Lack of Staff, Coordination

Testifying before the Senate VA Committee, John Daigh, MD, assistant inspector general for healthcare inspections, said he repeatedly sees two major gaps in VA’s delivery of mental-health care services.

“The first has to do with coordination of care,” Daigh said. “We have looked at a number of cases over the years where veterans have committed suicide or had other untoward outcomes. It’s been almost a constant factor in those cases — the level of the patient trying to get his care coordinated, either between community-based outpatient clinics [CBOC] and medical centers, or between VA facilities and [private providers].”

The second gap is access to mental-health specialists — psychiatrists, psychologists, and, Daigh pointedly added, pain-management experts. Atlanta VAMC had staffing shortages in most areas that would impact patient care. Positions for physicians, physician assistants and nurse practitioners were 73% filled, social workers were 65% filled, psychiatrists were 68% filled and psychologists were 45% filled.

“One of the factors that complicated the problem was that there was inadequate mental-health staffing at CBOCs, not that VA didn’t try to put mental-health [providers] there. But they weren’t there. That diminished the ability at Atlanta to deal with [the problem],” Daigh said.

VA facilities tend to have patients first see lower-level providers instead of the psychiatrists or psychologists best able to help them, according to Daigh. He said it can take considerable time for them eventually to be passed up the chain until they get to the specialists they need.

 “When you have patients dealing with extremely complex mental-health issues, I think they need to see rather quickly the captain of the team — a psychiatrist or an experienced provider,” he added. “And that individual then needs to lay out a plan that the rest of the team and support staff can follow.”

VA’s patient-aligned care teams (PACT) initiative is designed to help get patients to the providers they most need. Daigh said he is skeptical that the teams will actually get patients to the specialists they need to see.