[Federal Register Volume 86, Number 102 (Friday, May 28, 2021)]
[Notices]
[Pages 28932-28935]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2021-11398]


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DEPARTMENT OF VETERANS AFFAIRS


Notice of Asset and Infrastructure Review (AIR) Commission 
Foreword and Criteria

AGENCY: Department of Veterans Affairs.

ACTION: Notice of Final Action

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SUMMARY: The Secretary of the Department of Veterans Affairs (VA) is 
required to develop criteria that will be used in making 
recommendations regarding the modernization or realignment of Veterans 
Health Administration (VHA) facilities. This notice provides the 
required final selection criteria.

FOR FURTHER INFORMATION CONTACT: Valerie Mattison Brown, Chief Strategy 
Officer, Veterans Health Administration, Department of Veterans 
Affairs, 810 Vermont Avenue NW, Washington, DC 20420, (202) 461-7100.

SUPPLEMENTARY INFORMATION: Subtitle A of Title II of the Maintaining 
Internal Systems and Strengthening Integrated Outside Networks 
(MISSION) Act of 2018 (Pub. L. 115-182), requires VA to develop 
criteria that will be used to assess and make recommendations regarding 
the modernization or realignment of Veterans Health Administration 
(VHA) facilities (``Selection Criteria''). In 2019, VHA began working 
with various stakeholders and experts to identify factors to consider 
in developing the criteria. VHA solicited feedback from Veterans 
Service Organizations (VSOs), Community Veteran Engagement Boards 
(CVEBs) and a wide range of interdisciplinary VA leaders. Six criteria 
and associated sub-criteria were developed through these engagements. 
VA will use these criteria to evaluate potential market opportunities 
for submission to the statutorily mandated Asset and Infrastructure 
Review (AIR) Commission.
    On February 2, 2021, VA published a Federal Register Notice (FRN), 
requesting public comment on the draft Selection Criteria as required 
by Section 203 of the MISSION Act (86 FR 7921). The public comment 
period closed on May 1, 2021. VA received a total of 122 comments on 
the FRN from Veterans, caregivers, VSOs, legislative partners, research 
partners, business partners, and other stakeholders. Of the 122 
comments, 31 comments specifically referenced the draft Section 
Criteria, and 14 out of those 31 comments recommended specific changes 
or considerations be applied to the draft Section Criteria. These 14 
comments were further reviewed and considered by VA for inclusion into 
the final Section Criteria.
    The FRN comments are publicly available online at 
www.regulations.gov. Copies of the comments are also available for 
public inspection in the Office of Regulation Policy and Management, 
Room 1064, between the hours of 8:00 a.m. and 4:30 p.m., Monday through 
Friday (exception holidays). Please call (202) 461-4902 (this is not a 
toll-free number) for an appointment.

Foreword

    The Department of Veterans Affairs (``VA'') is honored to deliver 
exceptional health care and services to more than 9 million Veterans. 
As we look to the future, VA remains committed to a core set of 
immutable

