United States Government Accountability Office Report to the Ranking Member Committee on Veterans' Affairs U.S. Senate VA HEALTH CARE December 2023 Actions Needed to Improve Information Reported on Mobile Medical Units GAO-24-106331 December 2023 VA HEALTH CARE Actions Needed to Improve Information Reported on Mobile Medical Units Highlights of GAO-24-106331, a report to the Ranking Member, Committee on Veterans' Affairs, U.S. Senate Why GAO Did This Study What GAO Found Mobile medical units are vehicles The Department of Veterans Affairs (VA) operates mobile medical units to equipped to deliver clinical services in provide medical services to veterans. These units can deliver primary and self-contained environments away from specialty care to veterans in communities with veteran populations too small to parent facilities. Congress included a support local facilities, such as VA clinics, or in areas with limited access to provision in the Veterans Access, specialty care. Choice, and Accountability Act of 2014 for VA to develop operational Example of a Department of Veterans Affairs Mobile Medical Unit requirements for these units and annually report on performance against those requirements. GAO was asked to review VA's mobile medical units. This report's objectives include examining the information VA reports to Congress on the units' operations and performance. GAO reviewed VA's annual reports to Congress for 2018 through 2023, VA policies, and data for fiscal year 2022. GAO also interviewed officials from the Veterans Health Administration's Office of Emergency Management and from five regional networks and the 12 VA medical centers in those regional GAO found that VA's annual reports to Congress about the operations and networks about their 20 units. Regional performance of mobile medical units did not have quality information. networks were selected for variation in Specifically, VA reported some information that was inaccurate or lacked context geographic location and number of on why some operational requirements were not being met. For example, in its units, and to include a mixture of rural 2023 report, VA reported there were 52 active units. However, 25 of them and urban VA medical centers. GAO reported appointment data. GAO also found: also interviewed representatives from • VA inaccurately included nine of the 20 mobile medical units in GAO's review two veterans service organizations. in its total number of active units. Per VA's definition, these nine units were What GAO Recommends not active, meaning they were not open and treating patients away from parent facilities. VA officials said they do not assess the reliability of GAO is making two recommendations information they report on the units because such information is taken from to VA: (1) assess the reliability of data existing databases. it reports on mobile medical units and ensure their reliability, and (2) include • VA did not provide context for why 20 of 25 mobile medical units reporting contextual information about unit appointment data did not meet VA's operational requirement to conduct 845 operations in its reports to Congress. appointments. For example, one unit in GAO's review conducted 17 VA concurred or concurred in principle appointments; however, the unit was not yet fully operational. VA is not with GAO's recommendations and required to include such context, but without it, VA's report suggests that unit identified steps it plans to take to was underperforming. address them. Without quality information, VA and Congress cannot rely on VA's reports for a complete picture of overall operations and performance of mobile medical units. As a result, they may miss opportunities to use these units effectively to help View GAO-24-106331. For more information, ensure access to care for rural veterans, especially those living in areas with contact Alyssa M. Hundrup at (202) 512-7114 or hundrupa@gao.gov. limited access. United States Government Accountability Office Contents Letter 1 Background 4 VA Reports Lack Quality Information on Overall MMU Operations and Performance 8 Selected VA Medical Centers Use MMUs to Expand Access to Primary and Specialty Care for Rural Veterans 13 Conclusions 17 Recommendations for Executive Action 17 Agency Comments 17 Appendix I Objectives, Scope, and Methodology 19 Appendix II Comments from the Department of Veterans Affairs 23 Appendix III GAO Contact and Staff Acknowledgments 25 Tables Table 1: Examples of Mobile Medical Units (MMU) Inaccurately Reported as Active in VA's 2023 Report to Congress 9 Table 2: Examples of Conditions That Might Affect Mobile Medical Unit (MMU) Performance, According to Officials from Selected VA Medical Centers 11 Table 3: Examples of Mobile Medical Units' (MMU) Services, Schedules, and Staffing, June 2023 15 Table 4: Selected Regional Networks and Their Associated VA Medical Centers with MMUs 20 Figure Figure 1: Examples of Department of Veterans Affairs Mobile Medical Units 5 Page i GAO-24-106331 VA Mobile Medical Units Abbreviations Choice Act Veterans Access, Choice, and Accountability Act of 2014 MMU mobile medical unit VA Department of Veterans Affairs VHA Veterans Health Administration This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page ii GAO-24-106331 VA Mobile Medical Units Letter 441 G St. N.W. Washington, DC 20548 December 14, 2023 The Honorable Jerry Moran Ranking Member Committee on Veterans' Affairs United States Senate Dear Mr. Moran: The Department of Veterans Affairs (VA) administers one of the largest health care systems in the nation and offers health care services at 172 VA medical centers and more than 1,100 outpatient facilities. As of May 2023, approximately one-third of the nearly 8.7 million veterans enrolled in VA's Veterans Health Administration (VHA) health care system, about 2.8 million veterans, lived in rural areas. 1 Our past work and other research highlights a variety of factors that may affect rural veterans' access to health care, such as distance from health care facilities, increased wait times, lack of specialty services, and provider shortages. 2 VA has reported that these challenges can lead to disparities in quality of care and health outcomes for rural veterans when compared with their urban counterparts. 3 VA operates mobile medical units (MMU) as one way to serve veterans who have limited access to health care due to factors such as rurality, low population, or limited local demand for specialized services. MMUs are vehicles equipped to deliver clinical services in self-contained environments. In 2014, VA's Office of Inspector General reported that VHA lacked information on MMUs, including their locations, purpose, and patient 1VHA uses the Rural-Urban Commuting Areas system to define rurality. This system takes into account population density as well as how closely a community is linked socio- economically to larger urban centers. We use the term rural to include rural, highly rural, and insular island areas. 2For example, see GAO, VA Mental Health: Additional Action Needed to Assess Rural Veterans' Access to Intensive Care, GAO-23-105544 (Washington, D.C.: Feb. 9, 2023) and Veterans Health Care: Services for Substance Use Disorders, and Efforts to Address Access Issues in Rural Areas, GAO-20-35 (Washington, D.C.: Dec. 2, 2019). See also Department of Veterans Affairs, Veterans Health Administration Office of Health Equity, National Veteran Health Equity Report 2021 (Los Angeles, Calif.: Sept. 2022). 