VA257-17-R-0506-018.pdf

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Department of Veterans Affairs Veterans Health Administration Washington, DC 20420

VHA Handbook 1006.02 Transmittal Sheet

December 30, 2013

VHA SITE CLASSIFICATIONS AND DEFINITIONS

1. REASON FOR ISSUE: This is a Veterans Health Administration (VHA) Handbook, which establishes procedures for the implementation of the VHA Site Classifications and Definitions.

2. SUMMARY OF CHANGES: This VHA Handbook:

a. Defines the major points of service across the VHA health care system;

b. Provides standardized definitions to enable new delivery sites to be more uniformly planned and deployed and to facilitate cogent policy decisions regarding Veterans’ access to health care; and

c. Provides the methods and rationale for VHA site classifications.

3. RELATED ISSUES: VHA Handbook 1006.1, dated May 19, 2004.

4. RESPONSIBLE OFFICE: Office of the Assistant Deputy Under Secretary for Health for Policy and Planning (10P1) is responsible for the contents of this Handbook. Questions may be referred to 202-461-7113.

5. RESCISSIONS: VHA Directive 2004-060, VHA Site Tracking (VAST) System, is rescinded.

6. RECERTIFICATION: This VHA Handbook is scheduled for recertification on or before the last working day of December 2018.

Robert A. Petzel, M.D.

Under Secretary for Health

DISTRIBUTION: E-mailed to the VHA Publications Distribution List 1/2/2014

December 30, 2013 VHA HANDBOOK 1006.02 i

CONTENTS

PARAGRAPH PAGE

1. Purpose

2. Background

3. Definitions

4. Scope

5. Responsibilities

6. References

APPENDIX

A. Site Classification Process .................................................................................................. A-1

1. PURPOSE: This Veterans Health Administration (VHA) Handbook defines the major points of service across the health care system, provides clear standardized definitions to enable new delivery sites to be more uniformly planned and deployed and to facilitate cogent policy decisions regarding Veterans’ access to health care, and provides the methods and rationale for VHA site classifications. AUTHORITY: 38 United States Code (U.S.C.) 1706 and 7301(b).

2. BACKGROUND:

a. Facility definitions were established by the VHA Policy Board in 1998. Vet Centers are also tracked as part of the VHA Site Tracking (VAST) System. Vet Center is defined in 38 U.S.C 1712A(h)(1). Finally, the term “VA Medical Facility” was defined by the Under Secretary for Health and also is defined in subparagraph 3.s.

b. Currently, VHA has several sites for delivering medical care, which includes, but is not limited to, health care centers, outreach clinics, annex clinics, and mobile clinics. A clear, concise, and common set of definitions is needed for these sites, including the various points of service.

c. Current monitoring and tracking systems developed to capture workload and other information from hospitals and clinics were not designed for other types of sites that deliver medical care.

d. In an effort to help Veterans and their families navigate the Department of Veterans Affairs (VA) health care system, VA is providing new standardized definitions and names of the major points of health care service across the country. For example, large multi-specialty outpatient clinics that provide surgical services are now called Health Care Centers (HCC), so Veterans understand that more than just primary care is available at these sites. This initiative gives Veterans a new map for health care and a succinct way of navigating the system; therefore, it is easier for Veterans to see and understand where their care is delivered and what their expectations should be when they get there.

3. DEFINITIONS:

a. Administrative Parent. An administrative parent is defined as a collection of all the points of service that a leadership group (Medical Facility Director, Deputy Medical Facility Director, Chief of Staff, Associate or Assistant Director, and Nurse Executive) manages. The points of service can include any institution where health care is delivered. All of the data that originate from these points of service roll up to a single station number representing the administrative parent for management and programmatic activities.

b. Bed Day of Care. A Bed Day of Care (BDOC) is defined as an overnight stay of an individual in a VHA bed within an assigned treating specialty bed section. The BDOC is the unit of analysis used by VHA to determine inpatient, residential, and extended care workload at a

VHA HANDBOOK 1006.02 December 30, 2013 given point of service. The VHA official count of BDOC is in the VHA daily census file. The VHA site classification process uses the Decision Support System (DSS) Treating Specialty National Data Extract (NDE) and the DSS Treating Specialty Cube to generate the inpatient, residential, and institutional extended care ratings for each point of service.

