VA Office of Inspector General Veterans Health Administration Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System August 26, 2014 14-02603-267 ACRONYMS CBOC CBT COPD CPRS CSTAT CT DBT ED EHR EWL FY GAO HAS HRC HVAC ICD LPN NEAR OEF/OIF/OND OIG PCP PDF PET PSA PTSD PVAHCS RSA SPC VA VAMC VHA VISN VistA VSSC WIG Community Based Outpatient Clinic Cognitive Behavioral Therapy Chronic Obstructive Pulmonary Disease Computerized Patient Record System Consultation Stabilization Triage Assessment Team Computerized Tomography Dialectical Behavioral Therapy Emergency Department Electronic Health Record Electronic Wait List Fiscal Year Government Accountability Office Health Administration Service Health Resource Center House Committee on Veterans’ Affairs Implantable Cardioverter Defibrillator Licensed Practical Nurse New Enrollee Appointment Request Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Office of Inspector General Primary Care Provider Portable Document Format Positron Emission Tomography Prostate-Specific Antigen Post-Traumatic Stress Disorder Phoenix VA Health Care System Replacement Scheduling Application Suicide Prevention Coordinator Department of Veterans Affairs Veterans Affairs Medical Center Veterans Health Administration Veterans Integrated Service Network Veterans Health Information Systems and Technology Architecture Veterans Health Administration Support Service Center Wildly Important Goal The VA OIG Hotline is the responsible office for complaints of fraud, waste, abuse, and mismanagement within the Department of Veterans Affairs. Using the VA OIG Web page, at www.va.gov/oig, will facilitate the processing of your input. Federal regulations require that VA employees must report criminal matters involving felonies to the OIG. Complainants are protected under the Inspector General (IG) Act of 1978, which requires IGs to protect the identity of agency employees who complain or provide other information to the IG. In addition, the IG Act makes reprisal against an employee contacting the IG a prohibited personnel practice. -------------To Report Suspected Wrongdoing in VA Programs and Operations: Email: vaoighotline@va.gov Telephone: 1-800-488-8244 (Hotline Information: www.va.gov/oig/hotline) (This Page Left Intentionally Blank) EXECUTIVE SUMMARY The VA Office of Inspector General (OIG) reviewed allegations at the Phoenix VA Health Care System (PVAHCS) that included gross mismanagement of VA resources, criminal misconduct by VA senior hospital leadership, systemic patient safety issues, and possible wrongful deaths. We initiated this review in response to allegations first reported to the VA OIG Hotline. We expanded our work at the request of the former VA Secretary and the Chairman of the House Committee on Veterans’ Affairs (HVAC) following an HVAC hearing on April 9, 2014, on delays in VA medical care and preventable veteran deaths. Since receiving those requests, we have received other Congressional requests including those submitted by the Chair and Ranking Members of the following Committees and Subcommittees. A complete list of requestors is located in Appendix J.  House Committee on Veterans’ Affairs  HVAC Subcommittee on Oversight and Investigations  House Appropriations Committee  House Appropriations Subcommittee on Military Construction, Veterans Affairs, and Related Agencies  Senate Committee on Veterans’ Affairs  Senate Appropriations Committee  Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and Related Agencies On May 28, 2014, we published a preliminary report, Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System – Interim Report, to ensure all veterans received appropriate care and to provide VA leadership with recommendations for immediate implementation. This report updates the information previously provided in the Interim Report to reflect the final results of our review. We focused this report on the following five questions and identified serious conditions at the PVAHCS and throughout the Veterans Health Administration (VHA).  Were there clinically significant delays in care?  Did PVAHCS omit the names of veterans waiting for care from its Electronic Wait List (EWL)?  Were PVAHCS personnel following established scheduling procedures?  Did the PVAHCS culture emphasize goals at the expense of patient care?  Are scheduling deficiencies systemic throughout VHA? i Due to the multitude and broad range of issues, we assembled a multidisciplinary team comprising board-certified physicians, special agents, auditors, and health care inspectors to evaluate the many allegations, determine their validity, and assign individual accountability if appropriate. The team interviewed numerous individuals to include the principal complainants, Dr. Samuel Foote, a retired PVAHCS physician, and Dr. Katherine Mitchell, the Medical Director of the PVAHCS Operation Enduring Freedom/Operation Iraqi Freedom/and Operation New Dawn (OEF/OIF/OND) clinic. In addition:  We obtained and reviewed VA and non-VA medical records of patients who died while on a wait list or whose deaths were alleged to be related to delays in care.  We reviewed two statistical samples of completed primary care appointments to determine the accuracy of patient wait times based on our assessment of the earliest indication a patient desired care.  We reviewed over 1 million email messages, approximately 190,000 files from 11 encrypted computers and/or devices, and over 80,000 converted messages from Veterans Health Information Systems and Technology Architecture emails. The patient experiences described in this report revealed that access barriers adversely affected the quality of primary and specialty care at the PVAHCS. In February 2014, a whistleblower alleged that 40 veterans died waiting for an appointment. We pursued this allegation, but the whistleblower did not provide us with a list of 40 patient names. From our review of PVAHCS electronic records, we were able to identify 40 patients who died while on the EWL during the period April 2013 through April 2014. However, we conducted a broader review of 3,409 patients identified from multiple sources, including the EWL, various paper wait lists, the OIG Hotline, the HVAC and other Congressional sources, and media reports. OIG examined the electronic health records (EHRs) and other information for the 3,409 veteran patients, including the 40 patients reflected above in PVAHCS’s records, and identified 28 instances of clinically significant delays in care associated with access to care or patient scheduling. Of these 28 patients, 6 were deceased. In addition, we identified 17 care deficiencies that were unrelated to access or scheduling. Of these 17 patients, 14 were deceased. We also found problems with access to care for patients requiring Urology Services. As a result, Urology Services at PVAHCS will be the subject of a subsequent report. The 45 cases discussed in this report reflect unacceptable and troubling lapses in follow-up, coordination, quality, and continuity of care. During our review of EHRs, we considered the responsibilities and delivery of medical services by primary care providers (PCPs) versus specialty care providers (such as urologists, endocrinologists, and cardiologists). Our analysis found that the majority of the veteran patients we reviewed were on official or unofficial wait lists and experienced delays accessing primary care—in some cases, pressing clinical issues required specialty care, which some patients were already receiving through VA or non-VA providers. For example, a patient may have been seeing a VA cardiologist, but he was on the wait list to see a PCP at the time of his death. While the case reviews in this report document poor quality of care, we are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans. ii Supplementing data gathered from the EHR, we also analyzed information, when available, from sources that included Medicare, non-VA health records, death certificates, media reports, and interviews with VA staff. Approximately 23 percent of the patients we reviewed received private sector medical care funded by Medicare or Medicaid, and 35 percent had insurance coverage beyond VA. We identified several patterns of obstacles to care that resulted in a negative impact on the quality of care provided by PVAHCS. Patients recently hospitalized, treated in the emergency department (ED), attempting to establish care, or seeking care while traveling or temporarily living in Phoenix often had difficulty obtaining appointments. Furthermore, although we found that PVAHCS had a process to provide access to a mental health assessment, triage, and stabilization, we identified problems with continuity of mental health care and care transitions, delays in assignment to a dedicated health care provider, and limited access to psychotherapy services. As of April 22, 2014, we identified about 1,400 veterans waiting to receive a scheduled primary care appointment who were appropriately included on the PVAHCS EWL. However, as our work progressed, we identified over 3,500 additional veterans, many of whom were on what we determined to be unofficial wait lists, waiting to be scheduled for appointments but not on PVAHCS’s official EWL. These veterans were at risk of never obtaining their requested or necessary appointments. PVAHCS senior administrative and clinical leadership were aware of unofficial wait lists and that access delays existed. Timely resolution of these access problems had not been effectively addressed by PVAHCS senior administrative and clinical leadership. From interviews of 79 PVAHCS employees involved in the scheduling process, we identified the following types of scheduling practices not in compliance with VHA policy. Some schedulers identified multiple inappropriate scheduling practices.  Thirty staff stated they used the wrong desired date of care, resulting in appointments showing a false 0-day wait time.  Eleven staff stated they “fixed” or were instructed to “fix” appointments with wait times greater than 14 days. They did this by rescheduling the appointment for the same date and time but with a later desired date.  Twenty-eight staff stated they either printed out or received printouts of patient information for scheduling purposes. Staff said they kept the printouts in their desks for days or sometimes weeks before the veterans were scheduled an appointment or placed on the EWL. PVAHCS executives and senior clinical staff were aware that their subordinate staff were using inappropriate scheduling practices. In January 2012 and later in May 2013, the Veterans Integrated Service Network 18 Director issued two reports that found PVAHCS did not comply with VHA’s scheduling policy. Our review also determined PVAHCS still did not comply with VHA’s scheduling policy. As a result of using inappropriate scheduling practices, reported wait times were unreliable, and we could not obtain reasonable assurance that all veterans seeking care received the care they needed. iii The emphasis by Ms. Sharon Helman, the Director of PVAHCS, on her “Wildly Important Goal” (WIG) effort to improve access to primary care resulted in a misleading portrayal of veterans’ access to patient care. Despite her claimed improvements in access measures during fiscal year (FY) 2013, we found her accomplishments related to primary care wait times and the third-next available appointment were inaccurate or unsupported. After we published our Interim Report, the Acting VA Secretary removed the 14-day scheduling goal from employee performance contracts. Inappropriate scheduling practices are a nationwide systemic problem. We identified multiple types of scheduling practices in use that did not comply with VHA’s scheduling policy. These practices became systemic because VHA did not hold senior headquarters and facility leadership responsible and accountable for implementing action plans that addressed compliance with scheduling procedures. In May 2013, the then-Deputy Under Secretary for Health for Operations Management waived the FY 2013 annual requirement for facility directors to certify compliance with the VHA scheduling directive, further reducing accountability over wait time data integrity and compliance with appropriate scheduling practices. Additionally, the breakdown of the ethics system within VHA contributed significantly to the questioning of the reliability of VHA’s reported wait time data. VHA’s audit, directed by the former VA Secretary in May 2014 following numerous allegations, also found that inappropriate scheduling practices were a systemic problem nationwide. Since the PVAHCS story first appeared in the national media, we received approximately 225 allegations regarding PVAHCS and approximately 445 allegations regarding manipulated wait times at other VA medical facilities through the OIG Hotline, from Members of Congress, VA employees, veterans and their families, and the media. The VA OIG Office of Investigations opened investigations at 93 sites of care in response to allegations of wait time manipulations. In particular, we focused on whether management ordered schedulers to falsify wait times and EWL records or attempted to obstruct OIG or other investigative efforts. Investigations continue, in coordination with the Department of Justice and the Federal Bureau of Investigation. While most are still ongoing, these investigations confirmed wait time manipulations were prevalent throughout VHA. As of August 2014, among the variations of wait time manipulations, our ongoing investigations at the 93 sites have, thus far, found many medical facilities were:  Using the next available date as the desired date to “0-out” appointment wait times.  