3National Veteran Health Equity Report 2021. Page 1 GAO-24-106331 VA Mobile Medical Units workloads. 4 That same year, Congress included a provision in the Veterans Access, Choice, and Accountability Act of 2014 (Choice Act) for VA to develop standardized MMU operational requirements and annually report on their performance. 5 In response, for example, VA requires MMUs to operate a minimum of 137 days per year. VA has reported on how many MMUs meet requirements in annual reports to Congress since 2018. In its 2021 report to Congress, VA reported on MMUs' performance against operational requirements for fiscal year 2020. 6 For example, VA reported that 29 MMUs were providing clinical services, but that 19 of those units did not meet the VA requirement of operating 137 days or more during the year. You asked us to examine VA's use of MMUs. In this report, we 1. examine the information VA reports on MMU operations and performance and 2. describe how selected VA medical centers use MMUs. To answer our objectives, we reviewed VA policies and reports related to MMUs, and interviewed VA officials who have a role in how VA reports information on or uses MMUs. We interviewed officials from VA medical centers and Veterans Integrated Service Networks-regional networks of VA medical centers. 7 We also interviewed officials from VHA's Office of 4VA Office of Inspector General Office of Audits and Evaluations: Veterans Health Administration Audit of Mobile Medical Units, 13-03213-152 (Washington, D.C.: May 14, 2014). 5Pub. L. No. 113-146, § 204, 128 Stat. 1754, 1778-1779. 6Department of Veterans Affairs, Congressionally Mandated Report: Access to Health Care Through the Use of Mobile Vet Centers and Mobile Medical Units, (Washington, D.C.: September 2021). VHA's Readjustment Counseling Service operates a fleet of Mobile Vet Centers to provide outreach and support readjustment counseling for veterans and their families. Mobile Vet Centers are outside the scope of this work. 7VA's delivery of health care is divided into 18 regional networks that are responsible for managing and overseeing the VA medical centers and health care systems within their defined area. A VA health care system includes one or more VA medical centers or clinics that work together to offer services to area veterans. For this report, we use the term "VA medical center" to refer also to a VA health care system. Page 2 GAO-24-106331 VA Mobile Medical Units Emergency Management and Homeless Programs Office. 8 We interviewed officials from these offices about their roles and obtained documents about the programs they offer or the support they provide to MMUs. We also interviewed officials from five selected regional networks and 12 VA medical centers about their 20 MMUs. We selected the regional networks to represent variation in geographic area, a mixture of rural and urban medical centers that operate MMUs, and variation in the number of MMUs in the network. The information we obtained from these regional networks and associated VA medical centers is not generalizable, but rather provides illustrative examples of how VA medical centers use MMUs to deliver services to veterans. To gather veterans' perspectives on MMUs, we interviewed representatives from two veterans' service organizations: Disabled American Veterans and American Legion. To examine the information VA reports on MMU operations and performance we reviewed the reports VA issued to Congress from 2018 through 2023. These reports included data from fiscal years 2017 through 2022, respectively, which was the most recent available information at the time of our review. We also compared VA-provided MMU site-of-care data and appointment data for fiscal year 2022 and information from VA's reports to Congress against information gathered from selected regional networks and VA medical centers, as discussed later in this report. 9 8We also interviewed officials from VHA's Office of Rural Health, Office of Connected Care, and National Oncology Program. We determined that these offices currently do not play a significant role in how VA uses MMUs. VHA's Office of Emergency Management maintains assets that can include multi-use vehicles, mobile pharmacy units, mobile support units, and mobile emergency nutrition units. These units are not generally used to provide clinical services outside of emergent events; thus, they are not within the scope of this work. 9VA extracted site-of-care data for fiscal year 2022 from VHA's Site Tracking database. Sites of care are distinct places where veterans interact with VA providers, including MMUs, VA medical centers, and VA clinics. The database documents each site's associated regional network and parent facility, as well as each site's location, identification number, operational status, and mobile status. As with other sites of care, VA records the operational status of MMUs as active, temporarily deactivated, permanently deactivated, or planned. See Veterans Health Administration: VHA Directive 1229(1): Planning and Operating Outpatient Sites of Care, (Washington, DC: Jul. 7, 2017, amended Oct. 4, 2019). VA extracted appointment data for the same time period from its Corporate Data Warehouse via VHA's Support Service Center. Page 3 GAO-24-106331 VA Mobile Medical Units To gather information on how VA prepares annual MMU reports to Congress, we interviewed officials from VHA's Office of Emergency Management, the program office responsible for preparing these reports. We also interviewed officials from VHA's Office of Analytics and Performance Integration, which provides data for these reports. To gather information on VHA leadership's role in MMU operations, we interviewed an official from the Office of the Assistant Under Secretary for Health for Operations. We also assessed information from VA's annual reports to Congress, site-of-care and appointment data for fiscal year 2022, and interviews with regional network, VA medical center, and other VA officials against VA's strategic plan and federal standards for internal control for information and communication. 10 We determined that the principle of externally communicating the necessary information to achieve the entity's objectives was significant to this objective. See appendix I for additional details on our scope and methodology. We conducted this performance audit from October 2022 to December 2023 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. VA has operated MMUs since 1992. According to VA's national policy on Background MMU program management, MMUs are self-powered vehicles or trailers on wheels capable of moving from one physical location to another. 11 They deliver clinical services to patients in self-contained environments 10Department of Veterans Affairs, Fiscal Years 2022-28 Strategic Plan (Apr. 18, 2022). Internal control is a process effected by an entity's oversight body, management, and other personnel that provides reasonable assurance that the objectives of an entity will be achieved. See GAO, Standards for Internal Control in the Federal Government, GAO-14-704G (Washington, D.C.: Sept. 10, 2014). 