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values that empower, strengthen, and encourage a vibrant and healthy 
Veteran community. At the forefront of every decision VA makes is a 
commitment to serving as an integrated system to provide coordinated, 
lifelong, world-class health care and services that leverage cutting-
edge research and equitable access to the Nation's top academic and 
medical professionals. VA's vision is built on a foundation of 
inclusion, honor, and respect for every Veteran's unique experience. As 
VA transforms to optimize resources and modernize infrastructure and 
systems, the Department will remain committed to its role as the 
primary provider and coordinator of Veteran care. By expanding our work 
with communities, caregivers, and strategic partners VA will achieve 
outcomes that empower Veterans for generations to come.
    As the unprecedented COVID-19 public health crisis consumed the 
Nation and the globe, VA rose to the challenge, demonstrating the 
strength of our nationwide, integrated system, and solidifying our 
position at the leading edge of U.S. health care on behalf of those we 
serve. We employed each of our four health-related missions--health 
care, education, research, and emergency response--to lead the Nation 
forward beside our interagency and strategic partners. As demonstrated 
during the pandemic, these missions complement one another and together 
are vital elements of a complete VA transformation vision. Many U.S. 
healthcare leaders expect that health care delivery trends post-
pandemic will incorporate adaptations that worked well for many 
patients, including Veterans. In particular, a national survey of U.S. 
adults reported that 3 in 10 had at least one virtual visit during the 
pandemic.\1\ VA recognizes that a `new normal' with more virtual 
options for care and services may have significant implications for the 
way future health care delivery systems are designed. VA intends to 
stay at the leading edge of this type of person-centered innovation, 
employing the full complement of our core missions.
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    \1\ Link to survey: https://www.urban.org/sites/default/files/publication/103457/one-in-three-adults-used-telehealth-during-the-first-six-months-of-the-pandemic-but-unmet-needs-for-care-persisted_1.pdf.
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    As Veteran needs, preferences, and demographics shift over the 
coming decades, VA's top priority will be to design an integrated 
system of care and benefits that is outcomes-based, and values-driven. 
As an integrated system, VA will ensure reliable access to meaningful 
care coordination that includes expanding availability of digital 
health care services and maintaining capacity to serve as the backstop 
to the national health care system. VA will strengthen its partnerships 
with a growing network of public and private-sector allies and strive 
to lead the nation in Veteran-relevant research and innovation. At 
every turn, VA will remain committed to evidence-based policymaking and 
effective governance that always puts the Veteran first.
    In line with VA's vision, VA submits the following set of Selection 
Criteria for making recommendations regarding the modernization or 
realignment of VHA facilities as required by Section 203 of the MISSION 
Act of 2018. The Selection Criteria are designed to keep Veterans' 
needs at the center of the decision-making process, assuring that each 
Veteran can receive the integrated care they have earned and deserve.

Criteria

    VA's vision for the future of VA health care is an integrated 
system that honors America's Veterans by providing lifelong, world-
class care and benefits, while leveraging cutting-edge research and 
equitable access to the Nation's top health, academic, and research 
professionals. The market assessments required by Section 203 of the 
MISSION Act of 2018 were designed and being conducted in support of 
this vision. The assessments provide VA with the ability to plan for 
the continuing evolution of Veteran health care, incorporating major 
trends and events in the national and global health ecosystem (e.g., 
the COVID-19 pandemic and telehealth). Each assessment will identify 
strategic opportunities to position VA to increase health care access 
points in locations where the demand for VA health care services is not 
being met, enhance Veteran experience, account for social 
determinants,\2\ consider health equity factors \3\ and serve as the 
coordinator of Veteran health care and services. Through thoughtful and 
constructive engagements with internal and external stakeholders, the 
following criteria were developed to ensure opportunities identified 
for VA Market \4\ recommendations \5\ support VA's goal in designing 
high performing integrated networks through VHA realignment and 
modernization opportunities.
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    \2\ Social determinants as defined by the Department of Health 
and Human Services (HHS)--are ``conditions in the environments in 
which people are born, live, learn, work, play, worship, and age 
that affect a wide range of health, functioning, and quality-of-life 
outcomes and risks.'' Link: https://www.hrsa.gov/about/organization/bureaus/ohe/index.html.
    \3\ Health equity as defined by HHS--is ``the absence of 
disparities or avoidable differences among socioeconomic and 
demographic groups or geographical areas in health status and health 
outcomes such as disease, disability, or mortality. Link: https://www.hrsa.gov/about/organization/bureaus/ohe/index.html.
    \4\ A VA Market is comprised of VA owned and/or operated 
facilities, as well as Department of Defense (DoD), Tribal, other 
federal agency, academic affiliates, and other community partners.
    \5\ A VA Market recommendation is comprised of multifaceted, 
interdependent strategic opportunities across the continuum of care 
within a Market.
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    The Secretary will use the Selection Criteria to make 
recommendations to the AIR Commission regarding the modernization and 
realignment of VHA facilities. Recommendations submitted to the AIR 
Commission will focus on creating Veteran-centric outcomes that 
maintain or improve health care services through the most equitable 
modalities and at locations that are most beneficial to those VA 
serves. The recommendations will then go through the AIR Commission 
review process as outlined in the MISSION Act.
    The Selection Criteria are broken out into six domains, each of 
which complement the others. The ordering of the domains follows as 
they appear in the MISSION Act legislation. Each criterion begins with 
a commitment statement, outlining VA's philosophy and commitment to 
current and future Veterans, followed by the criterion statement, sub-
criteria, and explanatory statement:

Veterans' Need for Care & Services and the Market's Capacity To Provide 
Them (Demand)

