and sustain consult management performance beyond providing temporary administrative staff assistance.

The OIG learned that, due to insufficient staffing, system leaders only implemented the Referral Coordination Implementation in one specialty, despite the Veterans Health Administration requirement of implementation in 34 specialty medicine areas by February 2021. The OIG concluded that, consistent with other facilities, the system struggled with Referral Coordination Initiative implementation. 

The OIG found that Patient Advocate Tracking System data was collected and trended but the Deputy Chief of Staff did not ensure the data was analyzed or staff directly implemented action plans for quality or process improvements. 


The OIG made 7 recommendations related to assessment of the Care in the Community 7-day appointment scheduling requirement, completion of performance action plans, education to address incomplete consults, consult completion, care coordination documentation, Referral Coordination Initiative implementation, and Patient Advocate Tracker System data analysis. 

Report Type
Inspection / Evaluation
Agency Wide
Yes
Number of Recommendations
7
Questioned Costs
$0
Funds for Better Use
$0
Report updated under NDAA 5274
No
External Entity
24-02031-171

Open Recommendations

This report has 7 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
01 Yes $0 $0

The Under Secretary for Health assesses the feasibility of the 7-day appointment scheduling requirement for Care in the Community consults and considers stratifying the time frame requirement according to risk.

02 Yes $0 $0

The VA Maryland Health Care System Director develops and implements an education plan to address incomplete Care in the Community consult submissions and monitors efficacy of the plan.

03 Yes $0 $0

The VA Maryland Health Care System Director implements Care in the Community consult management process improvements, focusing on consult completion.

04 Yes $0 $0

The Veterans Integrated Service Network Director assists system leaders with completing corrective actions to improve Care in the Community performance.

05 Yes $0 $0

The VA Maryland Health Care System Director ensures system Care in the Community staff create and use care coordination plan notes for documenting all care coordination activities for consults with an assigned level of care other than basic and monitors for compliance.

06 Yes $0 $0

The VA Maryland Health Care System Director ensures full implementation of Veterans Health Administration’s enhanced Referral Coordination Initiative as required and monitors for compliance.

07 Yes $0 $0

The VA Maryland Health Care System Director ensures Care in the Community Patient Advocate Tracking System data is analyzed for use in service-level quality and process improvement and monitors for compliance.

Department of Veterans Affairs OIG

United States