11See Veterans Health Administration, VHA Directive 1154(1): Mobile Medical Unit (MMU) Program Management, (Washington, D.C.: Jul. 26, 2017, amended Mar. 11, 2020). MMUs are distinct from: semi-permanent buildings and clinic additions or modular structures that may be used to serve a temporary clinical need; dual use vehicles that provide VA beneficiary transportation between multiple service locations and patient movement for emergency facility evacuations; veteran transportation network vehicles; and Mobile Vet Centers which provide readjustment counseling and outreach services to veterans. Page 4 GAO-24-106331 VA Mobile Medical Units away from associated parent VA facilities. (See figure 1 for examples of these units.) Figure 1: Examples of Department of Veterans Affairs Mobile Medical Units Source: Department of Veterans Affairs. | GAO-24-106331 Page 5 GAO-24-106331 VA Mobile Medical Units Purpose of MMUs According to VA, MMUs can offer accessible, quality health care to veterans in communities with veteran populations too small to support Other Types of Mobile Units: Mobile local permanent facilities, such as VA clinics. 12 In particular, VA reports Prosthetic and Orthotic Care that MMUs with telehealth programs deliver services to rural and The Department of Veterans Affairs (VA) underserved areas where commutes to health care facilities may be operates other types of mobile units besides mobile medical units (MMU) that provide lengthy and can be a barrier to receiving needed clinical care. 13 However, services to veterans away from VA medical compared to brick-and-mortar locations, VA also reports that MMUs have centers. For example, VHA's Office of Rural Health funds the Mobile Prosthetic and reduced treatment space, equipment, supplies, and capabilities and that Orthotic Care program to deliver prosthetic they have reduced life spans as sites of care due to the rigors of travel. 14 and orthotic services to veterans in rural areas. As of fiscal year 2023, this program provides 10 VA medical centers with funds for VA's Fiscal Years 2022-28 Strategic Plan identifies rural veterans as an providers and custom-outfitted vans for underserved population and includes a goal to increase health care prosthetic and orthotic care, according to VA. Although mobile, these vans are not MMUs as access for rural veterans. 15 MMUs also may help VA support its "Fourth defined by VA because patients are not Mission" to provide service continuity during emergencies and disaster treated in the vans, according to VA; rather, providers travel in the vans and deliver support missions, such as when VA outpatient facilities are compromised services, such as modifications or fittings for or inaccessible. prosthetic devices, in VA clinics or veterans' homes. Source: Veterans Health Administration (VHA) documents and interview with officials from VHA's Office of Rural Health. | GAO-24-106331 VA's Annual Reports to VA has annually reported to Congress on MMU performance since 2018. Congress and National VA developed standardized annual requirements for MMUs delivering primary care services. Among other requirements, MMUs must meet the MMU Policy following minimum requirements: (1) 137 days of travel and operation, (2) three locations visited, and (3) 845 appointments conducted. 16 VA also developed requirements for when to notify individuals in an area about MMU schedules (within 10 business days) and telehealth capability (all should have network access). 12VHA Directive 1154(1). 13Department of Veterans Affairs, Congressionally Mandated Report: Access to Health Care through the Use of Mobile Vet Centers and Mobile Medical Units, (Washington, D.C.: September 2022). 14VHA Directive 1154(1). 15VA, Fiscal Years 2022-28 Strategic Plan. 16Department of Veterans Affairs, Congressionally Mandated Report: Access to Health Care through the Use of Mobile Vet Centers and Mobile Medical Units, (Washington, D.C.: September 2022). Page 6 GAO-24-106331 VA Mobile Medical Units First issued in July 2017, VA's national MMU policy defines responsibilities for operations and performance. According to VA, this policy establishes a consistent mission and standards for patient care, operation, procurement, and performance monitoring for MMUs. It also assigns responsibility for annual reporting to VHA's Office of Emergency Management. In addition, the policy states that MMUs should be maintained to ensure their readiness for deployment when needed for disasters and service disruptions. VA's MMU policy has been pending recertification since July 2022. 17 In June 2023, VA reported convening a workgroup to review and update the policy. MMU Roles and VA medical centers, VA regional networks, and VHA's Office of Responsibilities Emergency Management each have responsibilities related to MMUs: • VA medical centers can, according to VA policy, operate MMUs to improve access to health care for veterans in their service areas. 18 VA medical centers are responsible for managing their MMUs, according to VA. This responsibility includes, for example, funding maintenance, scheduling routes, and establishing staffing plans. • VA regional networks are responsible for ensuring that MMU data in VHA's Site Tracking database are current. 19 This responsibility includes ensuring changes to an MMU's operational status are reflected in the database. Examples of such changes include the activation of a new MMU or the temporary or permanent deactivation of an MMU when it is not active (open and treating patients). 20 • VHA's Office of Emergency Management is responsible for coordinating emergency management within VA, including the deployment of MMUs in support of VA's "Fourth Mission" for 17According to VA policy, recertification is the process by which a policy is evaluated for efficacy, updated by the policy owner, reviewed through the concurrence process and signed by the signature authority. See Veterans Health Administration, VHA Directive 0999: VHA Policy Management, (Washington, D.C.: Mar. 29, 2022). 18VHA Directive 1154(1). 19Veterans Health Administration, VHA Directive 1229(1): Planning and Operating Outpatient Sites of Care, (Washington, D.C.: July 7, 2017). 20According to VA policy, an MMU or other site-of-care should be temporarily deactivated when a site needs to be temporarily closed for at least 60 days and no more than 3 years. An MMU or other site-of-care should be permanently deactivated when it ceases operations permanently. See VHA Directive 1229(1). Page 7 GAO-24-106331 VA Mobile Medical Units emergency continuity and disaster support missions. 21 This office is also responsible for developing VA's annual MMU reports to Congress, and is the program office of record for national MMU policy. As of November 2023, VA reported it is working to fill a position for a full-time national MMU program manager within the Office of Emergency Management. According to VA policy, the program manager is responsible for developing reporting and data collection processes for MMUs, among other duties. 