Provision of Care to Veterans in Rural South Dakota Through the Department of Veterans Affairs Black Hills Healthcare System Hot Springs Campus

 

Every day in America 22 veterans commit suicide[1].

As this year has progressed, revelations from the Department of Veterans Affairs (VA) Office of the Inspector General (VAOIG) have made it clear that there have been serious lapses in the VA’s ability to provide care.  Appointment concerns veterans have noted for years – that they are having problems getting appointments and care from VA – are now well documented.  What VA had previously denied based on their own internal data was now shown to be true. 

On behalf of our National Commander Daniel Dellinger and the 2.4 million members across this nation, The American Legion is here to reaffirm our commitment to building a strong VA to serve the needs of this nation’s veterans.  By national resolution, The American Legion specifically calls on the Veterans Health Administration (VHA) leadership conduct an internal review and to develop an action plan to address its current geographic boundaries/catchment areas concerns, in order to better provide timely access and quality health care for veterans.[2]

On January 7, 2014, VA announced plans to move forward with their reconfiguration proposal at the Hot Springs Campus which would include elimination of mental health services, domiciliary care, urgent care services, the nursing home, and the entire hospital.[3]

Currently, VA Black Hills Health Care System (VABHHCS) provides primary and secondary medical and surgical care, along with residential rehabilitation treatment program (RRTP) services, extended nursing home care, and tertiary psychiatric inpatient services for veterans residing in South Dakota, portions of Nebraska, North Dakota, Wyoming, and Montana.  Care is delivered through the Fort Meade and Hot Springs VA Medical Centers, as well as through nine community-based outpatient and rural outreach clinics.

On January 10-11, 2012, The American Legion System Worth Saving (SWS) Task Force conducted a site visit to the VABHHCS, Hot Springs, South Dakota to discuss their December 2011 reconfiguration proposal.  Following the site visit, The American Legion issued a report which included seven recommendations.[4]

On February 17, 2014, The American Legion System Worth Saving (SWS) Task Force conducted a Town Hall meeting and follow-up site visit at the VABHHCS, Hot Springs, South Dakota.  The purpose of the visit was to hear from veterans firsthand about their concerns with VA’s proposed reconfiguration of services at the VABHHCS. 

Following the town hall meeting, from February 18-20, 2014, the task force met with VABHHCS Executive Leadership team and staff to discuss their proposed reconfiguration of services, recommendations from our previous 2012 SWS site visits, VA’s announcement to move forward with the Environmental Impact Study (EIS), and concerns addressed by the veteran community during the town hall meeting regarding access to care.  Additionally, on February 20, 2014, the task force met with the Fall River Heath Services (FRHS) Board of Directors and the Save the VA Committee.

Two years prior, The American Legion made several recommendations regarding the Hot Springs catchment area regarding VA services.  During the February 2014 SWS Site visit, The American Legion requested a status update on the recommendations, which is included following each recommendation.

SWS 2012 Recommendations and VABHHCS Response

 

        Recommendation 1: VA should not relocate and/or close medical services until a new facility is in place in order to accommodate the health care needs of the veterans in the Hot Springs catchment and/or surrounding areas. 

 

Ø  Response: The VABHHCS proposal for reconfiguration provides for seamless availability to care for veterans in the VABHHCS service area

 

        Recommendation 2: VA should maintain the same level of care and/or services, and provide equal understanding of veteran’s health care needs, if contracted to non-VA medical facilities. 

 

Ø  Response:  VABHHCS has no plans to reduce services pending a decision by the Secretary of Veterans Affairs regarding the proposal for reconfiguration.  If approved, the proposal for reconfiguration includes more robust services for veterans provided by VA and through VA purchased care.

 

        Recommendation 3: If the VA Medical Center was to be closed, VA should plan to open a super CBOC to provide both primary and specialty care services.  

 

Ø  Response: The VABHHCS proposal for reconfiguration includes plans to build or lease a new CBOC in Hot Springs.

 

        Recommendation 4: VA should keep the domiciliary on the Hot Springs Campus to provide long-term/extended care to meet veteran’s long term care needs.  

