veteran health network cdr bard, lcdr campbell, maj ford 5 june 2012 cdr bard, lcdr campbell, maj...

Veteran Health Network

Veteran Health Network

CDR Bard, LCDR Campbell, MAJ Ford5 June 2012

CDR Bard, LCDR Campbell, MAJ Ford5 June 2012

Outline Outline

• Backstory / Problem

• Abstract Network

• Network Operation

• Measure of Effectiveness

• Network Analysis

• Summary and Conclusion

2

Bill

Bill hands presentation to Jason

U.S. Dept. of Veteran Affairs (VA)U.S. Dept. of Veteran Affairs (VA)

VA Mission: Fulfill Lincoln’s promise

Serve and honor America’s Veterans

3

Lincoln’s Promise: “to care for him who shall have borne the battle, and for his widow, and his orphan”

VA 2011-2015 Strategic PlanVA 2011-2015 Strategic Plan

Strategic Goals

Access to Care

Optimal Value

4

Mindful of President Lincoln’s promise

Veteran Health Administration (VHA)

Veteran Health Administration (VHA)

Largest integrated health care system in United States

152 medical centers

1400 community-based outpatient clinics

5

21 Veteran Integrated Service Networks (VISNs)

Meets needs of 8.3 million Veterans each year

VA Sierra Pacific NetworkVA Sierra Pacific Network

• VISN-21 serves 1.2 million Veterans in northern and central California, northern Nevada, Hawaii, the Philippines, and Guam

• Consists of 40 sites across six Systems

• Each Health Care System is sub-network of larger VISN-21 network

6

Bill

Don't forget to click on PDF Link

Abstract of VISN-21Abstract of VISN-21

Examine three independent Health Care Systems

VA Palo Alto

VA Sierra Nevada

VA Northern California

Representative of urban, rural and hybrid areas

7

Community TermsCommunity Terms

• Urban (Palo Alto): Consists of major population centers

• Rural (Sierra Nevada): Sparsely populated with a few small urban areas

• Hybrid (Northern CA): Consists of major population centers surrounded by rural areas

8

Nodes and EdgesNodes and Edges

• Nodes:• SUPPLY - Veteran populations by county

• DEMAND - Treatment facilities

• Edges:• Connect each county with network

facility

• Cost is distance in miles

9

Simplified Graph Simplified Graph

10

Veterans Treatment

CLINICSCOUNTIES

Treatment Demand

Abstract of VISN-21Abstract of VISN-21

11

1 2

3

4

56

7

8

9Siskiyo

u County

VA Northern California(Hybrid)

Yreka

VA Northern California (Hybrid)

VA Northern California (Hybrid)

SUPPLY

COUNTIES

DEMAND

CLINICS

Network AnalysisNetwork Analysis

• Purpose: Provide outpatient care to Veterans

• Data Tracked:

• Cumulative Distance Traveled

• Per Capita Distance Traveled (outputs)

• Patients Assigned to Clinics

13

Measures of EffectivenessMeasures of Effectiveness

• Model allocates Veterans to treatment facilities

• Minimum-Cost Flow Modeling

• Minimize Veteran travel distance to treatment

• Objective Function:

min S cij yij

cij: cost (distance) per unit flow

yij: number of veterans (flow) on arc14

AssumptionsAssumptions

• All eligible Vets receive care from VA System

• One City per County for distance calculations

• No population distribution for veterans in county

• Community near geographic or population center

• Health Care Systems (HCS) operate independently

• Ability for interchange among HCSs for specialty care

• Not modeled for simplicity and tractability

15

ModelingModeling

• Begin with an unconstrained model

• Add network design constraints and evaluate responses

• Patient limits

• Patient limits with buffers

• Facility closure or patient capacity reductions

• Open a new clinic

• Year 2030 veteran populations

16

Unconstrained ResultsUnconstrained Results

17

Urban Hybrid Rural0

5

10

15

20

25

30

35

Distance to Care

Network

Dis

tance (

miles)

• All patients go to nearest clinic

• Per Capita Distance:

• Urban: 13.69 miles

• Hybrid: 17.37

• Rural: 30.02

Patient Limits Patient Limits

18

• Capacities chosen to ensure no unmet demand

• Modeled as upper bound on Clinic – Treatment Arcs

• Urban / Suburban Outpatient Clinics

• Capacity: 30,000 (urban / hybrid)

• Capacity: 25,000 (rural)

• Rural Outpatient Clinics

• Capacity: 10,000

• Hospitals

• Capacity: 75,000 (hybrid)

• Capacity: 50,000 (urban / rural)