c. Bed Section. The bed section identifies the type of clinical care provided during an overnight stay in a VHA bed. The term “bed section” is defined in 38 U.S.C. 8110(f)(2) as: “The term ‘bed section’, with respect to a medical center, means psychiatric beds (including beds for treatment of substance abuse and post-traumatic stress disorder), intermediate, neurology, and rehabilitation medicine beds, extended care (other than nursing home) beds, and domiciliary beds.” Bed sections are used in the VHA site classification process to identify points of service within VHA that provide inpatient, residential, and institutional extended care services. A bed section is denoted by treating specialty. The list of treating specialties is updated semi-annually, and is available on the National Patient Care Database (or its successor) Web site at:

https://vaww.npcd.aac.va.gov/. NOTE: This is an internal VA Web site and is not accessible to the public.

d. Clinic Stop Class. The clinic stop class identifies the type of service provided by an encounter by aggregating similar DSS identifiers into groups. The list of clinic stop classes is maintained by the Veterans Support Service Center (VSSC).

e. Community-Based Outpatient Clinic. A community-based outpatient clinic (CBOC) is a VA-operated, VA-funded, or VA-reimbursed site of care, which is located separate from a VA medical facility. A CBOC can provide primary, specialty, subspecialty, mental health, or any combination of health care delivery services that can be appropriately provided in an outpatient setting.

(1) Multi-Specialty CBOC. A multi-specialty CBOC is a VA-owned, VA-leased, mobile, contract, or shared clinic that offers both primary and mental health care and two or more specialty services physically on site. Access to additional specialty services may be offered by referral or telehealth. These clinics may offer support services, such as pharmacy, laboratory, and x-ray. The clinic may be operational from 1 to 7 days per week. These clinics are permitted to provide invasive procedures with local anesthesia or minimal sedation, but not with moderate sedation or general anesthesia (see VHA Directive 2006-023). The establishment of a new multi-specialty CBOC can only be approved by the Secretary, with Congressional notification consistent with 38 U.S.C. 8119(b)(2), (3), and (4).

(2) Primary Care CBOC. Primary care CBOCs are VA-owned, VA-leased, mobile, contract, or shared clinics that offer both medical (physically on site) and mental health care (either physically on site or by telehealth) and may offer support services such as pharmacy, laboratory, and x-ray. The clinic may be operational 1 to 7 days per week. Access to specialty care is not provided on site, but may be available through referral or telehealth. A Primary care CBOC often provides home-based primary care (HBPC) and home telehealth to the population it serves to meet the primary care and mental health needs of Veterans who have difficulty accessing clinic-based care. These clinics have access to a higher level of care within a VHA network of care. Primary care in VA includes both medical and mental health care services, as they are inseparable in providing personalized, proactive, patient-centered health care. The https://vaww.npcd.aac.va.gov/ establishment of a new primary care CBOC can only be approved by the Secretary of Veterans Affairs, with Congressional notification.

f. Decision Support System (DSS) Identifiers. VHA Directive 1731 defines DSS Identifiers as, “DSS ID, also referred to as a stop code, is a VHA term that characterizes VHA Outpatient Clinics by a six-character descriptor. The DSS ID value is transmitted to the National Patient Care Database (NPCD) with each separate outpatient encounter into the NPCD field ‘DSS ID.’

A primary stop code and a secondary stop code comprise the DSS ID.

g. Encounter. An encounter is a professional contact between a patient and a practitioner vested with responsibility for diagnosing, evaluating, and treating the patient’s condition.

Encounters occur in both the outpatient and inpatient setting.

(1) Contact can include face-to-face interactions or those accomplished through telecommunications technology.

(2) Use of e-mail does not constitute an encounter. E-mail communications are not secure, and e-mail must not contain patient specific information. NOTE: Secure messaging communication is available through the My HealtheVet (MHV) personal health record (PHR).

These communications may meet the definition of an encounter, based on the type of message and content.

(3) Encounters are neither occasions of service nor activities incidental to an encounter for a provider visit. For example, the following activities are considered part of the encounter itself and do not constitute encounters on their own: taking vital signs, documenting chief complaint, giving injections, pulse oximetry, etc.

