The nonpartisan U.S. Government Accountability Office released a report Thursday that made four specific recommendations to the Department of Veterans Affairs concerning primary and mental health care for veterans living in the Pacific.
According to the report, most veterans in the review received timely primary and mental health care, but there were some delays and weaknesses in the referral process to community providers, such as inconsistent guidance on staff roles and responsibilities.
Concerning Guam, the report stated more than 3,200 veterans on island received their care through VA Pacific Islands Health Care System and that in 2017 there had been more than 15,000 outpatient encounters.
When it came to mental health care, the report indicated that most veterans in the review received initial mental health care from VA providers within the goal of 30 days, but there were some delays completing comprehensive mental health evaluations.
For Guam's sample of 10 veterans who required that comprehensive checkup, six received it within 30 days. The report said Guam's clinic generally completed the comprehensive mental health evaluation during a veteran's first mental health care appointment, but sometimes needed to schedule a second appointment to complete the entire evaluation.
"Staff stated that the first priority is to treat and address what is clinically indicated, so they are sometimes delayed in completing all form requirements until a later time," the report said.
The latter third of the report primarily dealt with the major physician recruitment and retention challenges unique to Guam and the other Pacific islands.
"Overall, there were at least 17 physician vacancies out of approximately 100 positions across VAPIHCS as of October 2017, as well as several more vacancies for other types of health care providers, some of which have been unfilled for some time," the report stated. "Guam clinic staff told us that at one point between October 2016 and March 2017, the clinic had 1.8 primary care physician full-time equivalents, even though it was authorized for four."
The report also said there is only one dermatologist on Guam practicing at Naval Hospital Guam, and there is only one gastroenterologist in the community providing certain services. It further stated VAPIHCS has only one medical school to recruit from in Hawaii, and that doctors coming to the islands face a high cost of living, limited community resources and geographic remoteness.
The report discussed the technical limitations of working across the international dateline from a VA facility in Hawaii.
According to the report, the Guam clinic operates off a server located in Honolulu, which is 20 hours behind Guam. As a result, the report states, "physicians are frustrated working in a system that may require multiple days to complete clinical notes. ... If a Guam physician sees a patient on Monday at 3 p.m., it is 7 p.m. on Sunday in Honolulu. As a result, physicians must wait until the next day to retroactively complete clinical notes."
The report states veterans treated on Guam are essentially treated in the future because according to the VA server in Honolulu, the date of a health care appointment in Guam is always one day ahead of the server in Honolulu.
Because of the time difference, Guam staff only have about 16 business hours per week that the clinic is open that overlap with business hours of VAPIHCS doctors or staff working in Honolulu, which limits the amount of time physicians at the Guam clinic can consult with other physicians.
GAO's first recommendation states the VA should ensures that VAPIHCS review its referral process to Department of Defense providers, including referral cancellation, to determine why Veterans Health Administration policy is not being adhered to and make changes as needed.
Its second recommendation states the VA should ensure that VAPIHCS clarifies guidance to clearly define and document roles and responsibilities for VAPIHCS staff involved in the referral process with Naval Hospital Guam.
The third recommendation states the VA should ensure that VAPIHCS improves the monitoring of referrals and communication with Naval Hospital Guam to ensure the timely management of referrals there, including verifying the availability of services for veterans, ensuring referrals are entered into its electronic medical record system and obtaining information about the status of scheduling appointments for veterans.
GAO's fourth and final recommendation stated the VA should ensure that VAPIHCS evaluates the effectiveness of strategies it currently uses to promote physician recruitment and retention, including how the strategies could be improved. The plan should also include an assessment of whether additional strategies currently offered by Veterans Health Administration would be beneficial.
'Our veterans deserve better'
In a press release, Del. Madeleine Bordallo, who is seeking re-election, said, "Our veterans deserve better. Some progress has been made to improve health care services for veterans who live on Guam and the other Pacific territories, but this report underscores that more needs to be done."
Sen. Frank Aguon Jr., who is running for governor, said Bordallo must press the VA to improve services on Guam.
"We, veterans here on Guam, understand that the current staff at (Guam Community-Based Outpatient Clinic) are not to blame for the inconsistencies found in the recent GAO report," Aguon said. "We know that the Guam CBOC has more patients than medical professionals and their support staff are overworked. We know that the VA and the VAVHA leadership could do more, but chooses to do nothing."
Bordallo said she encouraged the VA to "swiftly implement the GAO's recommendations."