22 Based on our review of VA's reports to Congress and data from and VA Reports Lack interviews with selected VA medical centers, we found that VA's reports Quality Information on do not have quality information on overall MMU operations and performance. In particular, we found that VA reported some inaccurate Overall MMU information about the operations and performance of its MMUs in its 2022 Operations and and 2023 reports to Congress. Additionally, we found that VA's reports did not include contextual information important to understanding the Performance operations and performance of MMUs. Inaccurate information. In its 2023 report to Congress (which includes information for fiscal year 2022), we found VA reported some inaccurate information on the number of active MMUs. Specifically, VA reported that there were a total of 52 active MMUs across its network during fiscal year 2022. However, based on information from the selected medical centers in our review, we found that at least nine of these were not active-that is, they did not meet VA's criteria for an active MMU. 23 The nine MMUs did not meet the criteria because, according to medical center officials, they had not yet started operating, were not being regularly used for their intended purpose, were not providing clinical services, or were immobile. (See table 1 for examples.) Therefore, VA should not have categorized these nine MMUs as active in VHA's Site 21VHA Directive 1154(1). 22VHA Directive 1154(1). 23We assessed the operational status of selected VA medical centers' MMUs. We did not collect additional information to assess the operational status of MMUs outside our selection. As such, we did not determine whether more than nine MMUs were incorrectly identified as active in VHA's Site Tracking database in fiscal year 2022, or whether some active MMUs were missing from the database. Page 8 GAO-24-106331 VA Mobile Medical Units Tracking database, per policy, nor should it have reported them as active in its 2023 report to Congress. 24 Table 1: Examples of Mobile Medical Units (MMU) Inaccurately Reported as Active in VA's 2023 Report to Congress MMU Service Status description, as of May 2023 1 Specialty This MMU was equipped to deliver mammography, bone density, and ultrasound services, but was not yet in care operation as of June 2023. Medical center officials said they were awaiting final approval from VHA's Radiology Program Office before they could operate the MMU. Officials told us they anticipate receiving approval in 2023. 2 Specialty Staffing challenges, specifically the need for a driver with a commercial driver's license, have prevented the care MMU from being used, according to medical center staff. During the COVID-19 pandemic, the medical center used the MMU to provide additional clinical space at the medical center. Officials said they plan to use the unit as soon as they hire appropriate staff. 3 Outreach This aging MMU had not been in regular use since 2016 and, at the time of our review, was not used to provide clinical services. Medical center officials said they kept the MMU classified as active due to the administrative burden of changing its operational status in VA databases. An official said this unit would be deactivated. An official also said the medical center launched a new MMU in May 2023 to conduct outreach-to engage with veterans and educate them about VA benefits. This unit will not be used to deliver clinical care. 4 Specialty Due to maintenance challenges, the MMU is no longer mobile. The MMU is parked at a VA medical center and care used as an extension of the facility. Officials said the MMU's equipment is outdated, and it will be deactivated in September 2023. Officials plan to provide comparable services in the facility. Source: Interviews with officials from selected Department of Veterans Affairs (VA) medical centers. | GAO-24-106331 Notes: VA provides an annual report to Congress about MMU operations and performance. This report includes information about active MMUs. VA's 2023 report to Congress relies on 2022 data from the Veterans Health Administration's Site Tracking database. In this database, each of the MMUs in this table was identified as active, which according to VA means it is able to be moved and is open and treating patients away from a parent facility. This table describes examples of MMUs that were (1) planned, but not in use, (2) not regularly used for their intended purpose, (3) not providing clinical services, or (4) immobile. These MMUs may have been used on an ad hoc basis to support other VA functions, including continuity of care in emergent situations. Additionally, according to our analysis of VA appointment data from fiscal year 2021, we found that VA did not report accurate performance information for one of the 20 MMUs in our review. Specifically, VA's 2022 report to Congress (which includes information for fiscal year 2021) did not include any appointments for this MMU. 25 However, officials from this VA medical center reported they first used their MMU in the field in 24VHA Directive 1154(1) and Department of Veterans Affairs, VAST Database and Report Fields with Definitions, February 3, 2023. 25CongressionallyMandated Report: Access to Health Care through the Use of Mobile Vet Centers and Mobile Medical Units, 2022. We identified a similar issue with this VA medical center's appointment data for the first half of fiscal year 2022. As of May 2022, VA data indicated that the medical center was attributing appointments to the MMU. Page 9 GAO-24-106331 VA Mobile Medical Units November 2020 and provided us with appointment data for fiscal year 2021. After we brought this discrepancy to their attention, VA officials said they conferred with the medical center and determined the medical center had incorrectly attributed the MMU's appointments to the VA medical center or associated outpatient clinics in electronic health records. 26 The inaccurate information we found in VA's 2022 and 2023 reports to Congress reflect weaknesses in VA's efforts to collect data for its reports. To generate reports, VA officials query electronic health record data for appointments attributed to each MMU identified as active in VHA's Site Tracking database. However, VA officials said that they do not assess the reliability of the data they include in their annual reports to ensure that the data are accurate. For example, VA officials who compile the reports said they do not conduct outreach to facilities that have an MMU registered as active in the database, but that do not have appointment data for that MMU, to understand why there is not associated data reflecting the operations of the MMU. Rather, because the data are from existing databases, VA officials told us they assume the data are accurate. Limited contextual information. We also found that VA's annual reports to Congress for fiscal years 2018 through 2023 did not include contextual information important to understanding the operations and performance of MMUs. VA reports how many MMUs meet operational requirements, as required by the Choice Act. 27 However, it did not report information on MMU services, capacities, or other operational capabilities or limitations. VA is not required to report this information, but doing so would help VA and Congress understand the various ways in which MMUs are operating, and importantly, why many seem to be underperforming. MMUs providing primary care services are to meet certain annual operational requirements established by VA-a minimum of 137 days of travel and operations, three locations visited, and 845 appointments conducted. However, VA's reports to Congress do not explain why many were unable to meet these requirements. For example, in its 2023 report, VA stated that five of the 25 MMUs reporting clinical data met the 26An electronic health record is a collection of information about the health of an individual and the care provided to that individual, such as patient demographics, medications, and past medical history. Electronic health records should include information about when and where clinical appointments take place. Location data should include the identification number for the site-of-care. See, Department of Veterans Affairs, VHA Directive 1082: Patient Care Data Capture and Closeout (Washington, D.C.: Mar 9, 2023). 