When treatment room space got tight at the Monterey Department of Veterans Affairs clinic in Seaside and staff members needed a quick way to signal which rooms were open, they invented a very low-tech and friendly “Aloha signal” – a brightly colored silk Hawaiian lei on the doorknob that lets the staff know it’s free.
It’s makeshift technology in a 35,000-square-foot building estimated to be over 40 years old. Originally the Fort Ord troop medical building, the Army gave the building to the VA when the base closed in 1994. It looks like any medical building built in California in the 1970s, with adobe-style bricks and a Spanish tile roof on the exterior. Shiny, highly buffed linoleum tiles line the hallways, and doors on each side lead to exam rooms and offices. There is, of course, the main waiting room, where veterans sit and wait to be called.
The clinic serves approximately 10,000 patients a year, mostly from Monterey County, says Medical Director Mary Roberts, and they’re served by about 125 staff members. The clinic is strictly outpatient care; anything that requires invasive procedures like surgery is handled by what Roberts calls “the mothership,” the VA hospital in Palo Alto.
Down a back hallway near the staff offices, one of the walls is lined with pieces of white butcher paper covered with neat rows of different colored Post-it notes, with handwritten tasks detailing the massive undertaking that the clinic staff is currently facing. Also on the wall is a countdown calendar, with each day behind them crossed off with a big black “X.” It’s a countdown for the clinic’s own D-Day.
Instead of a beachhead, the clinic is headed from the old building into a shiny new one, costing an estimated $100 million, where patients will be welcomed through gleaming glass doors beginning on Aug. 14.
The Maj. Gen. William H. Gourley VA-Department of Defense Clinic, on 14 acres in Marina, will be the first of its kind in California – and only the second in the U.S. It brings both veteran and active service-member patients under one roof, instead of two isolated health systems. Bureaucratic trailblazing aside, a feature that stands out most is the building itself, a 149,000-square-foot LEED gold-certified space that’s been built to put the patient in center focus.
Instead of lining up for care in different departments, departments will come to the patient. The clinic turns on its head the military concept of putting the needs of the mission ahead of the needs of the individual.
In this model, known as Patient Aligned Care Teams, or PACT, patients are assigned to a team of providers for the duration of their care. The patient is at the hub, surrounded by a team of physicians, nurses, technicians, mental health professionals and others, without having to go from one doctor’s office to the next. Imagine that on a single visit, the primary care physician taps a specialist on the shoulder, right outside the treatment room, for an opinion and treatment. No referrals. No waiting for additional appointments.
It’s not a new concept in the medical world, nor to the VA, which started utilizing PACT care teams in Tampa, Florida, and elsewhere, a few years ago. But what is new in Marina is that the design of the facility is focused on the patient experience. Local veterans were included in planning sessions to share what they needed most out of their clinic visits. And VA officials are so pleased with the result that the design will now become the standard for new clinics in the pipeline to be built.
The new design is revolutionary for VA care, and it’s meant as a tool to bring ever-evolving high-quality care to patients.
“I would love for folks to understand that this isn’t just a new building,” Roberts says.
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It’s an overcast, moody April day in Marina. Inside the new clinic’s lobby, however, it’s bright. The lobby ceiling soars up three stories, with floor-to-ceiling windows. There are two entrances on opposite sides, with gleaming glass doors. The building is still in the process of being outfitted with equipment and furniture, so it’s sparse inside, but one thing is noticeable. Unlike most traditional medical buildings, there is no front desk. Instead, check-in will be at digital kiosks.
On the first floor is a cantina, with large spaces both indoors and outdoors for eating and relaxing. There’s also a resource center where veterans will have access to computers and books for research. In one hallway will be colorful mosaics that once hung in the bar at Stilwell Hall during Fort Ord’s heyday.
It does not look or feel like a traditional medical clinic, here or in the patient care areas on the upper floors.
Each patient care team and specialty inhabits its own “neighborhood,” says Chris Izzo, a VA facilities planner and transition coordinator. Like many VA staffers, he’s also an Army veteran. Izzo says the idea of the clinic as a community made up of neighborhoods is an idea that came directly from veterans who participated in the planning process.
On the second floor, for example, each neighborhood has six large treatment rooms that transform into consulting or counseling rooms – with no need for the patient to move to another room. “It’s very cost-effective and efficient for taxpayers, because we don’t have to do modifications that are very expensive,” Izzo says. With beechwood cabinets with modern silver hardware and walls painted beige, these rooms have a warmer feel than the more sterile clinic and hospital rooms of the old clinic.
There are large wooden doors on either side of the room, one for patients, and the other, a portal to the team area for staff. It’s a long, open area, with tall workspaces – not the enclosed offices of traditional medical facilities.