 

Ø  Response:  The VABHHCS proposal for reconfiguration includes relocating the Residential Rehabilitation Treatment Program to Rapid City, SD.

 

        Recommendation 5: The VAMC should search for opportunities to make use of the State Veterans Home in Hot Springs. 

 

Ø  Response: VABHHCS looks forward to continuing to partner with the State Veterans Home as they undertake construction and occupation of the new facility.

 

        Recommendation 6: Future plans should reflect necessary services that veterans in the Hot Spring’s catchment and surrounding areas need.  

 

Ø  Response: The VABHHCS proposal for reconfiguration includes more robust services for veterans provided by VA and through VA purchased care/

 

        Recommendation 7: Without viewing a finalized contract with the local hospital in Hot Springs, The American Legion at this time cannot ensure reconfiguration of inpatient services will provide the same quality of care that veterans are currently receiving at the Hot Springs Campus.  

 

Ø  Response: Fall River Hospital is licensed by the state and certified by Medicare and Medicaid.  In our experience to date there have been no issues about the quality of care provided.

 

On December 12, 2011, during a community meeting at the Mueller Civic Center in Hot Springs, SD, officials from VISN 23 and Director of the VABHHCS announced plans to reconfigure existing services between the Hot Springs VA Medical Center, Fort Meade VA Medical Center and the Rapid City Community Based Outpatient Clinic.  As outlined in the VABHHCS 2011 Proposal for Improvements and Reconfiguration of Services (Appendix A), one of the statements made was, “We have conducted a thorough review of the services provided in the region and believe that improvements and reconfigurations are needed to increase the scope of health care services that will be provided to Veterans at points of care close to their homes.”

According to VABHHCS Executive Leadership, if the plan to reconfigure services is approved, the plan will be implemented over a five-year period.

Based on our meeting with the Save the VA Committee, one of the issues under dispute concerning the VABHHCS reconfiguration of services is their data. Save the VA Committee informed us that VA’s data is unreliable and does not provide an accurate account of all the veterans in the counties serviced by the Hot Springs VA Medical Center.  They further indicated that VA’s data does not account for all the Native Americans on the Indian reservations.  In response, the Director and his staff informed us that they went to the tribal service officer to request the number of Native American veterans on the Indian reservations, and as of the date of our site visit, they are still waiting on the information.  When asked if the medical center has requested data from the Save the VA Committee, we were told they have, but to date, they have not received any information that would contradict their data.  VA Central Office is not able to provide census/demographic information.

Battle Mountain Sanitarium

The Battle Mountain Sanitarium opened in 1907, offering veterans a complete array of services.  Battle Mountain Sanitarium (now part of the Veterans Affairs Black Hills Health Care System) was the 10th and final facility built by the National Home for Disabled Volunteer Soldiers (NHDVS).  Battle Mountain was intended for use as a soldier’s home; instead, it was a short-term treatment facility for current residents of the NHDVS who suffered from lung or respiratory problems.  Between 1908 and 1909, 865 Civil War and Spanish American War veterans received treatment at the facility.  By World War I, tuberculosis treatment became the primary focus of the Sanitarium.  Because of the influx of veterans with tuberculosis, the increasing need for space led to construction of the Main Hospital (Building 12) in 1926 to the east of the original building complex. The number of veterans at the Sanitarium grew as veterans who were not members of another National Home branch became eligible for tuberculosis treatment at the Sanitarium.

Hot Springs VAMC

The Hot Springs VAMC has served the veterans of Hot Springs, South Dakota since 1907.  Construction on the Hot Springs Sanitarium (Domiciliary Building) was completed in 1907.  The Sanitarium provided Civil War veterans with a place to rest and recuperate.  Due to its unique location surrounded by the Black Hills, according to House Concurrent Resolution No. 1004, Hot Springs was formerly called Minnekahta, which means “warm waters” in the Lakota language. The healing waters that were so valuable to Native Americans became the foundation for two of the greatest institutions to be built in Hot Springs.  The main hospital building #12 was constructed in 1926.  Today, the Hot Springs campus serves veterans of Hot Springs and the surrounding area by providing the following hospital services: 10 acute medicine beds; 7 Community Living Center (CLC) beds; 160 Residential Rehabilitation Treatment Program (RRTP) beds; and 17 Transitional Residence (TR) House beds and outpatient services.  The inpatient average daily census is approximately 5 patients per day.