27Pub. L. No. 113-146, § 204(b), 128 Stat. 1754, 1778-1779. Page 10 GAO-24-106331 VA Mobile Medical Units requirement to conduct a minimum of 845 appointments. 28 One MMU in our selection recorded 17 appointments in fiscal year 2022, well below the 845 minimum appointment requirement. According to VA medical center officials, the MMU was not yet fully operational during that time, and they recorded those 17 appointments during test deployments. According to VA, the medical center should not have recorded test deployment appointments in VA's encounter data system. However, VA did not collect information from the medical center on why the MMU appointment numbers were low or include context about test deployments in its 2023 report. Without such information, one might conclude that this MMU was fully operational, but underperforming. More broadly, without information about any operational limitations or other context, VA's reports to Congress present an incomplete picture of overall MMU performance. In addition, we identified other factors that can affect MMUs ability to meet VA's operational requirements. Specifically, we found that MMUs vary in size, delivery models, and other operational conditions. (See table 2.) Table 2: Examples of Conditions That Might Affect Mobile Medical Unit (MMU) Performance, According to Officials from Selected VA Medical Centers Requirementa Examples of conditions that might affect MMU performance 137 days of Weather. Certain conditions, including winter weather and high winds, inhibit travel and operations. travel and Aging vehicles. It can take months to obtain parts for older vehicles that are no longer manufactured. operation 3 locations Maintenance. To keep maintenance costs lower, some older MMUs are parked in community locations or are not visited regularly moved. Road conditions. Due to poor road conditions and equipment sensitivity, MMUs may be parked at a single location and not frequently moved. 845 Low population. Some MMUs serve areas with low numbers of veterans in need of VA services. appointments Vehicle size. MMUs vary in size, with smaller ones having one exam room and larger ones having two or more. Smaller MMUs may have less capacity to serve veterans than larger ones. Service type. MMUs provide different types of services and the number of veterans served could vary by appointment length. Some types of appointments last 30 minutes, while others 60 minutes. Source: Department of Veterans Affairs (VA) reports and interviews with officials from selected VA medical centers. | GAO-24-106331 a VA developed minimum annual operational requirements for MMUs that provide primary care services. According to its reports to Congress, VA has not established requirements for MMUs that provide specialty care services, such as audiology and cardiology. 28In the 2023 report to Congress, VA reported that 27 of 52 active MMUs did not report clinical data on numbers of appointments for fiscal year 2022. Page 11 GAO-24-106331 VA Mobile Medical Units Additional context in VA's reports to explain how such factors affect performance could help VA and Congress understand why many MMUs did not meet operational requirements during the time period of our review. Such information could help VA identify the most efficient and effective uses of MMUs. For example, VA established requirements for primary care MMUs, but not for those that provide specialty care. However, VA did not specify what services the MMUs provided (e.g., primary or specialty care) in its annual reports. By providing information on type of care, among other things, VA and Congress may find it easier to interpret performance information in MMU reports. As a result of the weaknesses we found in VA's reporting, VA and Congress cannot rely on VA's reports for a complete picture of overall MMU operations and performance. VA's strategic plan calls for the agency to use data to understand critical problems and develop evidence- based solutions that improve outcomes for veterans and ensure efficient use of resources. 29 Further, federal standards for internal control state that management should communicate quality information externally so that external parties can help the entity achieve its objectives and address related risks. 30 Without quality information about MMUs, including the total number of active MMUs and number of appointments, as well as supplemental information to contextualize performance, VA and Congress may be limited in their ability to make informed decisions about how best to use MMUs. This could contribute to VA and Congress potentially missing opportunities to efficiently and effectively leverage MMUs to increase access to care and improve outcomes, especially for veterans living in rural areas. VA officials said they intend to revisit the content of the reports they provide to Congress as part of their review of national MMU policy. This policy outlines roles and responsibilities for MMUs, including those related to operational requirements and reporting. As of August 2023, VA officials reported the MMU policy recertification process is underway. However, VA officials had yet to lay out specific plans as to what their review of policy might include. As it moves forward with its recertification process, VA has an opportunity to assess and improve the accuracy and usefulness of the information it reports to Congress. 29VA, Fiscal Years 2022-28 Strategic Plan. 30GAO-14-704G. Page 12 GAO-24-106331 VA Mobile Medical Units From interviews with VA medical center officials, we found that the Selected VA Medical selected medical centers in our review primarily use MMUs to deliver Centers Use MMUs health care services to veterans living in rural areas. As of June 2023, officials from seven medical centers reported that they use 11 MMUs to to Expand Access to expand access to primary and specialty care. Officials reported that these Primary and Specialty units were active-open and treating patients-and providing primary care services, such as labs and chronic illness management, and Care for Rural specialty care services, such as audiology and cardiology services. Veterans According to medical center officials, MMUs offer benefits that help VA medical centers expand services to veterans-in particular, rural veterans-who may otherwise experience barriers to care. According to these officials, MMUs can help VA medical centers in the following ways: • Address veterans' transportation challenges. MMUs can help reduce travel burdens for veterans in rural or remote areas, according to some medical center officials. One medical center in our review reported using its MMU to deliver primary care services to veterans in remote areas who may have limited ability to travel long distances, for example, 3 to 4 hours, to a VA clinic. Officials said these veterans might rely on others for transportation or have health challenges that limit their ability to travel. Specifically, they said that many veterans who use the unit are elderly, are hard-of-hearing, or have trouble seeing, making it difficult for them to travel long distances. Officials from another medical center said veterans save time by receiving specialty care services at MMUs. Their units deliver audiology services, such as hearing tests and hearing aid fittings, at nearby VA clinics that do not offer these services. This reduces veterans' travel to distant VA medical centers or clinics, where the services are otherwise available. By delivering services closer to home, MMUs help veterans save transportation time and avoid missing work or other responsibilities to receive medical care. • Accommodate veterans' preferences. Officials from one VA medical center said veterans who use their MMUs prefer primary care Page 13 GAO-24-106331 VA Mobile Medical Units delivered by VA providers to that from community care providers. 