Canceling appointments and rescheduling appointments to make wait times appear to be less than they actually were. We substantiated that management at one facility directed schedulers to do this.  Using paper wait lists rather than official EWLs.  Canceling consultations (consults) without appropriate clinical review.  Altering clinic utilization rates to make it appear the clinic was meeting utilization goals. Wherever we confirm potential criminal violations, we will present our findings to the appropriate Federal prosecutor. If prosecution is declined, we will provide documented results of our investigation to VA for appropriate administrative action. We will do the same if our iv investigations substantiate manipulation of wait times but do not find evidence of any possible criminal intent. Finally, we have also kept the U.S. Office of Special Counsel apprised of our active criminal investigations as they relate to the U.S. Office of Special Counsel’s numerous referrals to VA of whistleblower disclosures of allegations relating to wait times and scheduling issues. This report cannot capture the personal disappointment, frustration, and loss of faith of individual veterans and their family members with a health care system that often could not respond to their mental and physical health needs in a timely manner. Immediate and substantive changes are needed. If headquarters and facility leadership are held accountable for fully implementing VA’s action plans for this report’s 24 recommendations, VA can begin to regain the trust of veterans and the American public. Employee commitment and morale can be rebuilt, and most importantly, VA can move forward to provide accelerated, timely access to the high-quality health care veterans have earned—when and where they need it. The VA Secretary concurred with all 24 recommendations and submitted acceptable corrective action plans. We will establish a rigorous follow up to ensure full implementation of all corrective actions. The VA Secretary acknowledged that VA is in the midst of a very serious crisis and will use the OIG’s recommendations to hone the focus of VA’s actions moving forward. The VA Secretary also apologized to all veterans and stated VA will continue to listen to veterans, their families, Veterans Service Organizations, and VA employees to improve access to the care and benefits veterans earned and deserve. RICHARD J. GRIFFIN Acting Inspector General v TABLE OF CONTENTS Executive Summary ...................................................................................................................... i-v Results and Recommendations ........................................................................................................1 Question 1 Were There Clinically Significant Delays in Care? ............................................1 Recommendations .............................................................................................33 Question 2 Did PVAHCS Omit the Names of Veterans Waiting for Care From Its Electronic Wait List? ........................................................................................34 Recommendations .............................................................................................47 Question 3 Were PVAHCS Personnel Following Established Scheduling Procedures? .......................................................................................................49 Recommendations .............................................................................................53 Question 4 Did the PVAHCS Culture Emphasize Goals at the Expense of Patient Care? .................................................................................................................55 Recommendations .............................................................................................63 Question 5 Are Scheduling Deficiencies Systemic Throughout VHA?..............................65 Recommendations .............................................................................................74 Appendix A Background .......................................................................................................76 Appendix B Scope and Methodology....................................................................................79 Appendix C Statistical Sampling Methodology ....................................................................84 Appendix D Phoenix Outreach Campaign, Health Resource Center.....................................86 Appendix E Chronology of OIG Oversight of Patient Wait Times ......................................90 Appendix F OIG Oversight Reports on VA Patient Wait Times ..........................................94 Appendix G VHA Directive 2010-027: VHA Outpatient Scheduling Processes and Procedures, June 9, 2010...................................................................................96 Appendix H Memorandum From the Deputy Under Secretary for Health for Operations and Management, April 26, 2010, Titled: Inappropriate Scheduling Practices........................................................................................107 Appendix I OIG Testimony on VA Patient Wait Times ....................................................114 Appendix J Congressional Requests...................................................................................117 Appendix K VA Secretary Comments.................................................................................119 Appendix L Office of Inspector General Contact ...............................................................132 Appendix M Report Distribution..........................................................................................133 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System RESULTS AND RECOMMENDATIONS Question 1 Were There Clinically Significant Delays in Care? The patient experiences described in this report revealed that various access barriers adversely affected the quality of primary and specialty care at the Phoenix VA Health Care System (PVAHCS). In the course of patient case reviews, we also identified other quality of care issues unrelated to delays. Patients recently hospitalized, treated in the emergency department (ED), attempting to establish care, or seeking care while traveling or temporarily living in Phoenix often had difficulty obtaining appointments. In February 2014, a whistleblower alleged that 40 veterans died waiting for appointments. We pursued this allegation, but the whistleblower did not provide us with a list of 40 patient names. From our review of PVAHCS electronic records, we were able to identify 40 patients who died while on the EWL during the period April 2013 through April 2014. However, we conducted a broader review of 3,409 patients identified from multiple sources, including the EWL, various paper wait lists, the OIG Hotline, the HVAC and other Congressional sources, and media reports. OIG examined the Electronic Health Records (EHRs) and other information for the 3,409 veteran patients, including the 40 patients, and identified 28 instances of clinically significant delays in care associated with access or scheduling. Of these 28 patients, 6 were deceased. In addition, we identified 17 cases of care deficiencies that were unrelated to access or scheduling. Of these 17 patients, 14 were deceased. We also found problems with access to care for patients requiring Urology Services. As a result, Urology Services at PVAHCS will be the subject of a subsequent report. The 45 cases discussed in this report reflect unacceptable and troubling lapses in followup, coordination, quality, and continuity of care. During our review of EHRs, we considered the responsibilities and delivery of medical services of primary care providers (PCPs) versus specialty care providers (such as, urologists, endocrinologists, and cardiologists). Our analysis found that the majority of the veteran patients we reviewed were on official or unofficial wait lists and experienced delays accessing primary care; in some cases, pressing clinical issues required specialty care, which some patients were already receiving through VA or non-VA providers. For example, a patient may have been seeing a VA cardiologist, but he was on the wait list to see a PCP at the time of his death. While the case reviews in this report document poor quality of care, we are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans. VA Office of Inspector General 1 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System Supplementing data gathered from the EHRs, we also analyzed information, when available, from sources that included Medicare, non-VA health records, death certificates, media reports, and interviews with VA staff. Approximately 23 percent of the patients we reviewed received private sector care funded by Medicare or Medicaid, and 35 percent had insurance coverage beyond VA. Clinically Significant Delays Clinically significant delays were found in the medical and/or surgical care or mental health care of 28 patients, including 6 patients who were deceased, 4 patients with newly diagnosed conditions, 17 patients with chronic conditions, and 1 patient considered to be a risk to the public. Deceased Patients (Cases 1–5, 27) Case 1 A man in his late 60s had a history of homelessness, diabetes, head injury, hepatitis, and low back pain. He had been seen at multiple VA health care facilities across the United States during 2011–2013. He presented to the PVAHCS ED with a minor injury and requested a place to stay. He was found to have markedly elevated blood glucose (477 milligrams/deciliter [mg/dl]) and was treated with insulin and intravenous fluids. The patient stated that he did not want to take insulin, an injectable medication, and was therefore started on metformin, an oral blood sugar-lowering medication. The ED physician requested that he have a follow-up appointment with Primary Care within 24 hours. The patient was not given an appointment to be seen in Primary Care; multiple visits to non-VA EDs ensued, and he was hospitalized at two different non-VA hospitals. A death certificate obtained from the State of Arizona indicates the patient died at a local non-VA hospital 8 weeks after the PVAHCS ED visit. Given the patient’s homelessness and uncontrolled diabetes, hospitalization would have been optimal. In that he was not admitted, a more urgent scheduling effort than a “Schedule an