Atlanta VAMC Resolving Issues that Led to Deaths of Mental Health Patients

by U.S. Medicine

October 7, 2013

By Annette M. Boyle

ATLANTA — The management breakdowns blamed by the VA’s Office of the Inspector General (OIG) for the deaths of three mental health patients at the Atlanta VAMC are being resolved, agency leadership testified at a Senate Veteran’s Affairs Committee field hearing in Atlanta.

Some community organizations testified, however, that veterans still were reporting a hard time getting appointments and that they often were shifted from one provider to another when they did.

The hearing, called by Sen. Johnny Isakson (R-GA) included a review of a pair of OIG reports issued earlier this year that detailed mismanagement of inpatient and contracted outpatient mental health programs at the Atlanta VAMC, as well as testimony about steps taken to address the issues raised in the report.

A fourth veteran seeking mental health treatment at the VA facility died from suicide around the same time but was not included in the OIG reports.

When you have a “failure, a breakdown in the system that contributes to the loss of life of an American veteran, an American citizen, you need to have a call to action,”  Isakson said.

VA Under Secretary for Health Robert A. Petzel, MD, assured the Senate committee that the VA was “taking aggressive action” to remediate the problems in Atlanta, including hiring 50 mental health providers in the last year and holding employees responsible for lapses in care.

On questioning, Petzel said that two individuals had resigned, the department had taken “corrective action” in three cases and that other actions were still pending.

 “We at VA are confident that these initiatives are on the right track and have already improved the safety and quality of care offered to veterans here in Atlanta,” he said. 

In addition, Petzel said that the Atlanta VAMC had reduced the number of contract care organizations from 26 to five and imbedded a case manager in each organization to ensure coordination of care and outreach to patients.

As a result, 89% of veterans with non-urgent mental health issues now have an appointment with a provider within 14 days, with the average wait time dropping to seven days, he said.

About 150 people attended the Mental Health Summit held at the Atlanta VAMC.

Hotline Calls

The investigations initially were prompted by two calls to the OIG’s hotline following three veteran suicides.

At the time of the OIG’s initial report on VA mental health services in Atlanta in 2011, more than 5,000 veterans had been referred to community organizations, with the VAMC failing to trackwhen or whether patients actually saw a provider.

The OIG found that 21% of referrals were never scheduled for an appointment and received no follow-up from the VAMC. Wait times for appointments averaged 92 days, with some patients waiting well over a year.

“The reaction to these reports echoes the absolute frustration and disappointment our team felt during the course of these two inspections” in 2012-2013, said Michael L. Shepherd, MD, of the VA’s OIG office. “The findings in these reports are disturbing.”

So far, the Atlanta VAMC has implemented five of the eight recommendations made by the OIG. Shepherd said his office would “vigorously follow up” to ensure changes were made and that the OIG would return for another visit to the facility this fall.

One key change “sealed up a lot of the cracks” that existed at the time of the reports, said Leslie B. Wiggins, the newly-appointed director of the VAMC. She said social workers, based at the community provider organizations, now serve as liaisons among those groups, the VAMC and patients.

The hearing included testimony from a number of community healthcare and veteran service organizations. Isakson urged VA officials to listen carefully to their comments as mental health issues “are not just a VA problem. This is an American problem. . . . The VA has got to be open to the solutions of those in the private sector who work with these problems.”

Not everyone on the community side saw as rosy a picture as Wiggins. While acknowledging some improvement in recent months, retired 1st. Sgt. Vondell Brown of the Wounded Warrior Project testified that he continues to “hear from our warriors about difficulty getting appointments when they need them, about being handed from one clinician to another, and about difficulty in developing rapport with their providers.”

He also noted that clinicians often fail to take the time to treat the root problems. “The experience of many warriors in the area – whether they are being treated by VA clinicians or VA contract providers – is that they are too often offered medication to ease symptoms rather than provided talk therapy that might help resolve their deeper problems.”

Given the high incidence of both drug abuse and suicide among veterans with PTSD and other mental health issues, Brown urged increased staffing to enable more individual therapy and greater continuity in care.

Leslie B. Wiggins, newly-appointed director of the VAMC, and Sen. Johnny Isakson (R-GA), pictured together at the Senate Veteran’s Affairs Committe field hearing held in Atlanta.
Mental Health Summit
Monique Hunter, PhD

A week after the Senate field hearing, the Atlanta VA hosted a community mental health summit, part of a nationwide program to build a network to support veterans in all aspects of their lives. Nearly 150 people representing local health care organizations and mental health advocates, veterans’ organizations, local colleges, the Red Cross, housing organizations and other nonprofits that offer assistance to veterans attended.

“We want to ensure veterans are fully integrated into the communities of their choice, so they can live life as fully as possible,” Monique Hunter, PhD, local recovery coordinator and clinical psychologist at the Atlanta VAMC told U.S. Medicine.

The community outreach program represents a change in mental health care planning. “We want to make sure our plans are recovery oriented and veteran centered, that the needs and preferences of the veteran are taken into consideration. The summit facilitates the exchange of information with agencies that can help us meet those needs,” Hunter said.

Following that meeting, Brown said “veterans shouldn’t have to come home and fight” for appropriate care. The VA and others must recognize that “physically veterans may come back, but mentally they may not come back for some time. They need a holistic approach to care,” he added.

That “whole person” approach to care needs to extend to the families of those with mental illness said Paul Wiser, an educator with the National Alliance on Mental Illness. “Families need to understand that mental illness is a lifetime problem. They need to receive information and support themselves so they can help their loved one over the long term.”


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