Care in the Community Deficiencies and Ineffective VISN Oversight at the VA Maryland Health Care System in Baltimore

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.