31 Reasons these veterans cited for preferring VA providers include greater familiarity with veterans' health issues, such as toxic exposures, and VA's suicide prevention resources. 32 Additionally, officials from this medical center said veterans who use their units are not interested in in-home telehealth. These veterans have shared that they want to have, at minimum, an in-person interaction with a nurse during appointments. • Mitigate local provider shortages. Officials at one VA medical center said that one in five veterans they serve live in rural or highly rural areas. 33 Officials said that in some of these areas there are no VA clinics or community care providers to serve veterans. All the locations where the medical center's two MMUs deliver primary and specialty care services are in counties with a federally designated shortage of providers, according to Health Resources and Services Administration data. 34 Officials said they hope these units will help ensure that rural veterans in their medical center's area can maintain continuity of care. • Respond to emergent situations. Officials from multiple VA medical centers said they have used MMUs to respond to emergent situations, such as the COVID-19 pandemic or temporary clinic closures. For example, officials at two medical centers said they used MMUs to 31Through VA's Veterans Community Care Program, veterans can receive health care services from a community provider rather than from a VA provider under certain circumstances. For example, veterans who are enrolled in VHA care can see a community provider if VA cannot provide care within designated access standards for average drive and wait times for appointments. See GAO, Veterans Community Care Program: Improvements Needed to Help Ensure Timely Access to Care, GAO-20-643 (Washington, D.C.: Sept. 28, 2020). 32As part of their military service, veterans may have experienced toxic exposures. These exposures include contact with toxic chemicals from burn pits during service in Iraq, Afghanistan, and certain other areas, and exposure to Agent Orange, an herbicide, during Vietnam-era service. There are known illnesses and conditions related to these exposures. See Department of Veterans Affairs, Exposure to Hazardous Chemicals and Materials (Washington, D.C.: July 18, 2023), accessed Sept. 13, 2023, https://www.va.gov/disability/eligibility/hazardous-materials-exposure/. 33According to the Rural-Urban Commuting Areas system, a highly rural area is a sparsely populated area where less than 10 percent of the working population commutes to any community larger than an urbanized cluster, which is typically a town of no more than 2,500 people. 34The Department of Health and Human Services' Health Resources and Services Administration defines a health professional shortage area as a geographic area, population, or facility that has a shortage of primary, dental, or mental health care providers. Page 14 GAO-24-106331 VA Mobile Medical Units deliver COVID-19 vaccines during the pandemic. Officials at an additional VA medical center said they used their MMU to support an outreach mission to Native American tribes in their area during COVID-19. Through this mission, the medical center provided assistance with materials, supplies, and COVID-19 surveillance. Additionally, officials at one VA medical center said they used an audiology MMU to continue audiology services at a local VA clinic. Officials said this clinic had flooded and temporarily could not provide the services. Officials from VA medical centers described varying ways they use MMUs to serve veterans. For example, MMUs may deliver services either in- person or through telehealth. When MMUs deliver services through telehealth, a support clinician, such as a nurse, facilitates the appointment in person, while another provider connects to the appointment remotely. MMUs also vary in services they deliver; schedules, such as how many locations they visit and how frequently; and staffing. (See table 3 for examples.) Table 3: Examples of Mobile Medical Units' (MMU) Services, Schedules, and Staffing, June 2023 Type of care Services, schedule (locations and frequency), and staffing Primary care Services: One VA medical center operates three MMUs that deliver services, such as labs and primary care exams. Each MMU delivers services at a dedicated community location. These locations include a state university campus, an armory, and a training facility. Officials said they chose these locations based on the number of veterans in the communities and to reach different populations, such as student veterans. Schedule: Each MMU remains parked at one designated community location. Officials said this is because the MMUs are older and area roads are frequently closed to large vehicles due to wind. Staff travel daily to the community locations. The staff visit one location 2 days per week, the second location 1 day per week, and the third location 1 day per week. Staffing: The three MMUs are staffed by one team, which includes a nurse, licensed practical nurse, and two technicians. Remote nurse practitioners connect to patients' appointments through telehealth. Officials said using telehealth allows providers to maintain productivity and see other patients during the time MMU staff travel. Audiology Services: One VA medical center operates two MMUs that deliver audiology services, such as hearing tests and hearing aid fittings and repairs at different VA clinics. Officials said their MMUs deliver services at three of the medical center's 14 clinics that do not have permanent audiology services. Officials said the MMUs allow the VA medical center to provide services at clinics where expansions might be difficult, such as leased locations or locations that do not have space for specialized equipment. Schedule: One MMU delivers services at the same clinic each week. The other MMU provides services at two clinics, one week at each clinic. Officials said this helps reduce wear and tear on the vehicles. Staffing: Each MMU is staffed with a team of two audiologists who provide services in person. Officials said they staff the MMU with audiologists to help ensure veterans receive any needed audiology service. Page 15 GAO-24-106331 VA Mobile Medical Units Type of care Services, schedule (locations and frequency), and staffing Cardiology Services: One VA medical center operates one MMU that delivers cardiology services, such as electrocardiograms and limited vascular studies, at three VA clinics. Officials said these locations were chosen based on the demand for cardiology services at the clinics and parking availability. Schedule: The MMU travels to two of the three clinics each week. It remains at each of the clinics for 