Long Wait Times for Mental Health Care Continue to Plague VA

by U.S. Medicine

September 7, 2011

WASHINGTON — Poor coordination and staffing problems were identified as major factors in veterans’ receiving inadequate care at Atlanta VA Medical Center mental-health clinics, according to a VA Inspector General (IG) report released last month. This report is the latest of many released by oversight agencies that point out the gaps in VA’s mental-health services.

murray photo.jpgLegislators expressed frustration at these continuing problems and asked VA leaders why these gaps have not been filled, despite years of effort.

“More than one-third of veterans returning from Iraq and Afghanistan who have enrolled in VA care have post-traumatic stress disorder.  An average of 18 veterans kill themselves every day,” said Sen. Patty Murray (D-WA), chair of the Senate VA Committee at a hearing last month on VA mental-health care. “In fact, the difficult truth is that, somewhere in this country, while we hold this hearing, it is likely that a veteran will take his or her own life. Just this past May, the 9th Circuit Court of Appeals issued an opinion that called attention to many of these gaps in mental-health care for veterans. And while that ruling has gotten the lion’s share of attention, it is one of far too many warning signs.”

The May decision was handed down by a three-judge panel of the appeals court. In July,VA asked for a full-court hearing, in which an 11-judge panel revisit and rehear the issues. The 9th Circuit has yet to respond to that request.

Fast-Growing Patient Population

The Atlanta VAMC has one of the fastest-growing patient populations in the VA system. In FY 2009, the facility served 71,000 patients — up 7% from the previous year. In FY 2010, that number rose to 77,000 — an 8% bump.

The number of veterans needing mental-health care grew at an even steeper rate. Required follow-up to positive mental health-related screenings rose from 3,848 in FY 2009 to 11,367 in FY 2010. The number of patients receiving inpatient mental-health care rose from 651 to 993 during that time, and the number of those receiving outpatient mental-health care rose from 201,915 to 225,000.

The result of this increase in demand was a proportional increase in waiting times for appointments. Between October 2009 and May 2010, the percentage of patients waiting longer than 30 days for an appointment rose from 0.6% to 4.5%.  The IG report found that, in most cases, facilities leaders were aware of the lengthy wait times but were slow in doing anything to address them.

VA took a step to address this problem nationwide when it implemented a new performance measure in October 2010 to track the percentage of new patients waiting to be seen within 14 days of their desired appointment date. The goal was to track first appointment wait times and ensure patients were seen quickly by a mental-health professional.

However, this measure only tracks first appointments, and VA does not track subsequent appointments. The result was that the Atlanta VAMC was able to show 100% compliance with this performance measure during the first three quarters of FY 2010, despite having hundreds of patients on various waiting lists to see mental-health providers.

Long Wait Times for Mental Health Care Continue to Plague VA Cont.

Going Beyond Fee Basis Care

While Daigh noted that VA needs to tap expertise outside of its system, he dismissed fee-basis care as an acceptable solution. Fee-basis arrangements are when VA agrees to reimburse a veteran for going to a private provider. Not only is the process of getting approval for such an arrangement long and work-intensive, it often creates more gaps in care than it fills, Daigh said.

“VA ought to consider establishing arrangements with providers that are beyond fee-basis arrangements,” he said,  making use of “prearranged partnerships with universities and private practices where you can easily call on them, rather than fee-basis care where you tell a veteran, ‘We can’t meet your demand. Here’s a check. Go get care.’ With these partnerships, they expect to see patients.”

Also, VA would better be able to share medical records and track patients, unlike with fee-basis care in which patients receive care that is never tracked or evaluated by VA.

In areas where VA does not have a mental-health care presence — communities that might be so small that there is not enough demand for mental-health providers — VA needs to sit down with local community leaders to talk about the issue, Daigh said. “They should see if they can’t pool patients to create a demand, and pull resources to provide funding to take care of those individuals where they live.”

Responding to the IG report and Daigh’s testimony, William Schoenhard, VA deputy under secretary for health, said, “We concur with the IG, and I’ve talked with [the director] there. We were not as quick as we should have been, and we’re going to learn from this. We’re taking this report, not just for Atlanta, but for other facilities, particularly in high-growth areas.”

While he and other VA officials at the hearing apologized for the problems veterans have faced getting care, they also assured legislators that VA was actively working to fill these gaps.

The committee members expressed a high level of anger and frustration and were skeptical of VA’s response. Sen. Murray told Schoenhard that assurances from VA Central Office were no longer sufficient.

 “I’d like you to go back to each one of the VISNs and survey the clinicians on the ground about these wait times we’ve been hearing about,” she said. “I think it’s really imperative that we hear directly from VA’s mental-health care providers who are on the front lines treating veterans. We need to know if the providers, not the administrators, have sufficient resources.”

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Long Wait Times for Mental Health Care Continue to Plague VA Cont.

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.

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