Once a patient is inside the treatment room, he or she remains there, and the team members come and go. Izzo says team members can also easily cross into other neighborhoods to call on specialists for help.
Imagine a doctor’s visit like this: You check in at a kiosk and head directly to the patient care area, and everything else unfolds in one location. There are the usual visits from a nurse or technician to take blood pressure and other readings, followed by your doctor. But say a new issue comes up, maybe a mole that the doctor wants examined. The doctor can step out of the room into a joint work area and find a dermatologist to come in and take a look. If blood tests are requested, the phlebotomist comes to you.
It’s not just in-person help that will come to the rooms. There will also be monitors for telehealth, long-distance consulting between patients and doctors and other health professionals located in Palo Alto and even other parts of the country. In one example, Roberts says she was able to connect a patient with a genetic counselor in Utah.
Also in the building is a women’s health area, and unlike older VA clinics, this one includes private lactation rooms. A friendly waiting area with a play structure and kid-friendly features is also included.
What won’t be obvious to patients is where the VA ends and the DoD for active service members begins. The DoD space is 16,000 square feet, about 10 percent of the total.
If there is any clear division, it’s up on the third floor, where the pediatric area is accessed through a door, then a more traditional front desk – in keeping with state and federal laws regulating access to children, Izzo says.
Also on the third floor is a spacious conference room with an expansive view of Monterey Bay. The room will be used for veteran town hall meetings. Also scattered through the building are group meeting rooms, which can serve as spaces for other activities like yoga or stretching. And to further make the clinic a one-stop for veterans, officials plan on sharing spaces with groups and organizations that help veterans with benefits and other services.
The old building, meanwhile, will remain in the VA’s portfolio, Roberts says. She’s heard ideas floated for repurposing it, like using it as a veterans’ resource center. “There’s an attachment to this building,” Roberts says, “so I hope we can keep it open and be another resource.”
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The roots of the VA go back more than 150 years to the Civil War, when President Abraham Lincoln signed an act establishing the very first VA facility named the National Asylum for Disabled Volunteer Soldiers. The VA claims it as the first government institution in the world created for honorably discharged military personnel. Since that time, the VA has grown into a system of 150 hospitals, 800 outpatient clinics and 126 nursing homes.
The Palo Alto VA hospital was opened in 1960, but it would be another 30 years before satellite clinics opened in Monterey, Capitola and San Jose. In 1995, that network of hospital and clinics became known as the VA Palo Alto Health Care System.
The very first Monterey-area clinic was located in a space behind a restaurant called Bubba’s Barbecue in Marina, long since closed, according to staff who were there at the time. It was a temporary spot for several months as Fort Ord prepared to close in 1994. When the clinic’s staff moved into their current home in Seaside, fledgling CSU Monterey Bay occupied one wing of the building.
Back then, care at the VA was – like most medical care in the U.S. – based on the traditional “physician-centric” model. Patients visited each doctor or specialist as needed, which meant a lot of appointments, a lot of waiting and a lot of shuffling around from department to department or other facilities. Also common at VA facilities is “sick call,” essentially urgent care.
Something new in the medical care industry was just starting to sprout around that time, however, and it actually goes back even further than that, to a surprising place – car manufacturing.
The Virginia Mason Hospital and Medical Center in Seattle was the first to pioneer using the Toyota Production System, or “lean manufacturing,” in providing medical care. Also known as “the medical home,” the concept flips everything from physician-centric to patient-centric.
Principles of lean manufacturing include eliminating all waste – including time – and employee underutilization, waiting, and inefficiencies. The Toyota system also emphasizes that the end-user, the customer, is paramount.
Similarly, the medical home concept is defined by the national nonprofit Patient-Centered Primary Care Collaborative as “patient-centered, team-based, coordinated, accessible and focused on quality and safety.”
Like other health care systems across the country, the VA has been studying how to incorporate the idea of patient-centric care. Roberts says staff at the current Seaside clinic have been using the PACT concept for a few years, but it’s been a challenge, since the old building – with its sectioned-off rooms and offices – doesn’t allow for easy collaboration.
The new building was designed with the PACT model in mind. The thing that excites Roberts the most is that in the new location there is no separate mental health clinic. Counselors and other professionals are a part of the overall care team.
“We really realized that we like to treat the veteran as the whole person that they are, and not separate their body out from their mental health issues,” she says. “Going forward, we’ll have everyone right there for the veteran – there won’t be a separate clinic to go to.”
Roberts estimates that 50 percent of the 10,000 veterans they currently treat at the clinic suffer from post traumatic stress disorder, and she sees first-hand the effects on patients’ health.