Appointment” consultation (consult) was required. Case 2 A man in his late 60s had a history of homelessness, hypertension, diabetes, cirrhosis, congestive heart failure, and emphysema. He had been hospitalized at a New England VA Medical Center (VAMC) and at a Texas VAMC. He presented to the PVAHCS ED with 1 week of generalized weakness and diarrhea. He had recently moved to the Phoenix area from New England. VA Office of Inspector General 2 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System A Schedule an Appointment consult for a new patient primary care appointment was placed on the day of the ED visit and again 2 days later. After an additional 2 days, the patient was hospitalized at a non-VA hospital for abdominal swelling and weakness. Eleven weeks after that admission, he was hospitalized at a different non-VA hospital for hepatic encephalopathy. More than 3 months after the patient’s death, PVAHCS staff attempted to call the patient to schedule a primary care appointment. Although unlikely to change the overall outcome for this patient with severe liver disease and other medical problems, primary care management could have improved symptom control and assisted with specialty care coordination. Case 3 A man in his mid-60s had a history of diabetes, hypertension, hyperlipidemia, cigarette smoking, and post-traumatic stress disorder (PTSD). He transferred his care from a Midwest VAMC and registered for care at PVAHCS. The patient’s family reported that he was having flu-like symptoms and that they attempted to get him an appointment at PVAHCS several times after registration without success. Four months after registering at PVAHCS, the patient sought care for flu-like symptoms and shortness of breath at a non-VA medical facility, where he was diagnosed and treated for pneumonia. A computerized tomography (CT) scan performed at that facility revealed a large left pulmonary mass and enlarged lymph nodes suggesting “local spread of malignancy.” The patient was advised to follow up with his PCP to have a positron emission tomography (PET) scan. Two weeks later, the patient called PVAHCS and explained that he had been recently discharged from a local hospital and needed “another test.” He was advised to “walk-in,” which he did, and was seen that same day. On examination, a provider noted an “enlarged, firm lymph node in the supraclavicular [above the collarbone] area on the left side” and ordered a CT scan of the chest. The CT scan, completed 1 month later, revealed a large left hilar mass and bilateral mediastinal and hilar adenopathy. Four weeks after the CT scan, the patient underwent “diagnostic bronchoscopy with endobronchial biopsy & lavage + axillary needle biopsy.” A diagnosis of lung cancer was made, and a PET scan confirmed widely metastatic disease. Arrangements were made to enroll the patient in hospice. The EHR contained no information indicating where the patient died, or whether hospice care was actually provided prior to his death. VA Office of Inspector General 3 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System There are two concerns in this case. First, the patient never received a primary care appointment as requested when he registered at PVAHCS, although this does not mean that the patient’s lung cancer would have been detected sooner. The second concern is that once malignancy was suspected, at least 9 weeks elapsed before a definitive diagnostic procedure was performed. Given the size and location of the tumor at the time of diagnosis, the delay in care for this patient was unlikely to have had a negative effect on his overall prognosis. However, his care might have been improved if palliative care had been implemented sooner. Case 4 A man in his late 70s had a history of hypertension, chronic alcohol abuse, and obesity. In late 2011, the patient was seen in the PVAHCS ED for “bronchitis vs early pneumonia.” He was not seen again at PVAHCS until the summer of 2013, when he presented to the PVAHCS ED with lower extremity edema. He was found to have deep vein thrombosis, was briefly hospitalized, and discharged home with anticoagulant medications. At the time, a Schedule an Appointment consult was entered for an urgent Primary Care appointment. The patient was seen again in the ED 2 weeks later for back pain. The treating provider’s note included the statement, “Follow up with assigned clinic or primary care physician within 72 hrs [hours] from this emergency room visit today.” At that time the patient was noted to be anemic (hematocrit 28 percent; normal is greater than 37). The patient presented again to the ED 1 month later with a nosebleed, and a nasal balloon was placed. He was seen in the ED 2 days later for removal of the nasal balloon, and at that time, another Schedule an Appointment consult was entered for Primary Care; an appointment “Within 1 week” was requested. One month later, the patient presented again to the PVAHCS ED with weakness and decreased urine output, and he was admitted to the hospital. He was noted to have a history of uncontrolled hypertension and was considered to be volume depleted. Laboratory testing revealed acute renal injury, hypoalbuminemia (low blood albumin), and nephrotic range proteinuria (large amount of protein in the urine). Following a 1-week hospitalization, he was discharged to a skilled nursing facility for rehabilitation. He died 5 weeks later. This patient had delayed Primary Care follow-up after several ED visits. With anticoagulation, anemia, hypertension, and kidney disease, earlier VA Office of Inspector General 4 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System primary care management could have expedited treatment of anemia and hypertension and facilitated coordination of his specialty care. Case 5 A man in his mid-50s had a history of pancreatitis, three cerebrovascular accidents (strokes), hypertension, and polysubstance abuse. He moved to the Phoenix area from the East Coast in early 2014. He had received treatment at another VAMC as well as from non-VA providers prior to his relocation to Phoenix. The patient presented to the PVAHCS ED with abdominal pain, was given medications for nausea and pain, instructed to follow up with a PCP “within 72 hours,” and discharged home. According to an entry on the Schedule an Appointment consult record, the consult was canceled the next day and a note was put in the EHR documents that a message was left for the patient to call and schedule an appointment. Ten days later the patient again presented to the ED because of persistent pain and he had run out of pain medication. According to the nursing triage note, “Pt [The patient] states he forgot to take his lisinopril [a blood pressure lowering medication] today.” His blood pressure was 209/107 millimeters of mercury (mm Hg). He requested methadone and Percocet [oxycodone and acetaminophen] but was prescribed only a limited supply of oxycodone and a medication for nausea. The plan outlined by the ED physician stated that the patient should follow up with Primary Care within 2 days. The patient died 12 days later at a non-VA hospital. The cause of death given on the death certificate was “multiple prescription medication intoxication.” Despite this patient’s need for blood pressure monitoring and treatment, as well as management of other chronic conditions, he never received an appointment with Primary Care. Patients With Newly Diagnos ed Conditions Case 6 A man in his mid-50s presented to the PVAHCS ED with shortness of breath, excessive sweating, thirst, and numbness in both hands. His blood glucose level was markedly elevated (516 mg/dl), and he was prescribed metformin and advised to see his PCP within 1 week. He was not seen by a PCP, ran out of medication, and returned to the ED 1 month later with symptoms of uncontrolled diabetes. His medications were renewed, and a diabetes teaching appointment was made. Twelve weeks later he was seen in Primary Care. VA Office of Inspector General 5 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System This symptomatic patient with newly diagnosed diabetes was not scheduled to see a PCP for almost 4 months after an ED visit at which significant symptoms and laboratory abnormalities were noted. Case 7 A man in his late 60s was evaluated in the PVAHCS ED for a subcutaneous cyst on his back and treated with an antibiotic. Eight months later, he was seen in the ED for chest pain. His blood pressure was 180/124 mm Hg, and an electrocardiogram showed an abnormality. After his hypertension was treated and testing showed no myocardial infarction, he was discharged with blood pressure medication and advised to follow up with a PCP within 2 weeks. No Cardiology appointment was made, but a Primary Care appointment was scheduled for 7 months later. A PVAHCS physician who became aware of this patient’s situation evaluated him 5 months after the ED visit and entered a referral to cardiology. The patient subsequently underwent coronary artery bypass surgery. Although this patient had a favorable outcome, the delay in scheduling follow-up care after an ED visit exposed him to unnecessary risk. Case 8 A man in his early 40s presented to the PVAHCS ED concerned that he might have melanoma, a potentially fatal form of skin cancer. The ED provider note described skin lesions on each arm and the left ankle, “present for about a year, recently getting larger, changing shape and darker…could be melanoma, needs further evaluation.” A referral to general surgery was requested by the ED provider, but this consultation was canceled by a general surgeon the next day with a notation that the patient should be evaluated and treated by dermatology. Approximately 10 months later, the patient was evaluated in Primary Care, and a consult was placed to Dermatology. The lesions were determined to be benign. Failure of basic consult management and coordination of care could have led to serious consequences had these lesions ultimately been diagnosed as melanoma. Case 9 A man in his 60s was treated in the past at PVAHCS for substance abuse, depression, and PTSD. After 15 years, he presented to the PVAHCS Mental Health Clinic, and a psychiatrist wrote that he had PTSD, depression, alcohol abuse, and multiple problems with his “primary support system.” At that VA Office of Inspector General 6 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System visit, the patient’s blood pressure was 191/102 mm Hg and a repeat measurement was 175/102 mm Hg; a Schedule an Appointment consult for routine Primary Care follow-up was entered. One week later the patient was added to the EWL for a PCP appointment, and an appointment was made for 15 weeks after the Mental Health Clinic visit. The patient was seen again in the Mental Health Clinic 5 weeks after the initial visit, but his blood pressure was not recorded. This patient’s hypertension warranted expeditious evaluation and treatment, which did not occur. Patients With Chronic Conditions Case 10 A man in his 40s had a history of hypertension, traumatic brain injury, and alcohol abuse. He reported to the OIG Hotline that he called PVAHCS for an appointment to have his blood pressure checked and was told that an appointment would not be available for 6 months. He stated that 3 months after calling PVAHCS, he awoke with vertigo, nausea, and slurred speech. These symptoms resolved within a day, and he did not seek medical attention for them. After an additional 2 months, he was in an all-terrain vehicle accident and began having more frequent symptoms of slurred speech and dizziness. When he was seen for his scheduled Primary Care appointment, his blood pressure was 163/107 mm Hg, and he was started on antihypertensive medications, counseled on alcohol use, and asked to follow up in 2 weeks. However, 1 week later he returned to the ED complaining of stuttering and slurred speech, and brain imaging was performed that revealed a large tumor. He subsequently underwent craniotomy and chemoradiation with no apparent recurrence of tumor. This patient waited 6 months for a PCP appointment, during