A Query of VA Mental Health Professionals Executive Summary and Preliminary Analysis September 9, 2011

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1 A Query of VA Mental Health Professionals Executive Summary and Preliminary Analysis September 9, 2011 Background: Secretary Shinseki has placed the highest priority on providing our Veterans living with mental health issues with timely, responsive and quality care. Under the President s budgets, VA has seen one of the largest increases in the past 30 years, which has allowed VA to hire more staff, treat more patients, and provide benefits to more Veterans. Under the President and Secretary Shinseki s leadership, VA has recently hired more than 3,500 mental health professionals, and our mental health staff now totals almost 21,000. Last year, 408,167 Veterans with a diagnosis of post-traumatic stress disorder (PTSD) received treatment at VA medical centers and clinics. More than 1.2 million Veterans received care from the VA for a mental health problem a caseload level that increases each year. All of this work to fully implement the Uniform Mental Health Services Handbook is moving the VA mental health care system forward; yet VA knows that more can and should always be done to improve the access to and quality of VA mental health care for Veterans. VA recently received the results of a report for which VA had contracted with Rand Altarum to complete a Program Evaluation of Veterans Health Administration (VHA) Mental Health Services. These results indicated that across the country, VHA facilities report substantial capacity for treating Veterans with mental illness. Moreover, VHA capacity has increased since the implementation of the Mental Health Strategic Plan. In addition, overall, the quality indicators assessed suggest that in most instances, the performance of VHA care is as good as or better than that reported in the literature by other groups or by direct comparisons conducted in the study. However, important gaps remain, and VHA has not yet fully met its aspirational goals. Query Summary: As requested at the July 14 th Senate Veterans Affairs Committee (SVAC) Hearing VHA Mental Health Care: Closing the Gaps, the VHA queried selected VA frontline mental health professionals for their perceptions on mental health issues as requested by SVAC staff. VHA expedited SVAC s request to meet their deadline and quickly developed a Web-based query that was administered from August 10 to August 17, Given more time, VHA would have sought the assistance of a professional trained in survey development, who may have provided different recommendations on the wording of specific questions, the size of the population contacted, and other factors related to survey methodology. In this effort, VHA queried 319 general outpatient mental health providers from each facility within five Veterans Integrated Service Networks (VISNs) that were selected by SVAC staff. A total of 272 professionals responded for a response rate of 85 percent. Approximately one-third (31 percent) of the respondents were social workers, about a quarter (25 percent) were psychologists, 22 percent were psychiatrists, and 22 percent were nurses. Appendix A provides the raw data captured by the query, and below we have summarized our initial findings, relevant facts, and potential actions. VHA leadership is taking the findings of this query seriously and is working to better understand where service gaps exist. Although the results and analysis presented in this summary are preliminary, many of our actions are underway. VHA is aggressively filling current mental health vacancies, is reviewing current performance measures related to access to mental health 1

2 services, and plans to follow up on these findings by directly engaging mental health leadership, frontline staff and Veteran patients regarding how to best meet the mental health needs of Veterans. In this effort, VHA leadership will hold focus groups in which both Veterans and mental health clinicians will be asked to provide their feedback. VA places the highest priority on providing Veterans with timely, responsive, and high quality mental health care. Key Findings from the Query, and Action Plans: Key Findings: Of the respondents, 63 percent reported they can schedule a new mental health patient appointment within 14 days in their own clinics, and 48.1 percent believe that Veterans they refer for mental health specialty appointments for conditions such as PTSD or substance use disorder will be seen within 14 days. Moreover, 61 percent of respondents reported that they can see established patients within their own clinic in 14 days of the desired date. However, 70.6 percent reported that in their opinion, their facility does not have adequate mental health staff to meet current Veteran demands for care. : 1) VHA has collected data on waiting time for these same clinics within the sampled VISNs. That data, based on valid performance measures, show a 30 percent discrepancy with these results; i.e., VHA waiting time data indicate that 96.7 percent of new patients referrals to general mental health clinics are seen within 14 days, and 97.1 percent of new patients for specialty mental health appointments are seen within 14 days. Similar findings emerged for established patients. VHA waiting time data shows that 97.4 percent of established patients are seen for general mental health appointments within 14 days of their desired date. 2) In attempting to understand this discrepancy, we reviewed the narrative responses to the questions. Some provider responses focused on an inability to provide mental health care as they would like; for example, not being able to provide the type of treatment indicated by the treatment plan, such as evidencebased psychotherapy, which may not be as readily available as needed. Other providers cited a shortage of a specific type of provider function, such as a case manager. We also noted that approximately 24 percent of the respondents were located in community-based outpatient clinics (CBOC). To understand the specific challenges in those settings, VHA will need to carry out further evaluation. 3) Of note, the providers are not ordinarily the individuals who actually schedule appointments. In our ongoing discussions with providers and their staffs, we hope to gain the input of additional staff, including schedulers. 4) As of May 2011, VHA vacancy data for mental health positions showed a vacancy rate of 13.6 percent across the country. Action Plans: 1) The Deputy Under Secretary for Health for Operations and Management (DUSHOM) has reinforced to network and facility Directors to aggressively recruit for all mental health vacancies. VHA is also exploring additional mechanisms to audit the scheduling practices of mental health clinics. 2) VHA is revising our access metric and performance measures for waiting times and further refining metrics that take into account specific types of care such as 2