(4) A telephone contact between a practitioner and a patient is only considered an encounter if the telephone contact is documented and that documentation includes the appropriate elements of a face-to-face encounter, namely history and clinical decision-making. Telephone encounters must be associated with a clinic that is assigned one of the DSS Identifier telephone codes and are to be designated as count clinics.

h. Extended Care. Extended care is defined by encounters between Veterans and providers within the VHA health care system either in VA institutional care or VA non-institutional care.

Extended care services is defined in 38 U.S.C. 1710B as including geriatric evaluation, nursing home care, domiciliary services, adult day health care, other noninstitutional alternatives to nursing home care, and respite care. Each point of service receives an extended care rating within the VHA site classifications based on the services provided at that location.

(1) VA Institutional Extended Care. VA institutional extended care is provided in beds associated with overnight institutional extended care programs. VA institutional extended care beds are defined by the treating specialty. There are three subtypes of institutional extended care beds: community living center (CLC) short-stay, CLC long-stay, and CLC hospice. The VHA site classification uses the sum of the BDOC of all three subtypes to calculate the total CLC

BDOC.

(2) VA Non-Institutional Extended Care. VA non-institutional extended care is care provided in an outpatient or home setting. This care is usually provided through the VHA HBPC program. The VHA site classification defines VA non-institutional care as those encounters that occur within the community, VA home-based health care, and home telehealth types of encounters.

i. Health Care Center (HCC). A HCC is a VA-owned, VA-leased, contract, or shared clinic operated at least 5 days per week that provides primary care, mental health care, on site specialty services, and performs ambulatory surgery and/or invasive procedures which may require moderate sedation or general anesthesia.

(1) The HCC designated as an ambulatory surgery clinic (ASC) must meet the requirements of the assigned surgical complexity level and provide all associated support infrastructure, such as pharmacy, laboratory, and x-ray, to perform these health care services safely and effectively. ASC programs are evaluated against clinical criteria established by VHA’s National Surgery Office (see VHA Directive 2011-037).

(2) The HCC not designated as an ASC but performing invasive procedures under moderate sedation must meet criteria established by VHA Directive 2006-023, Moderate Sedation by Non- Anesthesia Providers.

(3) The HCC either assigned an ASC designation or performing invasive procedures under moderate sedation or anesthesia must comply with external accrediting bodies’ standards for ambulatory surgery centers and/or provision of anesthesia or moderate sedation.

j. Health Care System. A health care system is an integrated health care delivery system under the direction of one administrative parent facility and comprised of multiple health care facilities, offering an array of health care services to Veterans in a defined geographic area.

Health Care Systems are not specifically classified under the VHA site classification.

k. Inpatient Care. Inpatient care is defined by encounters between Veterans and providers within the VA health care system that require an overnight stay in inpatient beds as described in subparagraphs 3.k.(1)-(5). Each point of service receives an inpatient care classification within the VHA site classification based on the inpatient services provided at that location.

(1) Acute Psychiatry Beds. Acute psychiatry beds are beds associated with acute psychiatric care defined by the treating specialty. Examples of bed sections considered to be acute psychiatry beds include an inpatient post traumatic stress disorder (PTSD) unit, acute psychiatry, and alcohol dependence treatment unit.

(2) Extended Psychiatry Beds. Extended psychiatry beds are beds associated with extended psychiatric care defined by the treating specialty. Examples of bed sections considered to be extended psychiatry beds include long-term and intermediate psychiatry beds.

(3) Medicine Beds. Medicine beds are beds associated with acute medical inpatient care defined by the treating specialty. The VHA site classification generally defines medicine beds as those in the intermediate, medicine, neurology, and medical subspecialties. Examples of bed sections considered to be medicine beds include cardiology, gastroenterology, and neurology.

(4) Rehabilitation Beds: Inpatient rehabilitation beds are associated with care that enables Veterans to acquire the skills and capabilities necessary for the development of personal independence and emotional stability. Rehabilitation beds are defined by the treating specialty.

Rehabilitation programs are dedicated to inpatient life skill development, such as: Spinal Cord Injury, Blind Rehabilitation, Polytrauma, Physical Rehabilitation, and others.