    Commitment Statement: VA is committed to providing Veterans the 
full range of integrated care and services needed and desired 
throughout their lifetime, to include preventive, acute and chronic 
care. These services will be carefully balanced to meet Veterans' needs 
and preferences with the capacity available through VA's direct care 
system, our Community Care Network (CCN), and government, academic, and 
other strategic partners. VA intends to ensure Veterans receive the 
personalized care they have earned. VA will do this by matching the 
services and support Veterans may need with VA's ability to provide 
those services in a timely manner.
    Demand Criterion: The recommendation aligns VA's high performing 
integrated network resources to effectively meet the future health care 
demand of the Veteran enrollee population with the capacity in the 
Market.
    Demand Sub-Criteria:
    The recommendation:

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    [cir] Aligns the quality and delivery of integrated care and 
services with projected Veteran demand across demographics and 
geography;
    [cir] Retains or improves VA's ability to meet projected demand; 
and
    [cir] Incorporates trends in the evolution of U.S. health care.
    When applying the demand criterion, VA will consider how a 
recommendation will impact VA's ability to meet the needs of Veterans 
in the future. An assessment of the existing health services available 
in the Market will aide in determining market adjustments. VA will 
consider what Veterans may need through understanding of the services 
that Veterans have accessed in the past and are projected to need and 
prefer in the future. VA will also consider how and where Veterans wish 
to receive services, including in ambulatory settings, hospitals, in 
the community, through telehealth, and through innovative models and 
modalities.

Accessibility of Care for Veterans (Access)

    Commitment Statement: VA intends to provide Veterans with an 
accessible, whole health experience, with services thoughtfully 
designed to meet their needs. VA will do this by making the services 
and support Veterans need accessible through locations, models, and 
modalities that most benefit them and match their needs and 
preferences.
    Access Criterion: The recommendation maintains or improves Veteran 
access to care.
    Access Sub-Criteria:
    The recommendation:
    [cir] Aligns VA points of care and services with projected Veteran 
need across demographics and geography;
    [cir] Ensures Veterans are provided a range of integrated health 
care options and the opportunity to choose the care they trust 
throughout their lifetime;
    [cir] Enables VA to serve as the coordinator of each Veteran's 
health care, whether provided within or beyond VA;
    [cir] Considers health equity, defined as the absence of 
disparities or avoidable differences among socioeconomic and 
demographic groups or geographical areas in health status and health 
outcomes such as disease, disability, or mortality;
    [cir] Reflects consideration of factors underpinning observed 
access patterns regarding conditions in the environment in which people 
are born, live, learn, work, play, worship, and age that affect a wide 
range of health functioning, and quality-of-life outcomes and risks; 
and
    [cir] Incorporates trends in the evolution of U.S. health care.
    When applying the `access' criterion, VA will consider how a 
recommendation will impact the convenience and experience of care 
provided to Veterans in the future. Key components of access include 
the time it takes to receive care in the VA system and in the community 
and the barriers and accelerators to receiving care, such as distance 
or availability of technology or availability of culturally competent 
experience in the community.
Impact on Mission
    Commitment Statement: VA is committed to delivering best-in-class 
care throughout Veterans' lifetimes. This means positioning VA health 
care system at the leading edge of the health care industry in 
education, research, and national emergency preparedness.
    Impact on Mission Criterion: The recommendation provides for VA's 
second, third, and fourth health related statutory missions of 
education, research, and emergency preparedness.
    Impact on Mission Sub-Criteria:
    The recommendation:
    [cir] Aligns resources to VA's education, research, and emergency 
preparedness missions across demographics and geography;
    [cir] Education: \6\ Maintains or enhances VA's ability to execute 
its education mission;
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    \6\ VA's education mission has a profound impact on VA's human 
capital requirements as well as the future healthcare workforce (70% 
of US physicians received some training in a VA health care 
facility).
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    [cir] Research: \7\ Maintains or enhances VA's ability to execute 
its research mission;
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    \7\ VA's research mission is grounded in care delivery to 
Veterans and focuses on health issues that affect Veterans.
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    [cir] Emergency \8\ Preparedness: Maintains or enhances VA's 
ability to execute its emergency preparedness mission; and
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    \8\ VA's strong emergency preparedness mission has provided 
broad support to Veterans and focuses on health issues that affect 
Veterans. Nation during multiple public health emergencies, 
including but not limited to COVID (e.g., for Hurricane Maria VA was 
THE source of `boots on the ground' for all relief efforts).
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    [cir] Incorporates trends in the evolution of U.S. health care.
    The `impact on mission' criterion allows VA to consider how a 
recommendation will impact VA's ability to execute our statutory 
missions of education, research, and emergency preparedness in support 
of Veterans and the Nation.