The Hot Springs VAMC does not have an emergency room, but does have an urgent care clinic.  In accordance with VHA Directive 2010-010, Standards for Emergency Departments (ED) and Urgent Care Clinic Staffing Needs in VHA Facilities, Urgent Care is defined as unscheduled ambulatory care for an acute medical or psychiatric illness or minor injuries for which there is a pressing need for treatment to prevent deterioration of the condition or impairing possible recovery.  Urgent Care Clinic (UCC) is defined as a clinic which provides ambulatory medical care for patients without a scheduled appointment who are in need of immediate attention for an acute medical or psychiatric illness, or minor injuries.  UCC can exist in facilities with or without an ED.  In either case, UCC are not designed to provide the full spectrum of emergency medical care.  Hours of operation are based on facility need and policy.

The Medical Center Director and staff pointed out that one of the major challenges at the Hot Springs VA Medical Center is recruitment of licensed practical nurses, registered nurses and physician hospitalists.  The average time frame for filling any vacancies in FY 2013 was 51 days and the average in FY 2014 is 42 days.  Currently mental health is using a cohort model, which includes a 12 veteran cohort.  However, this model has created a delay in appointment wait time.  In May, Mental Health will be starting a new process to help reduce their wait time.

During the site visit we toured the Hot Springs VAMC where a number of concerns were pointed out.  First in Building 4, male veterans are housed in an open-bay ward.  Although partitions have been put in place to separate veterans and give them a sense of privacy, living conditions are substandard.  Another concern are the steep ramps throughout the domiciliary, which the medical center staff indicated pose a safety concern and are not in compliance with the Americans with Disabilities Act of 1990 (ADA).

Refer to Appendix C on the Department of Veterans Affairs Accessibility Standards Guide, which includes specifications for Ramps in Department of Veterans Affairs Health Care facilities.

Fort Meade VAMC

Fort Meade was established in 1878 as a cavalry post for the 7th Cavalry.  The Fort Meade property was transferred to the Veterans Administration in 1944.  The facility began as a neuropsychiatric hospital and later added general medicine and surgery.  In 1967, the current hospital complex was completed.  Today, the hospital serves veterans of the community and surrounding area by providing the following services:  24 acute medicine/surgery beds; 4 intensive care unit beds; 10 acute psychiatric beds; 97 Community Living Center (CLC) beds; and 12 Transitions Residence (TR) house beds and outpatient services.

Meeting with VA Black Hills Executive Leadership and Staff

On February 18th and 20th the SWS task force members met with the VABHHCS Executive Leadership team and staff to discuss the proposed reconfiguration of services at the VABHHCS.  The Director indicated that VABHHCS’s proposal would allow them to provide care closer to where the veteran lives; however, based on our town hall meeting, veterans indicated they prefer that a full service hospital remain in Hot Spring, South Dakota.  The Director pointed out that due to challenges at the Hot Springs VA Medical Center, i.e. domiciliary ramps are not compliant with the Americans with Disability Act, etc, his plan calls for building a new Domiciliary/Residential Rehabilitation Treatment building in Rapid City, South Dakota to replace the existing Domiciliary in Hot Springs.  When we the asked the Director “if the Secretary decided to build a new Domiciliary in Hot Springs would he be supportive of this decision,” he responded, “yes,” he would support the Secretary’s decision to build a new Domiciliary in Hot Springs. 

If the reconfiguration of services is approved, the Director and staff indicated that outpatient services at Hot Springs would not be impacted. Nevertheless, our observation indicates inpatient and domiciliary services would be impacted, requiring veterans in the southern portion of the VISN having to travel further to receive their VA health care services.  Keeping VA inpatient and domiciliary services in Hot Springs, South Dakota would ensure VA services are in fact provided closer to where the veteran lives.