2 days. It travels to the third clinic (which has less demand) once a month. Staffing: Two teams of four staff the MMU. Each team includes a provider, nurse, stenographer, and driver. Staff are assigned to the MMU at least 50 percent of the time; the remainder of their time they work onsite at the main medical center. Staff travel separately to the clinic each day because the MMU cannot transport them. Source: Interviews with officials from three selected Department of Veterans Affairs (VA) medical centers. | GAO-24-106331 Looking forward, officials from multiple VA medical centers said they plan to increase health care services with new MMUs. For example, officials from one medical center told us they plan to use a new MMU to deliver primary, mental health, and specialty care services using telehealth. For this MMU, the provider will be remote, and staff will facilitate the veteran's appointment in the MMU. Officials said they are in the process of procuring the MMU and expect to receive it by the end of calendar year 2023. Additionally, two VA medical centers in our review will receive new MMUs in 2023 through VHA's Homeless Patient Aligned Care Team MMU initiative. VHA's Homeless Programs Office will provide the MMUs to help the medical centers deliver outreach, clinical, mental health, and social services to veterans experiencing homelessness. (See text box.) Homeless Patient Aligned Care Team Mobile Medical Units (MMU) In 2022, the Veterans Health Administration's (VHA) Homeless Programs Office awarded 25 MMUs to 24 Department of Veterans Affairs (VA) medical centers. The office projects delivery of the MMUs to medical centers on a rolling basis from August 2023 to February 2024. Officials expect the units to begin delivering services within 2 months of receipt. The 25 MMUs are to deliver outreach services and wrap-around care-clinical, mental health, and social services-to veterans experiencing homelessness in urban and rural areas, according to officials. Each unit will be equipped to provide medical exams and offer services such as rapid COVID-19 tests. According to program office officials, VA medical centers are to staff each MMU with a social worker and clinician. VA medical centers are also encouraged to collaborate with other local service providers, such as community centers and homeless shelters. Program officials said they hope that by providing a consistent community presence, these units will help VA build trust with veterans experiencing homelessness. Source: VHA documents and interview with VHA's Homeless Programs Office. | GAO-24-106331 Page 16 GAO-24-106331 VA Mobile Medical Units MMUs are an important tool VA medical centers can use to deliver care to Conclusions hard-to-reach veterans, including veterans living in rural areas. Medical centers have identified several benefits of using MMUs to deliver primary and specialty care to veterans, including reducing veterans' travel burdens and responding to local provider shortages. However, we found VA does not have quality information on the overall operations and performance of its MMUs, which in turn limits its ability to understand the various ways in which these units are operating, and importantly, why many seem to be underperforming. By ensuring the quality of information in its reports-including both the reliability of the data as well as contextual information-VA and Congress will have a more complete picture of overall MMU performance. Such information will then better position them to leverage MMU resources more efficiently and effectively to ensure access to care, particularly for veterans in rural areas and other underserved populations. We are making the following two recommendations to VA: Recommendations for Executive Action The Department of Veterans Affairs Under Secretary for Health should assess the reliability of the data it reports to Congress on the operations and performance of its MMUs and ensure the reliability of the data it reports. (Recommendation 1) The Department of Veterans Affairs Under Secretary for Health should include contextual information on MMU operations and performance to supplement the information it provides in its reports to Congress. Such information should include the types of services MMUs provide, as well as other information on operational conditions and any limitations, as appropriate. (Recommendation 2) We provided VA with a draft of this report for review and comment. VA Agency Comments provided written comments, which are reprinted in appendix II. In its comments, VA concurred with our first recommendation and identified steps it plans to take to address it, including initiating an integrated project team that will, among other things, work to ensure the reliability of the data management plan for MMUs. VA concurred in principle with our second recommendation. VA reported it plans to work with Congress to understand its reporting needs and update its next report accordingly. The department also provided technical comments, which we incorporated as appropriate. Page 17 GAO-24-106331 VA Mobile Medical Units We are sending copies of this report to the appropriate congressional committees, the Secretary of the Department of Veterans Affairs, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact Alyssa M. Hundrup at (202) 512-7114 or hundrupa@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix III. Sincerely yours, Alyssa M. Hundrup Director, Health Care Page 18 GAO-24-106331 VA Mobile Medical Units Appendix I: Objectives, Scope, and Appendix I: Objectives, Scope, and Methodology Methodology Our objectives for this report were to (1) examine the information the Department of Veterans Affairs (VA) reports on mobile medical unit (MMU) operations and performance and (2) describe how selected VA medical centers use MMUs. To answer our objectives, we reviewed VA policies and reports related to MMUs, and interviewed VA officials who have a role in how VA reports information on or uses MMUs. We interviewed officials from VA medical centers and Veterans Integrated Service Networks-regional networks of VA medical centers. 1 We also interviewed VHA's Office of Emergency Management and Homeless Programs Office. 2 We interviewed officials from these offices about their roles and obtained documents about the programs they offer or the support they provide to MMUs. We also interviewed officials from selected regional networks and VA medical centers about their MMUs. We used site-of-care data from VHA's Site Tracking database as of September 30, 2022, to identify the number of active MMUs, which VA defines as open and treating patients. 3 VHA's database showed 52 active MMUs at 34 VA medical centers, located across 15 regional networks. To understand how VA medical centers use MMUs and what information it reports on MMUs, we selected five regional 1VA's delivery of health care is divided into 18 regional networks that are responsible for managing and overseeing the VA medical centers and health care systems within their defined area. A VA health care system includes one or more VA medical centers or clinics that work together to offer services to area veterans. For this report, we use the term "VA medical center" to refer also to a VA health care system. 