Patient Limits ResultsPatient Limits Results

19



• Hybrid: 22.36

• Rural: 40.93

• 20 - 35% increase

Unconstrained Patient Limits0

5

10

15

20

25

30

35

40

45

Distance to Care

UrbanHybridRural

Model

Dis

tance

Patient Limits with Buffers Patient Limits with Buffers

20

• 1% buffer below capacity for all facilities

• Allow for patient transfers

• New sign-ups

• Recently moved

• Flexibility

Patient Limits with Buffers Results

Patient Limits with Buffers Results

21



• Hybrid: 23.0

• Rural: 41.25

• Baseline

• Closest to RealityUnconstrained Patient Limits With Buffers

0

5

10

15

20

25

30

35

40

45

Distance to Care

UrbanHybridRural

Model

Dis

tance

Budget Cuts Budget Cuts

22

• All HCSs must close a clinic or reduce staffing to save costs

• Force a clinic closure in each region

• Reduce patient limits across the board to simulate staffing cuts

• Model chooses optimal clinic to close and redistributes patients

ClosuresClosures

Hybrid: Yreka, CA

Rural: Winnemucca, NV

Urban: Capitola, CA

23

Budget Cuts ResultsBudget Cuts Results

24

• Per Capita Distance (optimal):


• Hybrid: 23.60

• Rural: 41.25

• Optimal Decision

• Urban: Staff Cuts (+0.67)

• Hybrid: Closure (+0.60)

• Rural: Closure (+1.50)

Unconstrained Patient Limits With Buffers Closure Staff Reductions0

5

10

15

20

25

30

35

40

45

50

Distance to Care

UrbanHybridRural

Model

Dis

tance

Budget Cut Takeaways Budget Cut Takeaways

25

• Can safely close one clinic in each network without disruption

• Two or more closures trigger unmet demand (untreated patients)

• Network is efficient but vulnerable

• Redundancy is expensive and not an efficient use of limited resources

• Maximum reductions in patient capacities (staff cuts) without disruption

• Urban: 10 percent – unmet demand

• Rural: 5 percent – unacceptable patient assignments

• Hybrid: 2.5 percent – unmet demand

Bill

Is staff reduction the same as capacity reduction?

Open New ClinicOpen New Clinic

26

• Political Pressures

• Can’t close a clinic and displace vets

• Must open a new clinic in each network

• Modeled after VA’s Rural Outreach Program

• Opening new small clinics in rural, underserved areas

• Yreka (CA) and Winnemucca (NV) are examples

• Optimal choice from among three communities in each region

UrbanUrban

Three possible locations

Rancho Calaveras, CA

Tracy, CA

Hollister, CA

27

HybridHybrid


Weaverville, CA

Orland, CA

Colusa, CA

28

RuralRural


Austin, NV

Fernley, NV

Mammoth Lakes, CA

29

Open Clinic ResultsOpen Clinic Results

30



• Hybrid: 21.92

• Rural: 49.72

• Reduction from Baseline

• Urban: 0.26 (1.5%)

• Hybrid: 1.08 (4.7%)

• Rural: 1.53 (3.7%)

Uncon

stra

ined

Patie

nt Li

mits

With

Buff

ers

Closu

re

Staff

Red

uctio

ns

Open

Clinic

0

5

10

15

20

25

30

35

40

45

50

Distance to Care

UrbanHybridRural

Model

Dis

tance

Open Clinic TakeawaysOpen Clinic Takeaways

31

• Not worthwhile in urban network

• Slight decrease in objective function

• No patient load decreases on full capacity clinics

• Effective in hybrid and rural networks

• Larger decreases in objective function

• Decreased patient loads at full clinics

Bill

Is staff reduction the same as capacity reduction?

20302030

32

• What does the future hold?

• Veteran population projections by county from the VA for 2030

• 40% reduction from current level

• Fewer WWII, Korea, and Vietnam era vets

• Drafts vs. Volunteer Force

• Assumed all current clinics remain

• Not likely to be true

• Will VA system be folded into National Health Care System?

2030 Results2030 Results

33



• Hybrid: 17.69

• Rural: 32.2

• Similar to Unconstrained model results

• Clinic capacities become inconsequential

• Future closures?Unc

onst

rain

ed

Patie

nt Li

mits

With

Buff

ers

Closu

re

Staff

Red

uctio

ns

Open

Clinic

2030

0

5

10

15

20

25

30

35

40

45

50

Distance to Care

UrbanHybridRural

Model

Dis

tance

ConclusionConclusion

• Network satisfies strategic objective

• Network resilient to limited disruption

• Offers insight to VA network of networks

• Project results in alignment with VA practices

• Flexibility for future Veteran population 34

Future WorkFuture Work

• Add competing objective function(s)

• Minimize Veteran traveling distance

• Minimize cost per patient

• Minimize overhead costs

• Increase granularity

• Determine Optimum Staffing Levels

• Model to help VA meet strategic goals considering 35-40% decrease in Veteran population by 2030

35

QUESTIONS?QUESTIONS?