Meeting with Fall River Hospital Board of Directors

On February 20, 2014, a meeting was held with the Fall River Hospital System (FRHS) Board of Directors.  As a Critical Access Hospital (CAH), certified by the federal government, Critical Access Hospitals are in rural areas and provide essential services to their communities, operating under certain stipulations regarding length of stay, number of beds, distance from tertiary hospitals, etc. The CAH program is designed to improve rural health care access and reduce hospital closures. A cost-based system is used, which is calculated by figuring all expenses needed to care for the patient. The hospital is then reimbursed based on that figure.  To date, however, the VA has presented no reimbursement proposals, cost analysis, needs assessments, or business plan to the board of directors of FRHS, so no comparison of probable costs/charges and proposed reimbursement has been possible.

According to Trica Uhlr, Hospital FRHS Administrator, the only service FRHS provides the VABHHCS is diagnostic radiology services.  The Board indicated that FRHS is not accredited by the Joint Commission on Accreditation of Healthcare Organizations, but is state accredited.  Services currently offered at FRHS include: Acute Care; Swing Bed; Emergency; Laboratory; Radiology (X-ray, CT, MRI, Digital Mammography); Ultrasound (Vascular, Abdomen, OB/GYN); Rehabilitation (PT, OT, ST, RT, and Cardio/Pulmonary) Surgery; Orthopedics; Podiatry; Sleep Studies; and Ambulatory Surgery, which is offered one day a week.  Fall River Hospital does not have an Intensive Care Unit. 

Board members further indicated that they had two meetings with VA Black Hills Executive Leadership to discuss their proposal. The first meeting was on December 21, 2011 and the second meeting was held on February 22, 2012.  Board members indicated that while the Director made several vague suggestions, he did not offer any details on what relationship VA is seeking with FRHS, did not present a business proposal, and when questioned what services would be requested of FRHS, HSVA leadership remained very vague with no new information or inquiries presented by the VA, despite the fact that the VA Director had requested the second meeting.

The FRHS board members expressed that they have repeatedly requested the VABHHCS Executive Leadership to provide them with their business plan outlining the services they would like the FFRHS to provide; however, as of the date of our site visit, they still have not received this information.

In a paper documenting the two meetings between the FRHS Board of Directors and HSVA leadership, FRHS Board members indicated that “the contents of the proposal presented by the local VA and VISN leadership on December 12, 2011, came as a surprise to the board of directors of the FRHS” who, despite the fact that the VA chose to publicly suggest some type of collaboration with the FRHS, had no prior knowledge of such a plan. To date, any suggestions or proposals made directly by the VA to FRHS have been very vague, at best—lacking any detail or sense of a business plan.  Despite the VA Director’s public mention of “building a wing” or “co-locating” at FRH, the FRHS board has never publicly or privately encouraged or responded, feeling, rather, that it is very unlikely that such an idea is feasible.

When asked if the VA’s Black Hills Health Care System proposal was approved and what services FRHS would be in a position to provide Hot Springs VA Medical Center, the board members indicated that without seeing a business plan from VA, which they have requested, they are in no position to state what services they would be able to provide. Nevertheless, they were in agreement that the FRHS would not be in a position to provide the following services:  mental health; pharmacy consultation; prosthetic; audiology; optometry; nuclear medicine; ENT; dentistry; dialysis; and home based primary care. 

Board members also voiced concerns about the lack of the ability to share patient records electronically between the two facilities.  They indicated this issue would need to be addressed.  In their closing comment, they indicated the VABHHCS is not in the FRHS long-term plan.

Meeting with Save the VA Committee

On February 20 2014, the task force members met with the Save the VA Committee at the Muller Center to discuss their concerns with the VABHHCS reconfiguration proposal.  The committee stated they are concerned about the data VA is using to support their proposal to reconfigure services at the Hot Springs VAMC.  When the task force members question them about the reasons the Medical Center cited moving services from Hot Springs to Fort Meade and closing the domiciliary in Hot Springs, we were told that their justifications were flawed and their data was problematic. 