2We also interviewed officials from VHA's Office of Rural Health, Office of Connected Care, and National Oncology Program. We determined that these offices currently do not play a significant role in how VA uses MMUs. VHA's Office of Emergency Management maintains assets that can include multi-use vehicles, mobile pharmacy units, mobile support units, and mobile emergency nutrition units. These units are not generally used to provide clinical services outside of emergent events; thus, they are not within the scope of this work. 3VHA compiles site-of-care data in VHA's Site Tracking database. Sites of care are distinct places where veterans interact with VA providers, including MMUs, VA medical centers, and VA clinics. The database documents each site's associated regional network and parent facility, as well as each site's location, identification number, operational status, and mobile status. As with other sites of care, VA records the operational status of MMUs as active, temporarily deactivated, permanently deactivated, or planned. See Veterans Health Administration: VHA Directive 1229(1): Planning and Operating Outpatient Sites of Care, (Washington, DC: Jul. 7, 2017, amended Oct. 4, 2019). Page 19 GAO-24-106331 VA Mobile Medical Units Appendix I: Objectives, Scope, and Methodology networks with 12 medical centers that have 20 MMUs. 4 We selected the regional networks to represent variation in geographic area, a mixture of rural and urban medical centers that operate MMUs, and variation in the number of MMUs in the regional network. (See table 4.) Table 4: Selected Regional Networks and Their Associated VA Medical Centers with MMUs Regional Number of network VA medical center (state) Urban or rurala MMUs 7 William Jennings Bryan Dorn VA Medical Center (South Carolina) Urban 1 10 Chillicothe VA Medical Center (Ohio) Rural 1 10 Cincinnati VA Medical Center (Ohio) Urban 1 10 Louis Stokes Cleveland VA Medical Center (Ohio) Urban 3 10 Central Ohio Healthcare System (Ohio) Urban 2 17 Dallas VA Medical Center (Texas) Urban 1 17 Audie L. Murphy Memorial Veterans' Hospital (Texas) Urban 1 17 VA Texas Valley Coastal Bend Healthcare System (Texas) Urban 2 19 Cheyenne VA Medical Center (Wyoming) Rural 4 19 Grand Junction VA Medical Center (Colorado) Urban 2 23 Iowa City VA Medical Center (Iowa) Urban 1 23 Des Moines VA Medical Center (Iowa) Urban 1 Total 5 Regions 12 VA medical centers 10 Urban, 2 Rural 20 MMUs Source: Mobile medical unit (MMU) data from Veterans Health Administration Site Tracking database and interviews with Department of Veterans Affairs (VA) medical centers. | GAO-24-106331 Note: VA's delivery of health care is divided into 18 regional networks that are responsible for managing and overseeing the VA medical centers and health care systems within their defined area. As a result of agency realignment efforts in 2002 and 2015, VA's regional networks are not consecutively numbered. A VA health care system includes one or more VA medical centers or clinics that work together to offer services to area veterans. We use the term "VA medical center" to refer also to a VA health care system. a In the Veterans Health Administration Site Tracking database, urban or rural status is based on the census tract where the VA medical center is located. To examine the information VA reports on MMU operations and performance, we reviewed Choice Act provisions that outline requirements for VA to report to Congress annually on MMU operations and performance. We reviewed the reports VA issued to Congress from 2018 through 2023. These reports included data from fiscal years 2017 through 2022, respectively, which was the most recent available 4We included one MMU in our review that was not in VHA's database. An official from one medical center in our selection identified an additional MMU that they said would become active in June 2023. We included information on that MMU, along with the 19 others listed in the database. Page 20 GAO-24-106331 VA Mobile Medical Units Appendix I: Objectives, Scope, and Methodology information at the time of our review. We also interviewed officials from the five selected regional networks and 12 VA medical centers about MMU operations and performance, including their data collection and reporting processes. We compared VA-provided MMU site-of-care data and appointment data for fiscal year 2022 and information from VA's reports to Congress against information gathered from selected regional networks and VA medical centers. 5 To gather information on how VA prepares annual MMU reports to Congress, we interviewed officials from VHA's Office of Emergency Management, the program office responsible for preparing these reports. We also interviewed officials from VHA's Office of Analytics and Performance Integration, which provides data for these reports. To gather information on VHA leadership's role in MMU operations, we interviewed an official from the Office of the Assistant Under Secretary for Health for Operations. We assessed information from VA's annual reports to Congress, site-of- care and appointment data for fiscal year 2022, and interviews with regional network, VA medical center, and other VA officials against VA's strategic plan and federal standards for internal control for information and communication. 6 We determined that the principle that externally communicating the necessary information to achieve the entity's objectives was significant to this objective. To describe how selected VA medical centers use MMUs, we interviewed officials at the five selected regional networks and their 12 associated medical centers with MMUs. We asked officials about the operations of their MMUs, as well as any plans for future use of MMUs. The information we obtained from the selected regional networks and associated VA medical centers is not generalizable but rather provides illustrative examples of how VA medical centers use MMUs to deliver services to veterans. To gather veterans' perspectives on MMUs, we interviewed 5VA extracted site-of-care data for fiscal year 2022 from VHA's Site Tracking database. VA extracted appointment data for the same time period from its Corporate Data Warehouse via VHA's Support Service Center. 6Department of Veterans Affairs, Fiscal Years 2022-28 Strategic Plan (Apr. 18, 2022). Internal control is a process effected by an entity's oversight body, management, and other personnel that provides reasonable assurance that the objectives of an entity will be achieved. See GAO, Standards for Internal Control in the Federal Government, GAO-14-704G (Washington, D.C.: Sept. 10, 2014). Page 21 GAO-24-106331 VA Mobile Medical Units Appendix I: Objectives, Scope, and Methodology representatives from two veterans' service organizations: Disabled American Veterans and American Legion. Page 22 GAO-24-106331 VA Mobile Medical Units Appendix II: Comments from the Department Appendix II: Comments from the Department of Veterans Affairs of Veterans Affairs Page 23 GAO-24-106331 VA Mobile Medical Units Appendix II: Comments from the Department of Veterans Affairs Page 24 GAO-24-106331 VA Mobile Medical Units Appendix III: GAO Contact and Staff Appendix III: GAO Contact and Staff Acknowledgments Acknowledgments Alyssa M. Hundrup, (202) 512-7114 or hundrupa@gao.gov. GAO Contact In addition to the contact named above, Janina Austin (Assistant Staff Director), Kelly Turner (Analyst-In-Charge), and Brittaini Maul made key Acknowledgments contributions to this report. Also contributing were Jennie Apter, Eric N. Chen, and Roxanna Sun. 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