36

BACKUPBACKUP

37

Patient Limits and Buffers Results

Patient Limits and Buffers Results

38

Urban Hybrid Rural0

5

10

15

20

25

30

35

40

45

Distance to Care

UnconstrainedPatient LimitsWith Buffers

Network

Dis

tance (

miles)

Capito

la

Frem

ont

Liver

mor

e

Menlo

Par

k

Modes

to

Monte

rey

San

Jose

Sono

ra

Stoc

kton

0

10000

20000

30000

40000

50000

60000

70000

80000

Urban Patient Loads


Facilites

Pati

ents

Assig

ned

Fairfi

eld

Sacr

amen

to

Valle

jo

Martin

ez

McCle

llan

Oakla

nd

Reddi

ng

Yrek

a

Chico

Yuba

City

0

20000

40000

60000

80000

100000

120000

Hybrid Patient Loads


Facilities

Pati

ents

Assig

ned

Aubur

n

Fallo

n

Carso

n Val

ley

Susa

nvill

eRen

o

Win

nem

ucca

0

10000

20000

30000

40000

50000

60000

Rural Patient Loads


Facilities

Pati

ents

Assig

ned

Budget Cuts ResultsBudget Cuts Results

39

Urban Hybrid Rural0

5

10

15

20

25

30

35

40

45

50

Distance to Care

UnconstrainedPatient LimitsWith BuffersClosureStaff Reductions

Network

Dis

tance (

miles)

Capito

la

Frem

ont

Liver

mor

e

Menlo

Par

k

Modes

to

Monte

rey

San

Jose

Sono

ra

Stoc

kton

0

10000

20000

30000

40000

50000

60000

70000

80000

Urban Patient Loads


Facilites

Pati

ents

Assig

ned

Fairfi

eld

Sacr

amen

to

Valle

jo

Martin

ez

McCle

llan

Oakla

nd

Reddi

ng

Yrek

a

Chico

Yuba

City

0

20000

40000

60000

80000

100000

120000



Facilities

Pati

ents

Assig

ned

Aubur

n

Fallo

n

Carso

n Val

ley

Susa

nvill

eRen

o

Win

nem

ucca

0

10000

20000

30000

40000

50000

60000

Rural Patient Loads


Facilities

Pati

ents

Assig

ned

Open Clinic ResultsOpen Clinic Results

40

Urban Hybrid Rural0

5

10

15

20

25

30

35

40

45

Distance to Care

UnconstrainedPatient LimitsWith BuffersOpen Clinic

Network

Dis

tance (

miles)

Capito

la

Frem

ont

Liver

mor

e

Menlo

Par

k

Modes

to

Monte

rey

San

Jose

Sono

ra

Stoc

kton

0

10000

20000

30000

40000

50000

60000

70000

80000

Urban Patient Loads


Facilites

Pati

ents

Assig

ned

Fairfi

eld

Sacr

amen

to

Valle

jo

Martin

ez

McCle

llan

Oakla

nd

Reddi

ng

Yrek

a

Chico

Yuba

City

0

20000

40000

60000

80000

100000

120000



Facilities

Pati

ents

Assig

ned

Aubur

n

Fallo

n

Carso

n Val

ley

Susa

nvill

eRen

o

Win

nem

ucca

0

10000

20000

30000

40000

50000

60000

Rural Patient Loads


Facilities

Pati

ents

Assig

ned

2030 Results2030 Results

41

Urban Hybrid Rural0

5

10

15

20

25

30

35

40

45

Distance to Care

UnconstrainedPatient LimitsWith Buffers2030

Network

Dis

tance (

miles)

Capito

la

Frem

ont

Liver

mor

e

Menlo

Par

k

Modes

to

Monte

rey

San

Jose

Sono

ra

Stoc

kton

0

10000

20000

30000

40000

50000

60000

70000

80000

Urban Patient Loads


Facilites

Pati

ents

Assig

ned

Fairfi

eld

Sacr

amen

to

Valle

jo

Martin

ez

McCle

llan

Oakla

nd

Reddi

ng

Yrek

a

Chico

Yuba

City

0

20000

40000

60000

80000

100000

120000



Facilities

Pati

ents

Assig

ned

Aubur

n

Fallo

n

Carso

n Val

ley

Susa

nvill

eRen

o

Win

nem

ucca

0

10000

20000

30000

40000

50000

60000

Rural Patient Loads


Facilities

Pati

ents

Assig

ned

veteran health network cdr bard, lcdr campbell, maj ford 5 june 2012 cdr bard, lcdr campbell, maj...

Documents

year slide

countiesclinics slide

orphan slide

va system

veteran affairs va va

va sierra pacific network

outpatient care

network facility cost