which time symptoms occurred that were attributed by the patient to hypertension. Although timely Primary Care management might have led to an earlier diagnosis of the patient’s brain tumor, his overall prognosis was probably unchanged. Case 11 A man in his early 60s had a history of alcohol abuse and untreated hypertension. At the end of 2013, he presented to the Phoenix ED complaining of 2 weeks of shortness of breath. He was admitted overnight, diagnosed with “decompensated heart failure,” and scheduled for an outpatient echocardiogram. A Schedule an Appointment consult was placed for Primary Care. The echocardiogram was performed 3 weeks later. VA Office of Inspector General 7 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System He returned to the ED after another 3 weeks with extreme shortness of breath and vomiting, was admitted to the hospital, and soon transferred to the Intensive Care Unit. The result of the recent echocardiogram was not readily available because the interpretation had not yet been entered into the EHR. After evaluation by cardiology, he was transferred emergently to a non-VA hospital where a defibrillator and pacemaker were placed. The EHR reveals that on the date of that transfer, the echocardiogram was interpreted as showing severely decreased cardiac function (left ventricular ejection fraction, 10 percent). The Schedule an Appointment consult was closed, and the patient was placed on the EWL with a comment stating that the “wait time is approximately 143 days for a new patient appointment.” This patient had severely impaired heart function identified by echocardiography. Prompt medical management might have prevented his subsequent deterioration. Case 12 A man in his 70s was found to have an elevated prostate-specific antigen (PSA) and was referred by a PCP to the Urology Service. However, the consult was amended as “needs another psa.” A Urology appointment was scheduled for 3 months later, but this appointment was canceled by the Urology Clinic 1 week before the scheduled date because “provider not available”; the appointment was not rescheduled. The PCP entered a referral for non-VA urology care 4 months after the original request, but this was denied on the basis that “the facility provides this service.” After an additional 4 months, the facility closed the Urology Service consult request, indicating “no longer accepting consults.” A request for non-VA urology care was again submitted, and the patient was seen by a non-VA urologist more than 11 months after the initial request. Prostate biopsy revealed prostate cancer. This patient had a prolonged delay between the time his abnormal blood test was noted and a diagnosis was made. Case 13 A man in his late 60s had an extensive cardiac history, including a myocardial infarction and placement of multiple coronary artery stents at non-VA facilities. After experiencing financial difficulties and unable to afford his medications, he was admitted to PVAHCS after presenting to the VA Office of Inspector General 8 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System ED complaining of palpitations. Tests revealed no new abnormalities, and he had marked symptomatic improvement after medications were resumed. During his hospitalization, an outpatient cardiology appointment was scheduled, but that appointment was canceled because “provider sick.” The appointment was rescheduled for the following month, but that appointment was canceled due to a “change in profile.” The consult was ultimately discontinued as “too old.” Four months after his initial ED presentation, during a routine Primary Care appointment, another Cardiology Service consult was entered. However, the consult was discontinued with the notation “cardiac work-up negative, symptoms due to non-compliance.” One month later, the patient presented to the ED with chest pain and palpitations and was admitted to the hospital. Another Cardiology Service consult was requested and the patient was seen as an outpatient the following month. This patient with significant cardiac disease experienced repeated delays in establishing follow-up care with Cardiology. Although no negative clinical consequences are certain, appropriate cardiology care may have prevented re-hospitalization. Case 14 A man in his 60s was found to have a nodular prostate. This finding prompted his PCP to place a referral to the PVAHCS Urology Service. An appointment was made for 3 months later, and the patient was seen and referred to an outside facility for a prostate biopsy. Approximately 6 weeks later, after the biopsy was completed, the patient delivered a pathology report describing prostate cancer to the PVAHCS Urology Clinic, and a VA urologist called the patient to inform him that surgery would be arranged at a non-VA hospital. In a complaint received by the OIG Hotline, the patient described a frustrating group of events over the next 2 months in which PVAHCS allegedly had no record of the non-VA referral for the procedure, the VA urologist who called the patient left PVAHCS, outside pathology and/or laboratory reports were misplaced, and multiple messages were not returned from the Patient Advocate’s office. In mid-November, the Patient Advocate’s office called the patient to state he had been approved for the outside surgical procedure and four follow-up visits. Eight months after the initial referral to Urology, the patient had an uneventful surgery. VA Office of Inspector General 9 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System This patient with biopsy-proven prostate cancer experienced repeated scheduling delays and poor coordination of care with non-VA providers. Case 15 A man in his late 50s was seen in the PVAHCS ED for toe pain. Because of an elevated blood glucose level (206 mg/dl), he was considered to possibly have a new diagnosis of diabetes. He was subsequently seen in the Ambulatory Clinic and received foot care. The patient was seen in Primary Care 3 months after the ED visit and hospitalized after he was found to have markedly elevated blood glucose level (739 mg/dl). The patient reported multiple symptoms consistent with uncontrolled diabetes, including weight loss, excessive urination, and excessive drinking. He was discharged from the hospital on insulin and metformin (an oral blood sugar-lowering medication). The elapsed time between the patient’s ED visit and his initial appointment to be seen in Primary Care was excessive. Had the patient been scheduled more timely to be seen in Primary Care, it is likely that medications, education, and risk-appropriate screenings could have prevented his later inpatient admission. Case 16 A man in his mid-30s had a history of anxiety and suicidal ideation. He called PVAHCS for an appointment and was placed on the EWL. Five weeks later, he was called by the facility and told he had a Primary Care appointment in another 4 weeks. The patient had been hospitalized at an East Coast VAMC for 1 week during the prior year for suicidal ideation and anxiety. At discharge, he declined further treatment, saying that he was moving to Phoenix. The East Coast VAMC Suicide Prevention Coordinator (SPC) wrote a note in the EHR indicating that PVAHCS SPC was alerted by a voice mail about this patient, but there was no documentation from the PVAHCS SPC that acknowledged receipt of that message. The patient was seen in a PVAHCS Primary Care Clinic as scheduled, and a referral was made to the Mental Health Clinic. Three weeks later, the patient was contacted by the Mental Health Clinic to arrange an intake appointment. For this patient with a history of hospitalization for suicidal ideation and anxiety, continued outpatient mental health treatment was important. The VA Office of Inspector General 10 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System delay in scheduling an initial Primary Care appointment led to a delayed referral to Mental Health. Case 17 A man in his 50s had a history of chronic tobacco use, chronic obstructive pulmonary disease (COPD), diabetes, and anxiety. In mid-December 2013, he presented to the PVAHCS ED with symptoms suggestive of an upper respiratory infection and COPD. The patient was treated and discharged with medications. Through a Schedule an Appointment consult, Primary Care follow-up was requested within 1 month. About 1 month later, the patient returned to the ED because he ran out of his medications. He had not been scheduled to be seen in Primary Care. In early February, he returned to the ED with symptoms suggestive of another COPD flare. About 1 month later, he returned to the ED requesting medication refills. In early May, he was seen for his first scheduled appointment in Primary Care. This case reveals a missed opportunity to treat a patient with a chronic disease in an outpatient setting and demonstrates why some patients use the ED for “primary care.” At least one of the patient’s COPD exacerbations may have been averted if the patient had been seen in Primary Care sooner. Case 18 A man in his late 80s lives in the Midwest for half the year and in Arizona the other half. He receives both private care and VA care, and is registered with and followed by Primary Care at a Midwest VAMC. In late December 2013, the patient presented to the PVAHCS ED with symptoms suggestive of a urinary tract infection, and blood tests revealed evidence of kidney disease. He was prescribed an antibiotic, and adjustments were made to his anti-hypertension regimen. In early January 2014, the patient walked in to Primary Care for repeat labs and a blood pressure check, as instructed by the ED physician. His blood pressure was found to be 165/82 mm Hg. He had a new patient appointment pending for about 3 weeks later at PVAHCS. When he arrived for that appointment, he was not triaged, but rather, a licensed practical nurse (LPN) informed him that he cannot have two Primary Care teams (that is, in Phoenix and the Midwest). The patient left after choosing the Midwest VAMC as his home base. While VHA policy discourages the practice of assigning more than one Primary Care team, it is not prohibited in all circumstances. VHA policy VA Office of Inspector General 11 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System allows for the assignment of two Primary Care teams when veterans split their time between different residences located in different geographic areas.1 The patient could have had a Primary Care team assigned at PVAHCS, while maintaining his care in the Midwest. This was an elderly patient with a change in his blood pressure medication regimen and significantly reduced renal function. The patient, after being on his new regimen for 1 week, had persistent hypertension and might have benefited from a medication adjustment. The patient presented for a scheduled appointment but left after being given misinformation regarding VHA management of veterans who split their residence between two different locations. Case 19 A man in his late 50s who had a history of methamphetamine abuse presented to PVAHCS in early May 2013 complaining of new blurry vision and was found to have a blood pressure of 224/124 mm Hg. He was evaluated that day by Ophthalmology and referred to Primary Care. The ophthalmologist who saw the patient in the following week attributed his visual changes to hypertension. Four months after his initial ED visit, the patient went to the ED requesting a refill of medications he had been prescribed a few days earlier at a non-VA hospital. He reported that he had been diagnosed with a stroke there. The ED physician who saw him submitted another consult request for Primary Care follow-up. In early October, the patient contacted the facility requesting a new Primary Care appointment “as soon as possible.” The first successfully scheduled Primary Care appointment was made for 1 month later. In early December, the patient completed an appointment in Primary Care. About a month later, the patient was admitted to a non-VA hospital for a new stroke, which resulted in significant loss of vision in both eyes. The patient was an amphetamine abuser and had dangerously elevated blood pressure during his initial visit. His wait for Primary Care was excessive, and while waiting, he suffered a stroke. A timelier Primary Care visit could have improved his blood pressure control and allowed for treatment of his substance abuse which could have reduced his risk for stroke. 