The SWS Task Force members were also informed that their justification for closing the domiciliary in Hot Springs and building a new one in Rapid City based on the ramps not being ADA compliant and posing a safety concern is not true.  We were provided with a February 19, 2013 report which pointed out that there are no records that indicate that over 107 years that these ramps have any kind of a “negative” safety record.  We were also told that based on their data, the domiciliary is in fact ADA compliant.  Save the VA Committee provided a number of documents to support their position. 

Meeting with the National Trust for Historic Preservation

The National Trust for Historic Preservation, the nation’s leading nonprofit advocate for the saving and reuse of America’s historic places, has a long-standing interest and involvement in the fate of historic buildings and landscapes that relate to the care of our nation’s veterans.  Since 2012, the National Trust for Historic Preservation has been highly involved with the Battle Mountain Sanitarium in Hot Springs, SD, after naming it one of its National Treasures as part of a campaign to preserve nationally significant places across the country.  In the case of Battle Mountain Sanitarium, a National Historic Landmark, National Trust resources are being placed toward preventing the closure of the medical facility and ensuring its preservation and continued use for veterans’ medical care, as well as drawing attention to the plight of other threatened historic VA sites across the country. 

In November 2013, the National Trust released a report entitled Honoring Our Nation’s Veterans:  Saving Their Places of Health Care and Healing[5], to open a dialogue with the VA to foster improved consideration and care for the historic facilities that have been providing quality medical care to veterans for decades.  One of the report’s top recommendations is that VA leadership commit to its requirements pursuant to the National Historic Preservation Act (NHPA) in the stewardship of its historic properties, as well as required compliance pursuant to the National Environmental Policy Act (NEPA).  The report details that both federal laws have been routinely circumvented by the VA, such as at Battle Mountain Sanitarium, where the VA announced its plans to close the campus in 2011 without undergoing NEPA and NHPA.  NEPA requires federal agencies to identify and meaningfully consider alternatives to proposed federal actions and to fully consider and publically disclose the “environmental” consequences before proceeding with agency action.  The law mandates that federal agencies share their decision making on programs and projects with stakeholders and the public by weighing the objectives to the served by a proposed action in light of the reasonably available alternatives and ways to avoid or minimize adverse impacts to the environment.

The report included eleven recommendations, which have been referred to the Department of Veterans Affairs for consideration. 

 

Treanor Architects Renovation Impact Review of the Hot Springs VAMC

On August 9, 2012, Treanor Architects completed a one-person/one-day assessment of buildings No. 1 through No. 12.  The assessment determined that the major interior component that will require a greater level of evaluation and study is the interior ramp system between the two-story arcade hallways and the three-story attached ward buildings.  While the interior ramp system was truly a cutting-edge design component circa 1900, the slope of the ramp does not comply with today’s building code or accessibility standards. In our opinion, the VA has done an admirable job in maintaining the interiors of the facilities and as long as the VA continues with the past level of routine maintenance and forecasted interior renovation projects, the interior of all 12 buildings can continue to be very usable. Following is a brief summary of the significant interior building components rated in the Building and Component/System Analysis form.

Appendix B provides extracts from Treanors’ report covering Section III, Existing Conditions and Section IV, Cost Estimate Evaluations.

Conclusion

The local community is opposed to the VABHHCS reconfiguration proposal and is adamantly against further reduction of services at the Hot Springs VA Medical Center, which includes relocating the domiciliary from Hot Springs, SD to Rapid City, SD.  Communication between the VABHHCS and the local community appears to be at a stalemate, with neither side willing to concede.  The VABHHCS has based its reconfiguration proposal on data obtained from the Veterans Health Administration’s Office of Policy and Planning, which depicts a declining veteran population in Hot Springs. 