Providing the Highest Quality Whole Health Care (Quality)

    Commitment Statement: VA is committed to providing Veterans with a 
high-quality, whole health care system that delivers an excellent 
experience of care and optimal health outcomes. VA will deliver the 
same high quality, evidence-based standards of care regardless of 
where, or by which modality, their care is received.
    Quality Criterion: The recommendation considers the quality and 
delivery of health care services available to Veterans, including the 
experience, safety, and appropriateness of care.
    Quality Sub-Criteria:
    The recommendation:
    [cir] Ensures the highest possible quality of care across 
demographics and geography;
    [cir] Promotes recruitment of top clinical and non-clinical talent;
    [cir] Maintains or enhances Veteran experience; and
    [cir] Incorporates trends in the evolution of U.S. health care.
    When applying the `quality' criterion, VA will consider how a 
recommendation will impact the quality of care for Veterans. Quality in 
health care is measured through metrics and ratings assessed by federal 
and commercial health care entities. VA will consider the care needs 
and preferences of Veterans in order to provide optimal experience, 
safety, and outcomes.

Effective Use of Resources for Veteran Care (Cost Effectiveness)

    Commitment Statement: VA is committed to optimizing the Veteran 
health care system through the effective and sustainable use and 
sharing of taxpayer resources, including staffing, space, 
infrastructure, and funding, with the goal of providing Veterans with 
the best health care and outcomes. VA will actively and mindfully 
manage resources, allowing VA to provide services and support that 
effectively match Veterans' needs and preferences while putting their 
health and empowerment at the center of system design.
    Cost Effectiveness Criterion: The recommendation provides a cost-
effective means by which to provide Veterans with modern health care.
    Cost Effectiveness Sub-Criteria:
    The recommendation:
    [cir] Reflects stewardship of taxpayer dollars by optimizing 
investments and resources to achieve advancements in access and 
outcomes for Veterans;
    [cir] Recognizes potential savings or efficiencies that may free 
resources for

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more impactful investment for Veterans; and
    [cir] Considers the value of Veteran and employee experience, 
innovation, and other intangible elements of value.
    When applying the `cost effectiveness' criterion, VA will consider 
whether a recommendation optimizes funding for Veteran care.

Ensuring a Safe and Welcoming Health Care Environment of Care 
(Sustainability)

    Commitment Statement: VA is committed to providing Veterans a safe 
and welcoming health care environment. Our goal is for Veterans to feel 
safe physically, mentally, socially, and emotionally when receiving 
care with access to a full range of experts and specialists. VA is 
committed to providing standard and complementary types of care for our 
unique Veteran population in an equitable and inclusive environment. VA 
will do this by ensuring points of care are modern and inviting, with 
an expert workforce and care options designed to meet Veterans where 
they are in their health journey.
    Sustainability Criterion: The recommendation creates a sustainable 
health care delivery system for Veterans.
    Sustainability Sub-Criteria:
    The recommendation:
    [cir] Aligns investment in care and services with projected Veteran 
care needs across demographics and geography;
    [cir] Reflects stewardship of taxpayer dollars by creating a 
sustainable infrastructure system for Veterans;
    [cir] Enables recruitment and retention of top clinical and non-
clinical talent; and
    [cir] Incorporates trends in the evolution of U.S. health care.
    When applying the `sustainability' criterion, VA will consider how 
a recommendation impacts our ability to offer Veterans a welcoming and 
safe care environment that meets modern health care standards and 
ensures sustainability for future generations of Veterans.
    Signing Authority:
    Denis McDonough, Secretary of Veterans Affairs, approved this 
document on May 25, 2021, and authorized the undersigned to sign and 
submit the document to the Office of the Federal Register for 
publication electronically as an official document of the Department of 
Veterans Affairs.

Jeffrey M. Martin,
Assistant Director, Office of Regulation Policy & Management, Office of 
the Secretary, Department of Veterans Affairs.
[FR Doc. 2021-11398 Filed 5-27-21; 8:45 am]
BILLING CODE 8320-01-P