“As a primary care physician for 30 years, you realize that the body and mind are not disconnected, they are intimately intertwined,” she says. “If folks aren’t doing well mentally, they aren’t doing well physically, and vice versa.”
Roberts and the staff see a large elderly population, as well. The biggest number of patients served in the Vietnam War era, she says, but there is another bubble of World War II vets. In her practice alone there are 42 veterans over age 90 that she says are “amazingly functional and so fun to work with.”
However, the clinic is seeing a growing number of vets from the Iraq and Afghanistan wars, and an increasing number of women, she says.
Under the PACT model each patient has his or her own team, and they see that team every time they come in, or converse with members of the team on the phone or by email. The team members come to know the patients, and work together with the patient to design the best care plans for them, Roberts says.
This focus on putting patients first and quality of care might be different than what members of the public expect from the VA. During the highly publicized scandal in 2014, touched off by media reports of long wait times for appointments and veterans sometimes dying while waiting for care, a Huffington Post/YouGov poll found that nearly half of all Americans thought the VA delivered worse care than other U.S. hospitals. It resulted in several investigations, including by the FBI and Congress, and the director of the VA at that time, Eric Shinseki, resigned and issued a public apology.
In the years leading up to the backlogs, 2007 to 2013, the VA experienced a 46-percent increase in outpatient visits, according to VA and Congressional reports, fueled by an aging population of Vietnam-era vets and more recent vets from Iraq and Afghanistan. The agency has had a lot of catching up to do, and Roberts says they’re doing it.
“When I first came here, I said we need a new motto: ‘It’s not your daddy’s VA,’” Roberts says. “The VA, if we do something wrong, it’s all over the paper. When we do something right it’s just like anything else, nobody notices. The thing I would like the public to know is that we’re really trying to gear this to what is important to the veterans and what they wanted.”
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Planning a revolutionary new building is no small undertaking. It was literally more than a dozen years in the making, although Izzo says the original plan was to build a more traditional-style building. But somewhere along the way the idea took hold to create something new specifically for the PACT model of care, and it came out of collaborative meetings between the VA’s Monterey staff, veterans who would use the building, designers, architects and other consultants.
In a bureaucratic organization known for its top-down structure, it was a feat of bottom-up planning.
Analyst Beth Kane, who heads up operations at the clinic, remembers one meeting when the entire group was discussing the new building, and the architects scratched the original plans right then and there, in the meeting. By the end, a whole new design was sketched out.
“And now this is the design for future clinics in the VA, Kane says. “It’s part of the VA.”
Roberts says she came to look forward to the meetings with veterans, even though it was sometimes hard to hear criticisms of the care they were providing.
“As painful as it was to listen to how unhappy some of our vets were, we needed to hear that and learn from them,” she says. (Most veterans, she notes, were pleased.)
“The biggest message I heard was, they want to get their care at the VA. They didn’t want to go in the community,” Roberts says. They also told VA officials that they wanted to walk in and get care when they needed it, to be treated with respect and recognized for their service. They also liked the idea of having a team of people who they can get to know and who know them.
(The Weekly asked for more details about the meetings and to speak to veterans who participated in the planning process, but a VA spokesperson said due to “numerous contractual aspects” with contractors the agency is not able to share more details about the process.)
For now, the VA side of the new clinic will provide the same medical services as at the old Seaside location, meaning outpatient services only.
That’s a bit of a disappointment to Kirk Johnson, a retired Army helicopter crew chief, who lives in Marina and is active in the Disabled American Veterans. While he is looking forward to the new clinic, he was hoping it would have MRI machines, which for now are only available up in Palo Alto.
But even after the clinic opens Aug. 14, it will likely continue evolving as far as services and scope; some press statements say it could serve up to 80,000 patients, eight times more than it currently does.
Part of the concept, going back to the Toyota, is continuous improvement, and that’s one focus of the VA Monterey staff, Roberts says.
“What we go over to the new clinic with is just the start,” she says. “And the goal is to identify problems, things that can be better, and keep regrouping in real time to keep moving the quality of health care we provide forward. So what we go over with on Aug. 14 will probably look very different next year on Aug. 14.”
The goal of patient-first will remain the same.
“There’s a book by Atul Gawande, Being Mortal, and it talks about really centering the care – the elderly in [the book’s] case – around what’s important to them and what their life values are,” Roberts says, “and I think we very much in this new clinic embody that philosophy of helping people keep what’s important to them in their lives, and keeping that focus.”
As for those Hawaiian leis they use in the Seaside building, Roberts says there the new building will use lights instead. The leis will be retired.