Care in the Community Inspection of South Central VA Health Care Network (VISN 16) and Selected VA Medical Centers

Report Information

Issue Date
Report Number
24-00823-68
VISN
16
State
Alabama
Arkansas
Florida
Louisiana
Mississippi
Missouri
Oklahoma
Texas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Care in the Community Healthcare Inspection
Report Topic
Care Coordination
Community Care
Patient Safety
Staffing
Major Management Challenges
Healthcare Services
Recommendations
13
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Care in the Community healthcare inspection program report describes the results of a focused evaluation of community care processes at eight South Central VA Health Care Network Veterans Integrated Service Network (VISN) 16 medical facilities with a community care program. 

This evaluation focused on six domains:
   •    Leadership and Administration of Community Care
   •    Community Care Diagnostic Imaging Results
   •    Administratively Closed Community Care Consults
   •    Community Care Provider Requests for Additional Services
   •    Care Coordination Activities for Patients Referred for Community Care
   •    Urgent Care in the Community

The OIG issued 13 recommendations for improvement in the six domains:
   •    Leadership and Administration of Community Care
     o    Community care oversight councils
     o    Staffing needs
     o    Patient safety event entry and briefing
     o    Community care document importing
   •    Community Care Diagnostic Imaging Results
     o    Significant findings alert
   •    Administratively Closed Community Care Consults
     o    Medical documents after administrative closure
   •    Community Care Provider Requests for Additional Services
     o    Request processing
     o    Approval and denial letters
   •    Care Coordination Activities for Patients Referred for Community Care
     o    Community Care–Care Coordination Plan note
     o    Appointment confirmation
   •    Urgent Care in the Community
     o    Community Care–Urgent Care Record note

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/7/2025

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care oversight councils function according to their charters and meet the required number of times per fiscal year.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, reassess community care staffing needs and act as necessary.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter community care patient safety events into the Joint Patient Safety Reporting system.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility staff import all community care documents into the patient’s electronic health record within five business days of receipt.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, requires facility community care staff to use the significant findings alert to notify the ordering provider of abnormal diagnostic imaging results.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documentation within 90 days of the appointment after administratively closing consults that are not low risk.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community providers’ requests for additional services within three business days of receipt.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to community providers for requests for additional services.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to patients for requests for additional services.

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create and use the Community Care–Care Coordination Plan note to document all care coordination activities for consults with an assigned level of care other than basic.

No. 12
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their community care appointments.

No. 13
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create the Community Care–Urgent Care Record note in the patient’s electronic health record when they receive medical documentation from the community provider.