1 VHA Directive 2007-016, Coordinated Care Policy for Traveling Veterans, May 9, 2007. VA Office of Inspector General 12 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System Case 20 A man in his mid-50s was seen in the PVAHCS ED in late January 2014, 2 weeks after his release from incarceration. He stated that his blood pressure was 180/120 mm Hg while incarcerated and that he had not been taking his medications after being released. In the ED, his blood pressure was 162/128 mm Hg, and his urine tested positive for amphetamines and cocaine. He was prescribed two medications for his blood pressure and instructed to follow up with a PCP, even if outside the VA system, or at an ED if his blood pressure readings remained markedly elevated. With blood pressure readings so high in a patient with significant heart disease, any delay in follow-up and primary care is concerning. The EHR did not reflect a sufficiently aggressive approach. Case 21 A man in his early 60s had a history of diabetes, COPD, obstructive sleep apnea, and obesity. He had been seen regularly at a PVAHCS Primary Care Clinic from 2007 through 2011. He had no further encounters until early March 2014 when he presented as a “walk-in” complaining of swelling and shortness of breath. He said that he had recently lost his private insurance and no longer had any medication. A nurse noted that his oxygen saturation was reduced (89 percent; normal is greater than 95 percent). After consulting with the physician on staff, the nurse advised the patient that she was going to call Emergency Medical Services so that patient could be transported to the nearest ED. The patient refused but did agree to drive himself to the PVAHCS ED. After an evaluation at the PVAHCS ED, the patient was admitted to the medicine ward. He was restarted on his medications, pulmonary function and other tests were scheduled, and a Schedule an Appointment consult was placed for Primary Care. Six weeks later pulmonary function tests were performed, revealing significant COPD. Nineteen weeks after hospitalization, the patient had not been scheduled with a PCP. Despite discharge instructions indicating a need for Primary Care follow-up within 2 weeks, this patient with significant pulmonary disease had not been scheduled for Primary Care. Case 22 A man in his late 60s was seen at the PVAHCS ED for right knee pain. In the course of his evaluation, the patient was also found to have a markedly elevated blood pressure (241/137 mm Hg). The ED provider treated his VA Office of Inspector General 13 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System hypertension and requested that the patient be seen by Primary Care within a week. Seven months later, the patient had not been scheduled for a Primary Care appointment nor had he made other visits to PVAHCS. This patient’s blood pressure elevation warranted treatment in the immediate weeks after his ED visit, but no treatment was documented for the next 7 months. Case 23 A man in his early 40s had a history of major depressive disorder, diabetes, hyperlipidemia, and hypertension. His initial contact with PVAHCS was in October 2013, when he was hospitalized for a major depressive disorder. At that time laboratory values indicated very poor diabetes control and marked cholesterol elevation (total cholesterol, 470 mg/dl; LDL cholesterol, 307 mg/dl). His medical regimen at discharge included drugs for diabetes and hypercholesterolemia, including insulin, glyburide, metformin, and atorvastatin. The discharge summary specified, “please schedule for a new patient Primary Care appointment.” The patient was not scheduled in Primary Care for 6 months. When he was seen, his diabetes control was even worse and he had blurred vision. This patient, with very poorly controlled hyperlipidemia, had substantially delayed care. diabetes and extreme Case 24 This patient is a man in his early 40s who registered for care at PVAHCS in September 2012, and his first primary care appointment was 8 months later. At that appointment, he revealed a history of hypertension, hyperlipidemia, severe alcohol abuse, anxiety, and depression. He was later diagnosed with steatohepatitis. The patient subsequently underwent successful treatment for alcohol abuse. This patient with significant mental and physical health issues waited 8 months for initiation of treatment. Case 25 A man in his 60s presented to the PVAHCS ED in late January 2014 with chest pain and shortness of breath. He reported that he had recently been treated at a non-VA hospital for coronary artery disease and had a stent placed. In the ED, an electrocardiogram showed no abnormalities, and blood tests were negative for acute myocardial infarction. He was considered to VA Office of Inspector General 14 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System have “atypical chest pain,” and a Schedule an Appointment consult was placed. An appointment for Primary Care was made for 2 months later. When he presented for that appointment, he was sent to the ED, where he was admitted with a cough and shortness of breath. He was subsequently evaluated by a pulmonologist and his symptoms were attributed to gastroesophageal reflux. This patient with known significant coronary artery disease had a delay in initial primary care that might have exposed him to unnecessary risk. Case 26 This man in his early 40s has a history of polysubstance abuse, panic disorder, and homelessness. In early December 2013, he was seen in the ED for a rash, and an ED physician placed a consult for a PCP assignment. Throughout January 2014, the patient repeatedly sought care in the ED, frequently requesting narcotics, and multiple references were made as to the need for “follow-up with PCP.” In late January, an ED physician again entered a consult requesting PCP services. This high-risk patient with polysubstance abuse was utilizing the ED for basic health care needs. As of June 3, 2014, the patient had not been seen in Primary Care. Patient Who Committed Suicide (Case 27) Case 27 A man in his late 50s had a history of bipolar disorder, alcohol dependence, and four suicide attempts. He moved to Phoenix from Texas where he had been followed by both Mental Health and Primary Care. His last visit with his mental health provider in Texas was in late July 2013, with plans for a follow-up in 4 months, which the patient did not attend. In early December, the patient registered with PVAHCS and applied for an outpatient medical appointment. He was placed on the EWL 3 days later. In early April 2014, the patient contacted PVAHCS about the status of his appointment and reported he was having “ongoing issues.” A medical services assistant informed the patient that he could come into any clinic as a “walk-in.” On two occasions in mid-April, PVAHCS staff unsuccessfully attempted to call the patient to set up a new appointment and left voice messages. In late April, the patient called to schedule an appointment; he was informed that someone would contact him. In early May, the facility made another VA Office of Inspector General 15 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System unsuccessful attempt to contact the patient and also sent a letter to the patient with the facility’s contact information. Three days later, the patient committed suicide by gunshot. His brother told the suicide prevention social worker that the patient had been depressed for a long time. This patient was at increased risk of suicide. A timely Primary Care appointment was not available at the time of initial contact, and the patient was placed on the facility’s EWL. Better availability of an appointment for this patient might have changed the outcome. Patient for Whom Risk to the Public Was a Concern Case 28 This man in his early 60s had a history of schizophrenia. He was released from prison after being incarcerated for 16 years following a conviction for manslaughter. One year later, he registered for care at PVAHCS at a “Stand Down” (a homeless veteran outreach event), and he was given an appointment for primary care for 4 months later. He was seen in Primary Care 2 weeks before his scheduled appointment, and hallucinations and suicidal ideation were discussed. He was referred to Mental Health. Although it is unclear what PVAHCS knew about his history at the time of registration, this patient was a potential threat to himself and others. He had schizophrenia and a history of violence and was without medication and having auditory hallucinations and suicidal ideation. A timely appointment at the time of registration should have been provided. Other Quality of Care Issues In addition to the 28 cases discussed earlier that had clinically significant delays, OIG identified deficiencies unrelated to delays in the care of 17 patients, including 14 who were deceased. Deceased Patients (Cases 29–42) Case 29 A man in his early 60s had a history of severe cardiomyopathy (disease of the heart muscle), hypertension, poorly controlled diabetes, hepatitis B, hepatitis C, and tobacco use. An echocardiogram performed in late summer 2013 showed the patient’s cardiac function was severely depressed, indicating severe heart failure and increased risk for abnormal heart rhythms and sudden death. The patient was followed in PVAHCS’s Primary Care and Cardiology Clinics. Two days following the echocardiogram, a cardiologist entered a consult to the Tucson, AZ, VAMC’s Cardiology-Electrophysiology Service for consideration of an implantable cardioverter defibrillator (ICD) with or without cardiac resynchronization. The patient had an ICD placed VA Office of Inspector General 16 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System approximately 5 years previously, but it was removed because of complications caused by either infection or metal allergy. Two weeks after the consult to the Tucson VAMC was entered, a Cardiology nurse practitioner at the Tucson VAMC called the patient. During that conversation, the patient stated that he wanted allergy testing before any new device was placed. Five weeks later, an allergy patch test revealed no reaction to metals. The PVAHCS cardiologist sent a note attached to the consult to the Tucson VAMC’s Cardiology-Electrophysiology Service stating that the patient “can now be scheduled for CRT-D [cardiac resynchronization therapy with defibrillator].” The cardiologist recommended that the procedure be done in the next 4 to 5 weeks. One month later, the patient was seen by a PVAHCS cardiologist. The cardiologist added another note to the Tucson VAMC Cardiology-Electrophysiology consult stating that the patient needed to be seen for device implantation. In early 2014, the patient had a routine follow-up appointment at PVAHCS in Primary Care. One week later PVAHCS was informed of his death. Medical records from a local non-VA hospital indicated that 3 days prior to his death, the patient’s family witnessed him collapse in his kitchen. Upon arrival, Emergency Medical Services notes indicated that the patient was pulseless and in ventricular fibrillation. According to PVAHCS records, the patient was on an EWL for an Endocrinology Service consult that had been placed in late spring of 2013 for management of the patient’s poorly controlled diabetes. The patient reportedly agreed to an appointment 1 month later, but he did not go to that appointment. The ICD should have been placed within a few months of the most current plan. This patient’s severe cardiac disease placed him at risk for sudden death at any time. ICD placement might have forestalled that death. Case 30 A man in his mid-50s had a history of hypertension and chronic pain due to degenerative joint disease involving his neck. He was followed by Primary