(5) Surgery Beds. Surgery beds are beds associated with acute surgical inpatient care defined by the treating specialty. Many do not have unique surgery wards, but instead combine surgery beds with medicine beds to form medical and or surgical wards (Med/Surg). Examples of bed sections considered to be surgery beds include vascular surgery, orthopedic surgery, and urology.

l. Moderate Sedation. Moderate sedation is defined as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Reflex withdrawal from a painful stimulus is not considered a purposeful response. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. VHA tracks those sites through the Clinical Inventory, a self-reported clinical services list hosted by the VSSC. The VHA site classification uses this self-report to identify the locations of HCCs based on the performance of moderate sedation.

m. Other Outpatient Services Site. Other Outpatient Services Sites are sites in which Veterans receive services that do not meet the criteria listed in subparagraph 3.e. to be classified as a CBOC or in subparagraph 3.i., HCC. Many of the services provided at these sites are contacts made by VA or VHA personnel to provide information, social services, homelessness outreach services, activities to increase Veteran awareness of benefits and services, and support services, such as those provided in Vet Centers. Other services could be more clinical in nature, in which clinical services are provided to remote areas through a Telehealth clinic or other arrangement. If any other services are provided in this venue (external to a VA clinic or facility), they must be associated with, attached to, and coordinated by a health care delivery site located in a clinic or facility.

n. Outpatient Care. Outpatient care is defined by encounters between Veterans and providers within the VA health care system that take place without an inpatient stay. Each point of service receives an outpatient care rating within the VHA site classifications based on the services provided at that location, including mental health, primary care, and specialty care.

(1) Mental Health. Mental health is the term used to describe health services provided in conjunction with psychiatric and psychological health. The VHA site classification defines mental health as those encounters that occur within the compensated work therapy (CWT), gero psychiatry, homeless, mental health, mental health intensive case management (MHICM), psychosocial rehabilitation and recovery center, PTSD, substance use disorder (SUD), and vocational rehabilitation classes of encounters.

(2) Primary Care. 38 CFR 17.108(c)(3) defines primary care visit as: “an episode of care furnished in a clinic that provides integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

Primary care includes, but is not limited to, diagnosis and management of acute and chronic biopsychosocial conditions, health promotion, disease prevention, overall care management, and patient and caregiver education.” The VHA site classification defines primary care as those encounters that occur within the primary care class of encounters.

(3) Specialty Care. Specialty care outpatient visit is defined in 38 CFR 17.108(c)(3) as:

“generally provided through referral. A specialty care outpatient visit is an episode of care furnished in a clinic that does not provide primary care, and is only provided through a referral.”

These services are generally divided into two sub-categories: medicine specialties and surgery specialties. The VHA site classification defines specialty care as those encounters that occur within the geriatric medicine; allergy; cardiology; dermatology; emergency; employee health;

endocrinology; gastroenterology; general medicine; hematology or oncology; infectious disease;

nephrology; neurology; outreach; pulmonary or respiratory disease; rheumatology; amputation follow-up; amputation; anesthesia; cardio-thoracic; ear, nose, and throat (ENT); eye; general surgery; gynecology (GYN); neurosurgery; orthopedics; plastic surgery; urology; or vascular clinic stops.

o. Point of Service. A point of service within the VHA health care system is a distinct place usually defined by an address or a continuous range of addresses that identifies the physical location of where a Veteran interacts with VA health care providers. The point of service is sufficiently distinct in that it can be geo-coded and mapped for the purposes of calculating drive times, mileage, and access standards.

p. Residential Care. Residential care is defined as encounters between Veterans and providers within the VA health care system that require an overnight stay in residential bed sections.

(1) Each point of service receives a residential care rating within the VHA site classifications based on the services provided at that location; and

(2) Although some residential care is also classified as extended care, two programs are specifically classified as “residential care” in the site classification: Residential Rehabilitation and Domiciliary Care (most residential rehabilitation programs are types of domiciliary care).

