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Photo by Jeff Stoffer |
By Jeff Stoffer
"The San Juan VAMC is an active medical center that is aging and in need of significant upgrades to ensure that patients receive care in a safe and efficient health-care environment."
Capital Asset Realignment for Enhanced Services (CARES) decision issued May 7, 2004, by former VA Secretary Anthony Principi
San Juan, Puerto Rico, proves that when given a chance chaos will eventually assume form. In the rum-buzzed downtown resort area of this swirling 16th-century Caribbean capital, tourists from around the world take their chances crossing traffic-choked streets, shuffling in flip-flops among casinos, hotels, restaurants, beaches and cockfights, oddly prohibited from smoking within 200 feet of any public entrance. Feral cats prowl shadowy alleys and parking lots. Condom World can be found next door to a cardiology clinic. Families with children in sandy bathing suits and floral shirts travel the same sidewalks as bronzed temptresses who pass out business cards promoting their various services.
The richly historical island itself is a near-perfect rectangle, 100 miles wide and 50 miles deep, a much-contested strategic outpost during early European exploration of the West Indies. It is also a place whose identity today stands at a three-way impasse between those who want Puerto Rico to be the 51st U.S. state, those who want it to break away completely, and those who are happy with the way things are: conveniently vague, as a U.S. commonwealth nearer to Venezuela than Florida, where cultures are marbled into a bilingual concoction of color, flavor, sound and motion that is, distinctly, Puerto Rican.
Amid all this, a health-care system operated by one of America's most multilayered bureaucracies, the Department of Veterans Affairs, serves more than 67,000 unique patients a year from a total veteran population of more than 153,000. The San Juan VA Medical Center, built in the middle of the Vietnam War, is the flagship of the Caribbean Health Care System, which also includes five community-based outpatient clinics - two on Puerto Rico and three on other islands. Despite its unique disposition in a tropical paradise, the system is challenged by most of the familiar issues confronting VA hospitals everywhere else: rapid patient growth, long appointment waiting times, nursing shortages, lagging services for women and mental health, outdated infrastructure and the sheer distance between hospitals and the veterans they serve.
"You missed one," says Dr. Rafael E. Ramirez, director of the San Juan VA Medical Center. "Parking ... We are short by about 1,000 parking spaces."
"It's the biggest problem facing the VA," says veteran Juan Pablo Gonzalez, who complains that he must arrive at the hospital a full two hours ahead of his appointments in order to find parking. Once, as time was running out, the 20-year patient of the facility says he was forced to leave his car on the outer edge of an undesignated area. He came back to a $100 ticket, a handsome sum in a VA market where, Ramirez says, "the income per-capita is half of that of the lowest state in the union. So that will give you an idea. Many of our patients who are not service-connected qualify for treatment here based on the fact that they are below the poverty level. This is the only place they have. This is their health insurance."
Some veterans say they must come to the hospital at 4 or 5 in the morning to find parking for 8 a.m. appointments. "The care here is excellent," says Emillio Cortes, a World War II veteran. "The problem is the parking."
It was a problem that worsened last summer, American Legion Department of Puerto Rico Adjutant Michael Quilles said, when one veteran, in a fit of anger, set fire to his own car inside the parking structure. Flames spread to other cars, and the damages closed down the entire structure for more than 45 days.
"We have a parking committee that works overtime," Ramirez says. "And no one is happy. It's a challenge."
In all fairness to VA, the entire city of San Juan has a parking problem. However, the San Juan VA Medical Center is now undergoing a major reconstruction program authorized by the department's Capital Asset Realignment for Enhanced Services (CARES) decision of 2004.
The potential for dramatic and deeply needed improvements appeared at hand when San Juan was mentioned in the same breath as Denver, Orlando and Las Vegas in terms of serious construction needs. In the time of CARES, the San Juan facility was in such urgent need of upgrades - seismic-structural issues, asbestos abatement, the ventilation system, patient privacy problems, handicap accessibility and, of course, parking - that it ranked No. 1 among all VA hospitals for physical deficiencies.
"We are in dire need of space in this medical center," Ramirez said during a site visit by American Legion Past National Commander Ronald F. Conley and members of the National Veterans Affairs & Rehabilitation staff last spring. "The CARES people made a survey and determined, based on workload, that we were short by about 600,000 square feet. It's a very difficult balancing act. We are up to our perimeter. The only way we can grow is to grow up."
A new, seismically correct bed tower for the San Juan VA Medical Center was among former VA Secretary Anthony Principi's highest priorities when he announced the CARES decision more than three years ago. VA pooled $46 million in funding that was previously authorized to seismically strengthen the building with another $25 million from a reserve account to get the project off the drawing board in April 2006. Now well under way, it is estimated to cost $85 million and is scheduled to be finished in summer 2009.
However, say Quilles and many veterans who attended a town-hall meeting during the Legion site visit, the project falls short of solving the space squeeze, easing the parking problem and fulfilling unmet clinical needs in such areas as mental health and women's care.