Care, and his pain management plan consisted of physical therapy and limited use of hydrocodone. He was awaiting a Neurosurgery evaluation of his neck to determine if a surgical intervention could help with his pain. VA Office of Inspector General 17 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System In mid-2013, the patient called his PCP requesting stronger pain medication, as his usual medication was not helping his “torso pain.” Two days later, the provider documented that the patient could pick up an alternative pain medication at the outpatient pharmacy. There is no documentation in the EHR that the provider evaluated the patient by phone or in person. Two days after starting the new medication, the patient presented to the ED complaining of severe abdominal pain. He was noted to have “10/10” (worst possible) abdominal pain, a temperature of 95 degrees Fahrenheit, and a pulse of 111 beats per minute. He was evaluated by an ED physician within 20 minutes. A CT scan of his abdomen, completed 2 hours later, showed a perforated bowel (a hole in the wall of the bowel that can quickly lead to life-threatening infection and/or sepsis). A surgical consult was requested 4 hours after the CT scan, and another hour passed before a surgery resident evaluated the patient. The patient was taken to the operating room for an exploratory laparotomy (a surgery that opens the abdominal cavity) within 2 hours of the surgeon’s evaluation. The patient remained on pressors (intravenous medications used to elevate blood pressure in the setting of shock) and ventilator support postoperatively. Two days later, the family removed life support and the patient died. This patient being treated for chronic neck pain described a new location of pain, and this description should have prompted a telephone or face-to-face assessment. At his final presentation to the ED, hypothermia and tachycardia warranted prompt and intensive interventions. Earlier diagnosis and treatment might have altered the outcome in this case. Case 31 A man in his mid-60s had a history of prostate cancer, diabetes, PTSD, and morbid obesity. He was followed routinely in Primary Care at PVAHCS. The patient was diagnosed with prostate cancer at another VA facility in the fall of 2010. He was treated with radiation therapy followed by leuprolide injections. His last normal recorded PSA was at the “undetectable” level, noted at a 2012 Urology Clinic follow-up appointment. The patient was instructed by the urologist to return in 6 months for an examination and repeat PSA. According to the patient’s EHR, that follow-up appointment was canceled by Urology staff 3 months before the appointment was to occur. There was no evidence in the EHR indicating that staff attempted to contact the patient to reschedule this appointment. Three months after the “canceled” appointment, during a Compensation and Pension examination, another PSA level was ordered. The result showed a VA Office of Inspector General 18 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System value of 0.90 ng/ml. (In a patient with a history of prostate cancer and a history of post-treatment undetectable PSA levels, any measurable PSA suggests recurrence of disease.) Seven months later, as part of a routine appointment, the patient’s PCP ordered laboratory tests, including a PSA. The value was then 98 ng/ml. A Urology Service consult was placed. Later that month, the patient was seen at the PVAHCS ED complaining of 2 months of back pain. X-rays revealed lytic (bone destructive) lesions in his lumbar spine, presumably from metastatic prostate cancer. Urology evaluated the patient that same day, and treatment was initiated. In early 2014, the patient was admitted to hospice; he died 2 months later. At one of this patient’s canceled Urology Service appointments, providers might have identified or confirmed the patient’s rising PSA, which could have prompted an earlier initiation of aggressive treatment. Case 32 A man in his late 50s was hospitalized at PVAHCS in late 2013 after liver nodules were found on a CT scan obtained at a non-VA hospital. A liver biopsy was required for a definitive diagnosis, and this was anticipated to be done after discharge from PVAHCS. Two Schedule an Appointment consults were entered during that inpatient stay—both for Primary Care and both were routine. Two days after discharge, a post-hospitalization call was made to the patient, but staff were unable to make contact with the patient, as his listed contact information was incorrect. Two additional attempts to reach the patient and discuss biopsy scheduling were also documented. A week after discharge the patient was seen in the PVAHCS ED. He was under the impression that he was to return that day to be admitted for a liver biopsy. He was sent home and advised to contact his PCP; he was seen in Primary Care 3 days later at an initial visit to establish care. One week later, the patient was readmitted to PVAHCS for severe groin pain and worsening edema. He was evaluated by the Hematology/Oncology Service the following day, but because of his advanced disease, chemotherapy was not advised. He died 3 days later in the PVAHCS Community Living Center hospice unit. In the care of this patient, there was significant confusion surrounding when or if the patient would have a liver biopsy. Given his clinical state, when the patient returned to the ED with intractable abdominal pain and probable metastatic disease, an admission for pain control should have been considered. Ultimately, a biopsy was not performed due to impaired blood coagulation, making the risk of bleeding complications too great to safely undergo the procedure. VA Office of Inspector General 19 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System Case 33 A man in his mid-60s had a history of aortic valve replacement and was being treated with an anticoagulant medication. He also had a history of coronary heart disease, hypertension, and iron deficiency anemia. He was followed routinely at PVAHCS and was admitted from the ED in the summer of 2013 for an abnormality in his bloodwork that suggested his anticoagulant dosage needed adjusting. At that time, he reported symptoms of fatigue and blood in his stool, received iron infusions, and was discharged with plans to get a colonoscopy and upper gastrointestinal endoscopy as an outpatient. The patient was contacted 5 days after discharge to set up an appointment with gastroenterology, but he informed the caller that he planned to get his care “outside the VA.” For the following 3 months, the patient’s only contact with PVAHCS was with the Anticoagulation Clinic staff. Six weeks after discharge from the hospital, the patient reported to the Anticoagulation Clinic pharmacist that he had dizziness and a low home blood pressure reading (93/47 mm Hg). The pharmacist advised the patient to hold his blood pressure medications, come to the clinic for an evaluation, and contact his provider. On the following day, the patient’s PVAHCS PCP acknowledged receipt of the pharmacist’s note. The final note in the EHR was approximately 5 weeks later when the patient’s wife called to inform facility staff of his death. This patient had symptomatic hypotension that was brought to the attention of a PCP. There is, however, no indication that anyone from Primary Care attempted to contact the patient. Though it appears in the record that the patient was getting private medical care, a patient reporting symptomatic hypotension should have been immediately contacted by a staff member to ensure an appropriate evaluation. Case 34 A man in his mid-60s had a history of tobacco use and persistent cough. He presented to the PVAHCS ED in the spring of 2013 with symptoms suggestive of an acute stroke. He was admitted, and during the hospitalization, a chest X-ray revealed a large density in the right lung. The radiologist recommended a CT scan of the chest for further evaluation of this lesion. The discharge summary from that admission cited the lung abnormality and advised that the patient make an appointment in Primary Care, and obtain a CT scan of his chest in 2 months. Six weeks later, the patient presented to the ED complaining of shortness of breath. He was admitted to the facility and diagnosed with advanced VA Office of Inspector General 20 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System non-small cell lung cancer. The patient was discharged to home hospice and died several days later. This was a patient with a newly described lung mass who required further diagnostic evaluation. If the CT scan could not have been performed during the patient’s hospitalization, an acceptable alternative would have been to discharge the patient with a scheduled appointment in radiology. The hospital discharge plan specified that the patient should schedule an appointment in Primary Care in 1–2 weeks and “obtain a CT scan of the chest in two months”; this is an unacceptable follow-up recommendation for a large lung mass in a patient with a history of cough and tobacco use. Case 35 A man in his late 40s with a history of depression presented to the PVAHCS ED in July of 2013. He had been living on the West Coast, getting private psychiatric care, when he began having paranoid delusional thoughts. He called his parents in Arizona asking for help. They traveled to his home and brought him immediately to the PVAHCS ED. The patient was evaluated by a mental health nurse in the ED. The patient reported to the nurse that he had been started on sertraline 5 days earlier. Additionally, he commented that 6 years prior, he had been prescribed paroxetine but had to stop taking this medication when he began having suicidal thoughts. He denied any history of suicide attempts and also denied any current suicidal or homicidal ideation. He declined hospital admission but did agree to stay with his parents and report to the Mental Health Clinic the following morning. At approximately 11 a.m. the following morning, the patient committed suicide. This patient’s symptoms at presentation were consistent with a depression-induced psychosis. Given his previous reaction to an antidepressant medication, as well as the fact that he was recently started on another antidepressant, hospital staff should have pursued processes for involuntary admission. Case 36 A man in his late 60s had a history of multiple medical problems with depression and chronic pain. He was hospitalized at PVAHCS after presenting to the facility’s Mental Health Clinic in the spring of 2012. He continued to be followed by Primary Care, with some limited involvement of the Pain Clinic. His last primary care visit was in the spring of 2013 for pain control follow-up; at that time his pain medications were adjusted, his sleeping medication dose was increased, and he was instructed to return in 6 months. VA Office of Inspector General 21 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System Three days later, the patient presented to the ED complaining of ongoing pain that was unresponsive to treatment. Though the patient denied suicidal or homicidal ideation at this visit, the ED physician documented that the patient stated, “the pain is so frustrating, it might make him suicidal.” The patient was described as “despondent” when he left the ED after being given a cervical collar and pain medication. Several days later, the patient presented unscheduled to the Primary Care Clinic and was evaluated by a registered nurse. He denied suicidal or homicidal ideation. According to the EHR, “Vet states is in ‘so much pain right now I could cry’.” The nurse documented that she suggested he report to the Mental Health Walk-In Clinic, but the patient declined. On the same day, the patient called the National Suicide Prevention Hotline. He complained of severe and chronic pain unresponsive to treatment, but no response is recorded regarding questions about suicidal ideation or intent. According to the EHR, the “Veteran stated his doctor is not calling him back.” A consult was sent to the local SPC at PVAHCS, but the consult