Breadcrumb

Community Care Coordination Delays for a Patient with Oral Cancer at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas

Report Information

Issue Date
Report Number
21-02326-233
VISN
16
State
Arkansas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Community Care
Care Coordination
Appointment Scheduling and Wait Times
Major Management Challenges
Healthcare Services
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a healthcare inspection related to community care coordination delays for a patient with oral cancer at the Veterans Health Care System of the Ozarks (facility) in Fayetteville, Arkansas. The OIG determined that the facility’s Office of Community Care (OCC) staff failed to schedule radical resection surgery within 30 days of an initial consult and failed to act or delayed taking action on five community care consults for the patient’s surgery. As a result, the patient’s surgery took place 205 days after the first consult was placed. Facility OCC staff could not provide an explanation for the failure to act or the delays. The OIG substantiated that facility OCC staff failed to coordinate radiation therapy and delayed coordinating chemotherapy to begin within six weeks after surgery, as requested. Community hospital staff did not use a request-for-services form when seeking approval for the patient’s radiation therapy and chemotherapy evaluation appointment. Facility OCC staff denied the referral for radiation therapy at the community hospital, citing a lack of Veterans Health Administration OCC guidance on community care referrals. Although facility OCC staff entered a consult for chemotherapy at the facility, they failed to communicate the urgency of the care to facility oncology providers. A facility oncology provider saw the patient nine weeks after surgery and documented changes to the patient’s oral cancer and that radiation therapy would not be beneficial. The patient was placed on palliative care and died. The OIG made one recommendation to the Under Secretary for Health related to standardizing community care coordination for follow-up requests from the community provider and two recommendations to the Facility Director related to completing consults within the 30 days and coordinating oncology care in the community.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Health Care System of the Ozarks Facility Director ensures that Office of Community Care staff take action on active consults within seven days and schedule community care appointments within the 30-day clinically indicated date requirement and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Health Care System of the Ozarks Facility Director evaluates the process for authorization of requests for community care and for coordinating care for patients receiving oncology treatment in the community, and takes corrective action to address any deficiencies identified.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary of Health ensures the Veterans Health Administration Office of Community Care defines a standardized process for community care coordination related to follow-up requests for additional services from community providers.