This along with an aging infrastructure, which has been designated as a National Treasure by the National Trust for Historic Preservation, has brought national attention to this issue.  Based on VA’s data, the Hot Springs Domiciliary is not ADA compliant.  As mentioned under the Treanor Architects Renovation Impact Review section, Treanor concluded that the slope of the ramps do not comply with today’s building codes or accessibility standards, but in their opinion, the VA has done an admirable job in maintaining the interiors of the facilities and as long as the VA continues with the past level of routine maintenance and forecasted interior renovation projects, the interior of all 12 buildings can continue to be very usable.

The issue is whether relocating services from the Hot Springs VA Medical Center to the Fort Meade VA Medical Center and the domiciliary to Rapid City are in the best interest of veterans.  This would require veterans to travel further to receive their health care.  Veterans at the town hall meeting voiced concerns that they do not want to travel to Rapid City, which is over 120 miles round trip.  FRHS has expressed that the VABHHC System is not currently included in their long range plan, but if they were, it appears FRHS could only provide limited services.  Since VABHHC System Executive leadership has not provided FRHS board of directors with a business plan, and the information verbally discussed has been vague, FRHS is not in a position to state what services they will be in a position to provide the Hot Springs VA Medical Center.  Nevertheless, they have made it clear that FRHS will not be in a position to provide mental health, pharmacy consultation, prosthetic; audiology, optometry, nuclear medicine, ENT, dentistry, dialysis, and home-based primary care.

As VA moves forward with the EIS, The American Legion requests that the study be conducted with true transparency, in an honest, fair and unbiased manner and as required by federal law, take into account the proposed needs, alternatives, affected environment, and environmental consequences.

Facility Challenges and Recommendations

Challenge 1:  Communication between the VABHHCS Executive Leadership and the local community has broken down and is at a stalemate.  The VABHHCS director and staff were not present at the town hall meeting, even though they were invited to attend. During our site visit, we learned that a member of Post 71 has often demonstrated threatening and unwelcoming behavior and in one instance informed the Director he is no longer welcome at his post.  This may support why the invitation to attend the town hall meeting was turned down; however, the Director assured us that, “he would go anywhere and speak to anyone about the VABHHCS proposal to reconfigure services at the VABHHCS.”

Recommendation: The VABHHCS Director and Executive staff should continue to work hard to gain the trust of their local community and be transparent with veterans, community and congressional leaders with regard to the VABHHCS proposal to reconfigure services and the pending EIS.

Challenge 2:  To date, Secretary Shinseki has not visited Hot Springs, South Dakota even though he was extended an invitation.

Recommendation:  Secretary Shinseki should arrange a visit to Hot Springs, South Dakota and schedule a Town Hall meeting to meet with veterans and hear firsthand their concerns about VABHHCS reconfiguration proposal.

Challenge 3.  During the Town Hall meeting, veterans and community leaders voiced concerns about the VABHHCS reconfiguration proposal.  It was made clear that they oppose the closure of inpatient services and relocating of the domiciliary to Rapid City.  Veterans further indicated that they do not want to obtain health care from FRHS or other community hospitals in Rapid City which have been traditionally provide by the Hot Springs VA Medical Center.  While the VABHHCS Director indicated he is in favor of realigning health care services closer to where the veteran lives, our observation indicates closing inpatient services at the Hot Springs VA Medical Center and moving domiciliary services from Hot Springs to Rapid City would adversely impact veterans, requiring veterans who live in the southern portion of the VISN to travel further to receive their VA health care services.  The American Legion is concerned that while VABHHCS reconfiguration proposal may be in the best interest of VA, veterans who live in Hot Springs do not feel it is in their best interest.

Recommendations: VABHHCS Executive Leadership, VISN 23 Director, VA’s Under Secretary for Health and the Secretary of the Department of Veterans Affairs must seriously take into account the concerns voiced by veterans and community leaders concerning the VABHHCS reconfiguration proposal.  The EIS is an important phase of the process and while The American Legion believes it should have been conducted in the beginning prior to making any public announcements, VA must ensure that the EIS be conducted with true transparency, in an honest, fair and unbiased manner taking into account the proposed needs, alternatives, affected environment, and environmental consequences.