was closed with a comment from the local SPC: “Call not related to SDV [self-directed violence]. Will forward to Veteran's PACT team. Please close consult.” Six days later, the patient committed suicide. Because of his past hospitalization for suicidal ideation, his voicing of ideas about suicide in the ED, and his call to the National Suicide Prevention Hotline, this patient should have been identified and managed as a patient at high risk for suicide. Case 37 A man in his 60s moved to Phoenix in August 2010 to care for his elderly mother. He reported a history of chronic cough and occupational exposure to asbestos to a PVAHCS provider 2 months later. A chest X-ray showed a suspicious lesion, and the patient underwent a CT-guided lung biopsy in early December. The biopsy did not reveal malignancy, but it was noted that the tissue may not “represent the lesion” and close follow-up was recommended. A request for a CT scan to be done 3 months later was entered, but the scan was never scheduled, and the order was canceled with a comment from the radiology staff to “resubmit if needed.” The patient was seen for a routine appointment 5 months after the biopsy, but there was no documented discussion of the CT scan and the scan was not reordered. The patient was seen 5 months later, and X-rays were obtained to evaluate knee pain. About 3 weeks later, he was seen in the ED with persistent leg pain. VA Office of Inspector General 22 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System Eleven months after the lung biopsy, a PVAHCS social worker documented a phone call from a non-VA hospital indicating that the patient had a craniotomy and was diagnosed with metastatic malignant melanoma. He subsequently received comprehensive palliative care at the PVAHCS prior to his death 6 months later. This patient had poor follow-up care following a lung biopsy. Although the cause of this patient’s death was metastatic melanoma and may not have been related to the lung mass, management of the mass was inadequate. Case 38 A man in his late 20s was seen by PVAHCS Mental Health and Primary Care beginning in 2010. He had a history of PTSD, bipolar disorder, and polysubstance abuse. In early 2012, he was hospitalized for suicidal behavior and a psychotic episode related to substance abuse. He completed a sobriety program and was followed by Mental Health every 1 to 2 months for the next several months. His last visit with Mental Health was in the summer of 2012, and his psychiatrist recommended follow-up in “1-2 months, or sooner as needed.” The patient did not keep the follow-up appointment scheduled for 6 weeks after that last appointment, and an attempt to contact him was not made until 12 weeks later. The patient contacted the facility 3 days after the missed appointment and spoke with a nurse about a worsening skin lesion. He was instructed to go to the ED for evaluation, but there were no further encounters with PVAHCS documented. He died 5 weeks later, and the death certificate obtained by OIG states that the cause of death was accidental “acute heroin toxicity.” This patient was at high risk given recent suicidal behavior and hospitalization with psychosis. He was lost to follow-up after he did not appear for an appointment. More timely attempts to contact the patient should have occurred. Case 39 A man in his 30s was first seen at PVAHCS in mid-2011. He had transferred his care from another VAMC, where he had been treated for schizoaffective disorder with disorganized thinking, paranoid ideation, and hallucinations; he also had a history of PTSD. The patient had made three suicide attempts, requiring hospitalization, in the prior 2 years. He was admitted to the inpatient mental health unit at PVAHCS in the spring of 2012 and transferred to a non-VA hospital after assaulting a staff member on the unit. He presented to the PVAHCS ED 2 months later after calling the crisis line. He reportedly called 911 and said that he was suicidal because he could not afford to stay at his motel. He told the triage nurse that he “hates life and it VA Office of Inspector General 23 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System is so stressful he doesn’t want to be in it.” He was evaluated by a mental health consultant, and his risk for suicide was considered to be low. The patient reported that he “would feel okay if he gets some place to live.” In the ED, he was treated with new medications (loxapine and mirtazapine) with a plan to follow up with his private mental health provider or the PVAHCS Mental Health Walk-In Clinic. The following day the patient committed suicide. Because this patient had a history of multiple suicide attempts, psychosis, and an unstable housing situation, an admission to monitor initiation of antipsychotic and antidepressant medications would have been a more appropriate management plan. Case 40 A man in his 20s had been evacuated from Afghanistan in 2009 because of shrapnel injuries and loss of consciousness. He had a history of seven mental health hospitalizations while in the military and a history of self-injurious behavior. He presented to PVAHCS in September 2012 with anxiety and several weeks later was admitted to a non-VA hospital following a suicide attempt. He was subsequently admitted to the PVAHCS inpatient mental health unit after presenting to the ED complaining of feeling angry all the time. He reported suicidal ideation, thoughts of harming his brother, and his sense that once enraged, he did not know if he could stop himself. The following day, a team had a conference, to which the patient presented as upset. His mother stated that the patient told his brother that “all I would have to do when I get out is point a gun at a cop and they would shoot me. I won’t have to kill myself.” The patient’s mother expressed concerns regarding the safety of the patient. Documentation noted the patient “is not exhibiting signs of SI/HI [suicidal or homicidal ideation] or medication withdrawal. Veteran’s mother verbalized she was unwilling to petition [pursuit of involuntary admission] him at this time.” He was discharged. Two days later, he was found dead in his apartment of a possible overdose on medication. There was not a delay in care, but this case raised a quality of care concern. In the context of his presentation the day before and at the conference, his prior mental health history, and the fact that he had not been stabilized on medication, it would have been prudent to either observe or stabilize the patient for a longer period, or for the providers to pursue a petition of involuntary admission, if the patient was unwilling to stay. VA Office of Inspector General 24 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System Case 41 A man in his 70s had a history of significant dementia. The case management notes stated, that for a period of time the veteran lived “off the grid,” with no electricity or telephone at his residence. He was followed in a PVAHCS Primary Care Clinic since 2008, at which time he had not been seen by a medical provider for over 4 years. The patient was seen several times in 2008 with his case manager present but then only for an ED visit in May of 2009, at which time he opted not to wait after being triaged for “flu like” symptoms. The medical record noted that the patient had been scheduled for three appointments in 2010 and 2011, all of which were canceled by the clinic staff without any notation explaining the reason for cancelation. In addition, there is no documentation that attempts were made to reschedule these canceled appointments. A death certificate obtained from the State of Arizona indicated that the patient was found dead in April 2014. The cause of death was listed as “hypertensive and arteriosclerotic cardiovascular disease.” In a patient with such severe cognitive impairment, his remote and isolated living conditions would have made his care management challenging; however, it is concerning that three appointments were scheduled and subsequently canceled by PVAHCS staff without a documented effort to reschedule. Such a pattern would likely discourage any patient from relying on this facility for his or her health care, but in a patient with such significant cognitive impairment, it is unlikely that he could have initiated the process of rescheduling these canceled appointments. Case 42 A man in his mid-50s had a history of hypertension, stroke, chronic hepatitis C, and alcohol and polysubstance abuse disorders. His first presentation to the VA system was when he visited the PVAHCS ED with a complaint of dizziness. He was prescribed medications for nausea and dizziness and discharged. The plan was for the patient to follow up with Primary Care within 1 week. The patient was admitted to the PVAHCS Substance Abuse Residential Rehabilitation Treatment Program 3 weeks later. He completed the treatment program after approximately 1 month and was discharged, taking only blood pressure medications. A suicide risk assessment completed prior to discharge found the patient’s suicide risk to be “low or nil.” Discharge instructions included that the patient was “to go to eligibility to get a Primary Care physician assigned for further follow up.” Three days after discharge, VA Office of Inspector General 25 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System an appointment to establish care with a PCP was made for 12 weeks later, but the patient committed suicide 2 weeks before the appointment. Although any relation to the patient’s death is unlikely, this patient should have had follow-up established with a PCP or mental health provider sooner than the 12 weeks that were planned. Other Patients Case 43 A man in his mid-60s had a history of asthma and COPD. He presented to the PVAHCS ED after having been recently discharged from a non-VA hospital with several medications that needed to be filled. A Schedule an Appointment consult was placed that requested Primary Care follow-up “within one week.” Two weeks later, the patient was hospitalized at another non-VA hospital for pneumonia. Three months later, he was again hospitalized for an asthma exacerbation. He presented to PVAHCS Primary Care approximately 1 week later as a “walk-in,” seeking to have his prescriptions from an outside hospitalization filled. At that time, he received both prescriptions as well as a new patient appointment for 10 days later. The patient completed that appointment and is currently followed as an outpatient. With the history of asthma and COPD as well as a recent hospitalization, this patient should have received primary care follow-up soon after his initial ED visit. It is possible that earlier management and monitoring within Primary Care may have prevented subsequent hospitalizations. Case 44 A man in his mid-50s had a past history of hyperlipidemia. He registered for care at PVAHCS in the spring of 2012, requesting a routine appointment in Primary Care. The patient was given an appointment for 4 months later. In mid-June, the appointment was canceled by the “clinic” and not rescheduled. The patient was not made aware of the cancelation and he reported that he showed for the appointment only to discover it had been canceled. There is no evidence in the EHR that the patient was offered another appointment time. At the end of 2013, the patient reported to an outside ED with chest pain and was taken the following day to the cardiology lab for left heart catheterization with stent placement. A week later, the patient reported to a PVAHCS Primary Care Clinic requesting medications and cardiology follow-up at PVAHCS. The patient was seen by a physician that day, and at that time, a consult for cardiology was placed, as the patient could not afford to “pay out-of-pocket” for a post-procedure cardiology office visit. VA Office of Inspector General 26 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System The patient also reported that when he submitted all the medical bills from his outside hospital care to the PVAHCS business office, he was denied reimbursement, as “he was not