Specifically, a Mental Health Residential Rehabilitation Treatment Program (RRTP) provides residential rehabilitative and clinical care to eligible Veterans who have a wide-range of problems, illnesses, or rehabilitative care needs, which can be medical, psychiatric, SUD, homelessness, vocational, educational, or social services. The term RRTP refers to the bed category and includes the following programs: Domiciliary Residential Rehabilitation Treatment Programs (DRRTP), Domiciliary Care for Homeless Veterans (DCHV), Health Maintenance Domiciliary, Psychosocial Residential Rehabilitation Treatment Programs (PRRTP), PTSD Residential Rehabilitation Treatment Program (PTSD-RRTP), Substance Abuse Residential Rehabilitation Treatment Program (SARRTP), and CWT-Transitional Residence (TR).

q. Station Number. The station number (STA6A, as represented in VA Databases) identifies unique points of service within VHA. The station number is used by the VHA site classification process to identify the workload associated with individual sites of care. The station number list is maintained by the VA Office of Financial Services Center and is tracked by point of service using the VAST database.

r. VA Hospital. A VA hospital is any VA-owned, staffed, and operated facility providing acute inpatient and/or rehabilitation services.

s. VA Medical Center. A VA medical center is a VA point of service that provides at least two categories of care (inpatient, outpatient, residential, or institutional extended care). For purposes of this Handbook, Vet Centers are not assigned a category of care, and do not affect the site classification.

4. SCOPE: It is VHA policy that each point of service with a station number is assigned a site classification. When new sites of care are established, it is VHA policy that those sites use the standardized definitions provided in this Handbook.

5. RESPONSIBILITIES:

a. Under Secretary for Health. The Under Secretary for Health is responsible for designating the site classifications for each VHA point of service that provides direct patient care services.

b. Deputy Under Secretary for Health for Policy and Services. The Deputy Under Secretary for Health for Policy and Services (10P) is responsible for:

(1) Reviewing and revising classification data sources annually at the end of the fiscal year;

(2) Executing the VHA site classifications at the end of each fiscal year; and

(3) Communicating the VHA site classifications to the Deputy Under Secretary for Health for Operations and Management (10N), VISN Directors, and Facility Directors annually.

c. Deputy Under Secretary for Health for Operations and Management. The Deputy Under Secretary for Health for Operations and Management (10N) is responsible for:

(1) Ensuring the appropriate communication and use of the VHA site classification designations in VHA daily operations; and

(2) Hosting and maintaining the accuracy of the VAST database.

d. VHA Chief of Staff. The VHA Chief of Staff is responsible for communicating the VHA site classifications and updates with external stakeholders, e.g., Congress, Veterans, and the general public.

e. Assistant Deputy Under Secretary for Health (ADUSH) for Policy and Planning. The ADUSH for Policy and Planning (10P1) is responsible for developing guidelines for opening new sites of health care and monitoring existing sites of care, in conjunction with the VHA site classifications, for planning and policy purposes.

f. Chief Readjustment Counseling Service (RCS) Officer. The Chief RCS Officer is responsible for maintaining an end-of-fiscal year list of all mobile and non-mobile Vet Center sites, and transmitting that list on an annual basis to the Deputy Under Secretary for Health for Policy and Services.

g. Director of VHA National Surgery Office. The Director of VHA National Surgery Office (10NC2) is responsible for maintaining an end-of-fiscal-year list of all inpatient and ambulatory surgery sites, and transmitting that list on an annual basis to the Deputy Under Secretary for Health for Policy and Services.

h. Veterans Integrated Services Network Director. Each Veterans Integrated Services Network (VISN) Director or designee is responsible for:

(1) Verifying that all points of service within the VISN are appropriately classified according to the VHA site classification methodology; and

(2) Communicating classification discrepancies to the Deputy Under Secretary for Health for Policy and Services (10P) through the “VAST Administrators” VA internal email distribution group..

i. Medical Facility Director. Each medical facility Director or designee is responsible for:

(1) Verifying that all points of service within the management of the administrative parent facility are appropriately classified according to the VHA site classification methodology (see Appendix A); and

(2) Keeping the facility’s VHA Clinical Inventory up to date with accurate information, especially with regard to the provision of moderate sedation at all sites.

6. REFERENCES:

a. VHA Handbook 1006.1, Planning and Activating Community-Based Outpatient Clinics, http://vaww.va.http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=410. NOTE:

This is an internal VA Web site and is not accessible to the public.

b. VHA Directive 1731 Decision Support System Outpatient Identifiers is available at:

http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1788. NOTE: This is an internal VA Web site and is not accessible to the public.

c. VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=1409. NOTE: This is an internal VA Web site and is not accessible to the public.

http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=410 http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1788 http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=1409

d. VHA Directive 2011-037, Facility Infrasture Requirements to Perform Invasive Procedures in an Ambulatory Surgery Center, http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=2452. NOTE: This is an internal VA Web site and is not accessible to the public.

http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=1409

APPENDIX A

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SITE CLASSIFICATION PROCESS

Veterans Health Administration (VHA) points of service are all rated through the VHA site classification process. Each unique point of service is rated in all four major medical care categories: outpatient, inpatient, residential, and extended care. These ratings are broken down into sub-ratings for each category and are based on actual workload completed at each point of service in the prior fiscal year.