Challenge 4:  Veterans in Hot Springs, South Dakota, Nebraska, North Dakota and Wyoming who obtain their care from the Hot Springs VA Medical Center are fearful that someday the Hot Springs VA Medical Center will eventually close.  Like many veterans around the nation who are faced with the loss or reduction of VA health care services (i.e., Fort Wayne VA Medical Center pause of services, which resulted in the closure of their intensive care unit, VAMC Roseburg, Oregon closure of their intensive care unit, the closure of VA Community Based Outpatient Clinics, and the closure of VA emergency departments or their downgrade to urgent care departments), veterans across the nation are in fear of losing their VA health care.

Recommendation:  The Department of South Dakota American Legion needs to work with The American Legion’s Headquarters office in Washington, DC, to draft a national resolution calling for Congress to enact legislation to stop VA from closing hospitals and community based outpatient clinics unless existing requisite community services that VA currently provides to veterans are met or exceeded.  

Challenge 5:  The American Legion was provided letters from the local congressional members showing they have submitted counter proposals in an effort to keep all of the services at the Hot Springs VA Medical Center.  The Save the VA Committee has developed their own proposals to keep a full services VA hospital in Hot Springs; however, the VABHHC System has not responded to these proposals.

Recommendation:  Congress needs to conduct a Congressional Hearing to be conducted by the House Veterans’ Affairs Subcommittee on Oversight and Investigations on VA closure of hospitals, community-based outpatient clinics and investigate VA health care facilities that are threatening to reduce VA health care services like the VABHHCS reconfiguration proposal.

Challenge 6:  The Hot Springs VA Medical Center has provided health care to veterans of the Hot Springs community for over ten decades.  Being the biggest employer in the community, cutting services and relocating employees from Hot Springs to Fort Meade and or Rapid City, will have a devastating impact on the community of Hot Springs.  VA cannot ignore this issue and must address this concern.

Recommendation:  As stated before, the EIS is an important phase of the process and while The American Legion believes it should have been conducted in the beginning prior to making any public announcements, VA must ensure that the EIS be conducted with true transparency, in an honest, fair and unbiased manner taking into account the proposed needs, alternatives, affected environment, and environmental consequences.

Challenge 7:  While the VABHHCS believes their reconfiguration proposal is in the best interest of veterans, veterans are oppose to the VABHHCS reconfiguration proposal.  The Hot Springs VA Medical Center has provided health care to veterans in Hot Springs and the surrounding communities for over 100 years.  The threat of relocating services from the Hot Springs VA Medical Center to Fort Meade and Rapid City, South Dakota is an unpopular decision as many veterans have stated if services were relocated to Fort Meade and Rapid City, they would no longer use VA as their provider of health care.

Recommendation:  VABHHCS should retain long term care at Hot Springs with a CBOC.  Acute service should be contracted with the private facility in the community.  Discuss with the private and state facilities in HS the availability of skilled personnel for recruitment and retention.  The availability of staff is crucial to making any decision on services to be provided.

Challenge 8:  VABHHCS reconfiguration proposal does not address how services with the State Veterans home could be coordinated to assure a full range of sub-acute services are available to veterans.

Recommendation:  VABHHCS Executive Leadership should coordinate services with the State Veteran Home in Hot Springs to assure coverage and a full range of sub-acute services are available to veterans in Hot Springs in a continuum of care perspective.

Challenge 9:  The VABHHCS Executive Leadership reported that the Hot Springs VA Medical Center is not ADA compliant.

Recommendation:  VABHHCS Executive Leadership should upgrade the existing Hot Springs VA Medical Center to meet disability requirements and maintain the current facility at Hot Springs.

[1] http://www.va.gov/opa/docs/suicide-data-report-2012-final.pdf

[2] http://archive.legion.org/bitstream/handle/123456789/2071/2012N162.pdf?sequence=1

[3] http://www.blackhills.va.gov/VABlackHillsFuture/ 

[4]http://www.legion.org/sites/legion.org/files/legion/publications/SWS%20Report%202014%20-%20Black%20Hills.pdf

[5] http://www.preservationnation.org/information-center/saving-a-place/va-hospital/NTHP-VA-Report-FINAL.pdf