enrolled in a Primary Care Clinic within the VA.” The delay between the patient’s registration and initial request for care and an actual appointment was excessive, and when that appointment was inexplicably canceled, PVAHCS staff did not attempt to reschedule the patient. In addition, managing the patient’s post-procedure cardiology follow-up and reimbursing him for life-saving interventions at an outside facility failed to happen in a timely and coordinated manner. Case 45 A man in his late 60s was followed in a PVAHCS Primary Care Clinic. He had a history of diabetes, hypertension, COPD, coronary artery disease, PTSD, depression, and gastroesophageal reflux. He underwent a barium swallow X-ray at a non-VA facility, and 2 days later, home telemetry recorded a blood pressure of 82/67 and that “he’s been terrible sick the past two day since he had his barium swallow … he’s had a terrible headache, chest pain, abdominal pain and constipation.” The patient and his wife presented to his PCP as instructed and were advised to “push fluids, 7 cups water daily,” as the patient’s wife admitted his fluid intake had been low. The patient’s temperature was not taken, no abdominal exam was recorded, and no diagnostic studies were obtained. Two days later, the patient’s wife took him to a non-VA hospital where he was febrile and admitted for urosepsis. The quality of care concern in this case relates to an incomplete evaluation of an ill hypotensive patient, including the lack of a temperature recording or examination of the abdomen. Earlier treatment could have been initiated if an appropriate evaluation had been conducted. Access to Mental Health Care at PVAHCS Although we found a process to provide ready access to mental health assessment, triage, and stabilization had been in place at PVAHCS, we identified issues with continuity of care, care transitions, delays in assignment to a dedicated psychiatrist/mental health nurse practitioner in the outpatient mental health clinic, and impaired access to specific types of evidence-based psychotherapies. Mental health leadership had been addressing these issues at the time of our April–May 2014 visits to the facility. VA Office of Inspector General 27 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System Access, Continuity of Care, and Provider Assignment For several years, PVAHCS has increasingly used a mental health consultation stabilization triage assessment team (CSTAT) to address access for mental health patients. The CSTAT essentially serves as a daily walk-in clinic. New patients presenting for assessment, patients discharged from the hospital, and patients in need of a follow-up appointment but who could not get a timely appointment with their assigned provider in the mental health outpatient clinic, were told to go to CSTAT. On one hand, sending patients to a CSTAT clinic can provide ready and potentially critical access to mental health care, especially for outpatients in need of timely assessment and/or stabilization interventions, and can enhance timely follow-up when a mental health outpatient service is short-staffed. However, when a facility becomes reliant on a CSTAT-like clinic to increasingly provide daily routine or ongoing mental health services because of diminished access to the regular outpatient mental health clinic, issues with provider continuity, care transitions, and provider assignment arise. One issue raised during our interviews was that if a new mental health patient could not be seen for a scheduled appointment with an assigned mental health provider in a mental health clinic, they would be seen in CSTAT instead. If provider availability was still an issue, additional follow-up appointments would occur in CSTAT until assignment to a provider could be accommodated. Although patients could readily access mental health care, actual assignment to a provider might not occur or could be delayed several months. Some new patients might receive a timely initial visit but not a full comprehensive multidisciplinary evaluation until a few months later. In addition, since CSTAT appointments were not with a particular provider, at each CSTAT visit, patients might see different clinicians, an arrangement that lacks continuity of care and the inherent benefits of being assessed and treated by a consistently assigned provider and treatment team. Two additional concerns expressed were: (1) when a mental health provider leaves the facility, the process has been to send the provider’s former patients to CSTAT instead of redistributing or reassigning the patients among existing mental health outpatient clinicians, and (2) transfer patients are sent for walk-in appointments instead of being scheduled for regular appointments. Further, if an assigned patient’s provider did not have availability for a patient to be seen for follow-up in the clinician’s recommended time frame, the patient might also be sent to CSTAT, again raising continuity of care issues. Although CSTAT enabled patients to be seen, broader qualitative issues, such as continuity of care and delayed assignment to a dedicated mental VA Office of Inspector General 28 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System health provider, are not addressed by overreliance on this alternative clinic structure. Care Transitions Patients discharged from the inpatient Mental Health Service, especially but not exclusively those without an assigned Mental Health provider, were often sent to CSTAT for their 14-day follow-up appointment, which is required by VHA policy.2 CSTAT, by design, was a walk-in clinic to provide ready access. However, because it was a walk-in clinic, depending on the patient volume and acuity, the day a recently discharged patient presented for follow-up, the patient might experience a several hour wait to be seen. Patients recently discharged from inpatient mental health care are at increased risk, which in part is the rationale for VHA’s goal to maintain at least phone contact with these patients within 7 days of discharge and face-to-face contact within 14 days of discharge. A concern raised during an interview was that some recently discharged patients would become frustrated and opt to leave CSTAT before being seen by a clinician because of long waits in this walk-in clinic. Though certainly better than a situation where access is not available, the arrangement is not ideal when compared with having a traditional scheduled appointment with an assigned provider in a mental health clinic. Changes Instituted by the Chief of Psychiatry Since coming to PVAHCS in October 2013, the new Chief of Psychiatry successfully recruited 13 additional mental health-prescribing clinicians to the facility within a 7-month period and has begun reorganizing the service. Nine of the new providers are presently on board (several we interviewed in early June had started within the prior 2–3 months), one was due to start the first week in June, and three were in the credentialing process. The influx in new psychiatrists has provided an ability to assign patients to a mental health provider and an availability of new and established patient appointments. As part of a reorganization process, starting in April 2014, the facility has begun implementing a team-based model whereby each day the walk-in clinic will be arranged around teams comprising three to four prescribing clinicians (psychiatrists and nurse practitioners), one psychologist, one social worker, and nursing staff. Each of the new teams were rolled out in 2-week intervals. In place of CSTAT, each team has been assigned a clinic day during which clinicians will see both new patients with scheduled appointments in addition to walk-in patients. The new patients and walk-in patients (who do not already have an assigned Mental Health provider) who are seen that day will then become assigned to one of that team’s providers and be followed by that provider in his or her regular Mental Health Outpatient Clinic. As of July 10, 2014, all five teams were operational with 2 VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, September 11, 2008. VA Office of Inspector General 29 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System some prescribing providers covering 2 days and use of a locum tenens (temporary) physician as part of the Friday team. Newly hired providers who came on board in mid-July were to complete the teams allowing one distinct team of providers per day. The new structure should help provide both enhanced access and continuity of care. Delayed Access to Individual and Specialized Psychotherapy Services VHA has disseminated different evidence-based psychotherapies during recent years including cognitive behavioral therapy (CBT) and acceptance and commitment therapy for depression, cognitive processing therapy and prolonged exposure therapy for PTSD, and dialectical behavioral therapy (DBT) for issues with regulation and modulation of emotions. Within the general mental health clinic there are CBT-based groups for depression, anxiety, and mindfulness that were described to us as “tier 1” groups. These groups meet for 4 weeks, and patients can participate in these groups more than once. PVAHCS has fairly ready access to these groups. The anger management group, which begins every other month; the CBT coping skills group, which begins every 5 weeks; and the pathfinders group (“DBT lite”) comprising three 5-week modules, were described to us as “tier 2” groups. Reportedly, these groups are geared toward stabilizing patients to a level at which they would be ready for individual psychotherapy if indicated and desired. Intensive DBT therapy group, which runs from 6 to 12 months in duration, and individual psychotherapies were described as “tier 3” groups. Several clinicians and clinic staff reported that depending on the circumstances, access to tier 2 groups might be delayed at least 2 months, while access to individual psychotherapy and the intensive DBT group was impaired and involved prolonged, several-month-long waits. Some clinicians expressed frustration that patients referred for individual or intensive therapies were screened using rigorous threshold criteria and deemed inappropriate for these therapies. Psychology leadership reported that some patients referred for these therapies are not stable enough for the level of intensity. Psychology leadership also reported that by 2011, the division had lost a significant number of clinical staff and was not allowed by the prior PVAHCS director to fill the vacancies. As of early June 2014, Psychology leadership reported 11 vacancies for which 9 candidates had been selected and were pending offer acceptance, credentialing, privileging, and/or on-boarding. We obtained a list of patients waiting for individual therapy or specialized mental health therapy services. These services are unrelated to PVAHCS facility leadership performance evaluation metrics. The list contained 171 patient names with the longest wait dating back to November 2013. In early May 2014, the facility had begun working to provide services to these patients through the Non-VA Medical Care program. In June 2014, we VA Office of Inspector General 30 Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System reviewed patient EHRs. None of the patients on the list were deceased. We found some of the patients on the list were being seen internally at the PVAHCS for the requested individual or specialized therapy. A few were being seen by an outside vendor. Some of the patients had either declined or opted to wait to receive therapy internally rather than through Non-VA Care. For the majority of patients, however, Non-VA Care consults had been authorized, but appointments had not yet been scheduled. Of the 128 patients for whom the EHR indicated authorization but scheduling of an appointment via TriWest was still pending, status updates via the TriWest portal indicated that for 96 patients, the authorizations were erroneously sent directly to the patients instead of to...
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