1. DATA: The data used to rate each point of service in the four major medical care categories span two databases: one database for outpatient care and one for bed-based care. The summary of how the data sources including Decision Support System (DSS) identifiers and treating specialties are used to classify sites using the VHA site classification process will be hosted by the VHA Support Service Center (VSSC).

a. Outpatient Classification Data. The VHA site classification process uses the official VHA source for outpatient data, the National Patient Care Database (NPCD or its successor). This database uses DSS stop codes that classify encounters into types of workload. Those types of workload are used to classify the sites for the VHA site classification process. The list of clinic stop codes are updated semi-annually, available on Decision Support Office web site at:

http://vaww.dss.med.va.gov/programdocs/pd_oident.asp. NOTE: This is an internal VA Web site that is not accessible to the public.

b. Inpatient, Residential, and Extended Care Data. The VHA site classification process uses the DSS Treating Specialty National Data Extract (NDE) for determining bed-based workload totals. This database uses treating specialities that classify bed days of care into bed sections that can be used to determine what type of workload took place. Those types of workload are used to classify the sites for the VHA site classification process. The list of treating specialties are updated semi-annually, and are available on the National Patient Care Database Web site at:

http://vaww.npcd.aac.va.gov/. NOTE: This is an internal VA Web site that is not accessible to the public.

2. OUTPATIENT CLASSIFICATION: Each point of service receives one of the following outpatient ratings based on services provided. All outpatient ratings are mutually exclusive.

a. Other Outpatient Services. A site that either provides services to Veterans, but does not generate VHA encounter workload, or does not meet minimum criteria to be classified as a community-based outpatient clinic (CBOC) or Health Care Center (HCC), is classified as “Other Outpatient Services.” This means these sites are not included in geographic access calculations or counted in Congressional reports as CBOCs.

b. Primary Care CBOCs.

(1) Requirements. Primary Care CBOCs are required to provide both primary care and mental health services. Sites that do not provide both primary care and mental health services are classified as Other Outpatient Services.

http://vaww.dss.med.va.gov/programdocs/pd_oident.asp http://vaww.npcd.aac.va.gov/

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(2) Primary Care Requirements. A point of service is said to provide primary care services if the site registers more than 500 primary care encounters within the primary care stop class within a given fiscal year.

(3) Mental Health Requirements. A point of service is said to provide mental health services if the site registers more than 500 mental health encounters within a single mental health clinic stop class within a given fiscal year. Mental health services may be provided using telehealth, if the workload at the point of service would not otherwise justify the presence of mental health providers.

(4) Remedial Action Required. Points of service that fail to meet the Primary Care CBOC standard for providing mental health and primary care services will be notified by the Deputy Under Secretary for Health for Operations and Management (10N) and will be instructed to implement the missing services as required. Until remedial action is completed, the point of service will be classified as Other Outpatient Services.

c. Multi-Specialty CBOCs.

(1) Requirements. Multi-Specialty CBOCs are subject to the same requirements as Primary Care CBOCs, and are also required to provide multiple (two or more) specialty services.

(2) Specialty Care Requirements. A point of service is said to provide a specialty service if the site registers more than 500 encounters within a single specialty clinic stop class (e.g., cardiology, neurology, etc.) within a given fiscal year. A site must provide at least two specialties at this level to be classified as a multi-specialty clinic.

d. Department of Veterans Affairs (VA) Health Care Center (HCC). VA HCCs are subject to the same requirements as Multi-Specialty CBOCs, and are also required to provide ambulatory surgery and/or invasive procedures requiring moderate sedation as defined by the Joint Commission.