3 evidence-based treatment, to include in the fiscal year (FY) 2012 Performance Contract for network directors. 3) VHA is reviewing the Mental Health Staffing Plan in every Network and developing a national staffing model in conjunction with the Mental Health Executive Councils of each Network. 4) VHA will directly engage mental health leadership and mental health frontline staff to gain additional understanding of staffing patterns and barriers to access. Almost 70 percent of providers replied that their sites had shortages in mental health space. We have no comparative data available. Action Plan VHA will directly engage with mental health leadership and mental health front line staff to discuss their reports of space shortages. Based on those discussions, VHA will explore ways to maximize the use of clinical space. Of respondents, 46 percent reported that the lack of off-hour appointments was a barrier to care. 1) The DUSHOM memo of June 1, 2007, required medical centers to provide mental health/substance abuse clinics at least one evening a week, and preferably more, by August ) Some Veterans Affairs Medical Centers (VAMC) that established after hours clinics found that appointment slots were not used or did not appear to be meeting Veterans needs. Action Plan VHA will continue to explore possible barriers to care and develop new policies to address this issue and better meet the needs of the Veterans seeking mental health services. Of respondents, 26.5 percent reported that the demand for Compensation and Pension (C&P) exams pulled clinicians away from direct care. Demand for C&P exams has risen dramatically from FY 2009 to FY Data as of May 2011 suggests that the rate of growth during this period is about 148 percent. Many VAMCs are using existing mental health clinicians to meet this demand. Action Plans 1) VHA will work with other offices such as the Office of Human Resource Management and Veterans Benefits Administration to review these workload issues and develop options. 3

4 2) The VHA tele-mental health program is developing models of regional centers to provide support for C&P exams. 3) The VA Office of Disability and Medical Assessment is working to ensure every facility has a separate C&P service. Of respondents, 50.1 percent reported that growth in patient numbers contributed to mental health staffing shortages. From 2005 to 2010, the number of patients (uniques) seen in VA in mental health specialty settings rose by 39 percent. At the same time, the number of Veterans Affairs mental health staff increased by 46 percent. Action Plan VHA will continue to be aggressively recruit mental health providers to ensure access to our growing patient population. Veterans Health Administration September 9,

5 Appendix A Query Results (August 10 to August 17, 2011) Raw Data Discipline of respondent? N % Psychiatrist % Psychologist % Nursing APH % Nursing RN % Social Work % Total Responses How long does it take you on average to schedule a new mental health patient appointment in your clinic? No wait can see Veteran immediately or at their earliest preferred date % Can see Veteran within 14 days of their earliest preferred date % Can see Veteran within 30 days of their earliest preferred date % Cannot see Veteran until days of their earliest preferred date % Cannot see Veteran until more than 60 days after their earliest preferred date % 2. How long does it take you on average to schedule an already established mental health patient relative to the desired date? No wait can see Veteran immediately or at their earliest preferred date % Can see Veteran within 14 days of their earliest preferred date % Can see Veteran with 30 days of their earliest preferred date % Cannot see Veteran until days of their earliest preferred date % Cannot see Veteran until more than 60 days after their earliest preferred date % 3. If you need to refer a Veteran to a mental health specialty appointment such as for PTSD or Substance Use Disorder, how long on average does it take for the Veteran to be seen? No wait can see Veteran immediately or at their earliest preferred date % Can see Veteran within 14 days of their earliest preferred date % Can see Veteran with 30 days of their earliest preferred date % Cannot see Veteran until days of their earliest preferred date % Cannot see Veteran until more than 60 days after their earliest preferred date % 4. Does your site have adequate mental health staff to meet current Veteran demands for care? Yes % No % If you answered No to #4, indicate the discipline and number of vacancies for all understaffed positions. Psychiatrist % Psychologist % Nursing % Social Work % If you answered NO to #4, what are the causes of these staff shortages? {Check all that apply} Difficulty in recruitment % Increase in volume of Veterans seen for mental health care % Unfilled vacancies % Narrative responses problems with HR, lack of ability to replace staff that leave, not enough case managers, psychiatrists or therapists. In process of developing coding system to better characterize these responses. 5

6 5. Does your site have mental health space shortages? Yes % No % 6. Are there other system barriers that delay access to care? Yes % No % If you answered YES to #6, please describe these barriers in the space provided below: Veterans need off hour appointments (evenings, weekends) % Shortages of Clerical/Scheduling staff % Demand for C&P exams that pulls clinical staff away from direct care % Other in process of coding responses % September

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