"What they are doing is they are building a new hospital in the same place, with 315 beds," Quilles says. "We used to have 325 beds. Nothing is gained, and we lose more parking."
Puerto Rico's American Legion National Executive Committeeman, Carlos Orria-Medina, is concerned that VA is going to find itself in an endless cycle of building and rebuilding the San Juan medical center. "When they finish this construction, the rest of the building will be old. They let the old part of the building get too old. We deserve a new hospital."
Ramirez says the new 315-bed tower can only be seen as the first step in a long march toward a big-enough San Juan VA Medical Center. "If we get Phase I but not Phase II, we're lost," Ramirez says. "This (construction project) is only a bed tower, exclusively a bed tower, not a hospital." A second phase, which would add clinical space and a new administration building, is estimated to cost $156 million. Phase II is not funded.
Meanwhile, veteran demand continues to grow and evolve. The individual patient load in the San Juan system climbed from 61,000 in 2000 to 64,000 in 2003, and to 67,932 in 2006, with no end in sight. A spike in the number of veterans from Operations Iraqi Freedom and Enduring Freedom - 4,779 unique veteran patients from OIF and OEF used the system in 2006 - has amplified the facility's need for new and different services.
"We are planning a full women's clinic," says Mary Lou Sanchez, women's health-care director at the medical center. "We hope it could be 2009 or 2010. In the meantime, we are planning a temporary clinic on the first floor."
At the town-hall meeting in San Juan, female veterans expressed frustration over a lack of services for them at the medical center, especially in the emergency room after 5 p.m. Legion officials listened to complaints that psychological programs are geared toward men only and that the facility lacks female doctors, therapists and service officers to help them.
Hospital officials say they are trying to improve public perceptions of their women's services. "At this moment we have like 1,500 female veterans accessing the system," Sanchez says. "With the younger population, the ones from Iraq and Afghanistan, there's about 160 or 170. We want more women to come in because we know there are more women out there. The number has been increasing slowly, year by year."
Veterans at the meeting also grumbled about the time it takes to see specialists at the San Juan VA - sometimes three to five months for an appointment. "For an eye exam, I wait two years," Quilles says. "For everything, you have lines."
Army veteran Osvaldo Gonzalez says he has been coming to the San Juan VA Medical Center for 28 years. "I have no objection to the care," he says. "It's excellent. But it's the waiting and the space. This is a small hospital for 150,000 veterans. We need a new one."
That thought, given the amount of work needed at the current location, was on the table when the CARES Commission visited Puerto Rico in July 2003. Commission members were presented an idea from the U.S. Army commander at Fort Buchanan, who proposed a combined VA-DoD facility on the post. The cost to VA would be about $400 million. Another DoD partnership option would have sent the VA medical center to the Roosevelt Roads Naval Hospital, on a soon-closing Navy base about 90 minutes from San Juan.
"There is a declining DoD presence on the island that could leave (the VA medical center) as the only backup for all medical services in the island," the CARES Commission site-visit report stated. "It could also be an opportunity for DoD collaboration on a large scale."
The San Juan VA Medical Center is the local DoD and civil-defense backup, as is the case with most VA facilities of similar size, in the event of natural disaster. "We're right in the middle of hurricane alley," Ramirez explains. "Every time there is a near miss, which is frequent, we have to be ready."
"Everything we saw as a problem when we visited San Juan in 2003 has multiplied," says Conley, who dedicated most of his year as American Legion national commander to inspection of VA health-care facilities and the launch of the Legion's "System Worth Saving" task force. "Now there are new veterans arriving every day from the war in Iraq and Afghanistan, and the need has grown and changed tremendously since CARES. We could easily anticipate this, and we did. We were at war, and VA kept looking at the veteran population, the patient population, and estimating that it was going to decline. Well, it didn't, certainly not in San Juan. So they have a construction project nearly finished that, once it's done, won't cut it for the number of patients it's supposed to see."
Conley, who was asked by 2006-2007 National Commander Paul A. Morin to revisit the San Juan facility last spring, said it's a credit to the patient-care staff that the Caribbean VA Health Care System is commonly regarded as the highest quality available in the entire region. However, he added, "if you cannot park there, or you miss an appointment you spent three months waiting for, that quality of care doesn't do you much good. Then it's an access issue. CARES was supposed to solve the access issue, the infrastructure issue, but by the time the money and construction came around, everything changed, and at least in this case, it wasn't enough."
In that sense, VA - and CARES in particular, which was described as a roadmap to the 21st century of VA health care - has proven that there's a flipside to the theory. It's that, if given a chance, form also can eventually assume chaos.
Jeff Stoffer is managing editor of The American Legion Magazine.
Comments (1)
Mr Stoffer, if you are going to talk about the VA Health Care system I would ask you to refrain from bringing the prejudicial note in pargraphs two and three. It is really uncalled for.
Posted by Joe | 12/07/07 3:03 PM |