(1) Ambulatory Surgery Requirements. If a site is rated as an ambulatory surgery center pursuant to VHA Directive 2011-037, Facility Infrasture Requirements to Perform Invasive Procedures in an Ambulatory Surgery Center, regarding performing invasive procedures in an Ambulatory Surgery Center, the site is classified as a VA Health Care Center. The list of sites that meet this guideline is maintained by the VHA National Surgery Office at:

http://vaww.dushom.va.gov/surgery/Surgical_Complexity.asp. NOTE: This is an internal VA Web site that is not accessible to the public.

(2) Moderate Sedation Requirements. If a site is certified by the Joint Commission for administering moderate sedation, the site is classified as a VA HCC. The list of sites that meet this guideline is maintained by the VSSC as a component of the facility self-reported clinical inventory found at:

http://vaww.vssc.med.va.gov/ClinicalInventory/FacilitySearch/FacilitySearch.aspx. NOTE:

This is an internal VA Web site that is not accessible to the public.

http://vaww.dushom.va.gov/surgery/Surgical_Complexity.asp http://vaww.vssc.med.va.gov/ClinicalInventory/FacilitySearch/FacilitySearch.aspx

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e. No Rating. No rating is given if a site fails to meet the requirements for any of the previous ratings. This usually occurs when no outpatient services are provided at that location.

f. Save Ratings. To prevent constant re-shuffling of outpatient ratings, each point of service retains its outpatient rating until there have been 2 consecutive years where a rating has been downgraded, or where there is confirmation by the Veterans Integrated Service Network (VISN) Director that a site has reduced the service provided.

3. INPATIENT CLASSIFICATION: Each point of service receives one or more of the following inpatient ratings based on services provided. Medicine and Medical and/or Surgical ratings are mutually exclusive. Other ratings are not mutually exclusive.

a. Inpatient Acute Medicine. Points of service with inpatient medicine beds must have had at least one active medicine bed section in the previous fiscal year.

b. Inpatient Acute Medical and/or Surgical (Med/Surg). Points of service with inpatient Medical and/or Surgical beds are subject to the same requirements as points of service with inpatient medicine beds. In addition, the point of service must have at least one active surgery bed section in the previous fiscal year.

c. Inpatient Acute Psychiatry. Points of service with inpatient acute psychiatry beds must have at least one active acute psychiatry bed section in the previous fiscal year.

d. Inpatient Extended Psychiatry. Points of service with inpatient extended psychiatry beds must have at least one active extended psychiatry bed section in the previous fiscal year.

e. Inpatient Rehabilitation. Points of service with inpatient rehabilitation beds must have at least one active inpatient rehabilitation bed section in the previous fiscal year.

f. No Rating. No rating is given if a site fails to meet the requirements for any of the previous ratings. This usually occurs when no service is provided at that location.

4. RESIDENTIAL CARE CLASSIFICATION: Each point of service receives a residential rating based on services provided.

a. Residential Care. Points of service with residential care beds must have at least one active residential care bed section in the previous fiscal year.

b. No Rating. No rating is given if a site fails to meet the requirements for any of the previous ratings. This usually occurs when no service is provided at that location.

5. EXTENDED CARE CLASSIFICATION: Each point of service receives one or more of the following extended care ratings based on services provided. These ratings are not mutually exclusive.

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a. VA Institutional Care. Points of service with VA institutional care (nursing home or Community Living Center (CLC)) beds must have at least one VA institutional bed section, such as a CLC, that has over 500 bed days of care (BDOC) in the previous fiscal year.

b. VA Non-Institutional Care. A point of service is said to provide VA non-institutional care services if the site registers more than 500 VA non-institutional care encounters within a single VA non-institutional care clinic stop class within a given fiscal year.

c. No Rating. No rating is given if a site fails to meet the requirements for any of the previous ratings. This usually occurs when no service is provided at that location.

6. EXCEPTIONS: Some points of service will not be classified properly by the site classification process. For sites where an administrative parent or VISN believes that there has been a misclassification of a point of service, an appeal may be sent to the Office of the Assistant Deputy Under Secretary for Health for Policy and Planning (10P1) for review. The Assistant Deputy Under Secretary for Health for Policy and Planning (10P1) will review the workload associated with the point of service and will take into consideration the recommendation of the facility and VISN. If the site has been misclassified, the Assistant Deputy Under Secretary for Health for Policy and Planning (10P1) will make a manual exception to the site’s classification and retain documentation of the exception. Each exception will be handled separately in its own appeal process.