By Stephen Spotswood
WASHINGTON —VA’s announcement that 1,900 mental-health staff will be added to its roster is more reactive than proactive, VA Secretary Eric Shinseki told legislators at a recent hearing.
“A certain number of folks walk in the door, and we try to extrapolate that into the future,” Shinseki explained to the House Committee on Veterans’ Affairs. “But we’re really looking at four years into the future. And what this means is that we are essentially in a reactive cycle. What walks into the door becomes the basis for understanding what we need in the future. When we have spikes in the [trend], then we have these occasional needs to address. ”
One contributor to the urgent need is the 2010 simplification of rules for veterans submitting PTSD-related benefit claims, he added.
VA Secretary Eric Shinseki testified recently before the House Committee on Veterans’ Affairs.
“The claims have been submitted, and we’re beginning to see a growth in PTSD mental-health requirements,” Shinseki said.The announcement that the agency hopes to hire 1,600 mental-health clinicians and 300 support staff — for a total VA mental-health staff of 22,490 — comes only weeks after a VA Inspector General report found VA’s self-evaluation of its mental-health appointment scheduling significantly flawed.
VA leaders contend the two are unrelated and that the addition of staff is not a reaction to the IG report but to increased needs.
However, IG investigators note that, until VA drastically changes how it tracks mental healthcare being provided to its veterans, it will have no real idea of what percentage of its patient population is being treated in a timely manner.
Quickly hiring so many people is easier said than done. VA historically has had difficulty recruiting mental-healthcare professionals, especially those with extensive training, such as psychiatrists, and those willing to work in rural and remote areas.
According to VA officials, the agency will be employing a fourfold strategy to recruit the 1,9000 employees:
- a robust marketing and advertising campaign;
- national recruiters tasked with filling vacancies at specific medical centers and Veterans Integrated Service Networks (VISNs);
- strong involvement by VA leadership; and
- recruiting from VA’s active pipeline of trainees and residents.
The latter method is expected to make up the majority of the new staff hired, said VA Undersecretary of Health Robert Petzel, MD. “We’re the largest trainer of mental-health professionals in the country. And this group of trainees is the primary place that we’re probably going to be recruiting.”VA Seeks Increased Mental-Health Staff to Respond to Growing Needs Among Veterans
As for the hard-to-find psychiatrists, VA plans to sweeten the deal by offering more money.
Noting that the most difficult mental-healthcare staff to recruit are psychiatrists, especially in rural or remote areas, Petzel said. “I recently sent a memo to the secretary, that he is about to sign, to change the pay table for psychiatrists and to make available other incentives so we can compete more equitably with [the] private sector and DoD.”
As of May, VA had recruited 37 of the 57 psychiatrists it plans to hire as part of the 1,900 new staff. Of those 37, seven already are serving, and the remaining 30 are being processed.
According to VA, it will take about four to six months to fill these vacancies overall, although the harder-to-fill positions could take as long as a year. VA has an average vacancy rate of 7.23% for mental-health professionals.
The cost in FY 2012 should be approximately $29 million, and, in FY 2013, when most of the new hires will come on board, the funding will come through each VISN’s budget allocation.
“Each VISN is going to get a hiring target,” Petzel said. “And we’re going to keep very close track of their hiring target, essentially looking at it daily.”VA Seeks Increased Mental-Health Staff to Respond to Growing Needs Among Veterans
Poor Performance Measurements
How many mental-healthcare professionals VA fields is dependent on the need and how well that need is being met. The IG report found, however, that the VA’s ability to track that is compromised.
One of the main goals of VA is for all first-time patients referred to or requesting mental-health services to receive an initial evaluation within 24 hours and a more comprehensive mental-health diagnostic and treatment planning evaluation within 14 days. The goal of the initial 24-hour evaluation is to identify patients with urgent care needs and to trigger hospitalization or immediate initiation of outpatient care.
Two of the principal measures VA uses to monitor access to mental healthcare are the percentage of patient evaluations completed within 14 days of an initial encounter and patient waiting times calculated by measuring the elapsed days from the desired date for an appointment and the actual date of the appointment.
According to VA’s FY 2011 Performance and Accountability (PAR) Report, 95% of first-time patients received a full mental-health evaluation within 14 days. However, according to the IG, this data has no real value, because VA providers did not adhere to a standardized scheduling or data-input system.
Using the same data that VA used to complete its PAR report, the IG calculated that VA completed only 49% (approximately 184,000) of its evaluations within 14 days of the veterans’ request or referral. On average, it took VA 50 days to provide patients with a full mental-health evaluation.
“Once an evaluation takes place, VA schedules them for an appointment to treat them. In FY 2011, we determined that VHA completed approximately 168,000 (64%) new patient appointments for treatment within 14 days for their desired data,” Linda Halliday, assistant IG for audits and evaluations, told legislators. “In comparison, VA’s [self-evaluation] showed that 95% received timely care.”
According to the IG report, 88% of veterans received a follow-up appointment within 14 days of their desired date. In comparison, VA’s self-evaluation reported 98% received timely care.
The actual numbers could be far worse. During their investigation, IG officials found that providers were basing desired date of care on their own schedule availability. This is in direct conflict with a VA directive to use the date the patient requests as the desired date of care.
“We reported concerns with VA calculated wait-time data in earlier audits of patient scheduling in 2005 and 2007,” Halliday said. “During both audits, we found that schedulers were inputting incorrect desired dates.”
Veterans could have waited two or three months for an appointment, but VA data could show zero-wait time, she said. “VA needs a reliable set of performance measures and consistent scheduling practices to accurately determine whether they are providing patients with timely healthcare services.”
The IG’s findings overshadowed VA’s staffing announcement and made the announcement seem, to some legislators, as an inadequate remedy for a more systemic performance measurement problem.
“It appears that VA’s response in this instance is yet another example of a federal bureaucracy providing a quick-fix, cookie-cutter solution,” said House VA Committee Chairman Jeff Miller, R-FL. “I would like to see from VA the priority that has been placed on veterans homelessness mirrored in mental healthcare.”
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