WASHINGTON, DC — VA’s mental health services handbook is almost a decade out of date, making consistent care more difficult to achieve and possibly putting veterans’ safety at risk, according to a report by the VA Office of the Inspector General (OIG).
The handbook identifies mental health services that must be available and accessible for patients accessing VA care. However, inspectors said the current version “does not fully capture the scope of current mental health programs and services, contains broken links for related information, and requires research on the part of providers to locate up-to-date information.”
The current version of the “VHA Handbook, Uniform Mental Health Services in VA Medical Centers and Clinics,” was published in September 2008. It was scheduled for recertification by September 2013. Parts of the handbook were amended in November 2015, but no recertification ever occurred.
Consequently, the handbook fails to mention major VA mental health initiatives that have been launched in the interim. For example, the handbook makes no mention of the Behavioral Health Interdisciplinary Program—a now-required team-based approach to addressing a veteran’s mental health needs. It contains nothing about the Veterans Community Care Program, established in 2019 to furnish care to veterans in the community when it was not accessible at VA. And it is absent any updated guidelines on the expected care of transgender veterans.
“Several VA/DoD Clinical Practice guidelines have been updated since the handbook’s overdue recertification date,” the OIG report notes. “[This includes] the management of post-traumatic stress disorder, major depressive disorder, and the management of patients at risk for suicide.”
Instead of the new guidelines, the handbook contains broken links to previous guidelines.
The same recertification delay has occurred with VA’s Inpatient Mental Health Services handbook. Published in September 2013, it was scheduled for recertification by September 2018, though none occurred. The now-outdated handbook fails to include things like VA’s Bed Management Solution, used to track inpatient bed availability and updated suicide screening tools.
According to OIG’s report, these outdated handbooks contributed to VHA being put on the Government Accountability Office’s (GAO’s) high-risk list in 2015.
“Ambiguous policies have led to inconsistencies in the way VA medical centers operate at the local level, posing risks for veterans’ access to healthcare, and for the quality and safety of that care,” the report states.
In lieu of updating the handbooks, VA offices have been reliant on issuing operational memoranda, which the department has recognized is not a suitable alternative. In August 2022, VA reissued a previous notice about the review and management of operational memoranda in the context of VHA’s continued presence on GAO’s high-risk list.
The notice stated that “program offices’ reliance on issuing operational memoranda in lieu of VHA national policies remains a concern.”
It went on to note that these memos were often believed to be a form of VHA policy by staff and oversight bodies, which they were not. The memos may also contradict existing policies and are not subject to the same level of scrutiny as official handbooks.
“Continued provider reliance on or unfamiliarity with operational memoranda in lieu of policies may create a disconnect between outdated policies and current expectations,” the OIG report said.
To provide the most consistent care, VA needs to have updated national handbooks clearly stating the department’s policies and goals, inspectors noted. “Mental healthcare evolves and changes over time, and policies that remain outdated for many years may impact staff awareness of requirements, which impacts the delivery of quality clinical care and patient safety.”
According to department officials, both handbooks are in various stages of VHA recertification.
In response to OIG’s report, VA Undersecretary for Health Dr. Shereef Elnahal wrote, “VHA will move both policies into the approval process within the next few months. For purposes of ensuring all stakeholders have an opportunity to provide input on changes to national policy, VHA requires a comprehensive series of thorough reviews. In addition to review by VHA leadership, legal counsel, subject matter experts and users, VHA will include up to three months for unions to provide input. Once cleared by all parties, VHA will expeditiously publish the policies.”
VHA’s goal for publication is September 2023.
