Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Implementation of VHA’s 

Uniform Mental Health Services 

Handbook 

Report No. 08-02917-105 April 6, 2009

VA Office of Inspector General 

Washington, DC 20420 
 

 

 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 between 8:30AM and 4PM Eastern Time,

 Monday through Friday, excluding Federal holidays

 E-Mail: vaoighotline@va.gov 
Implementation of VHA’s Uniform Mental Health Services Handbook 

Contents 

Page 

Executive Summary ..............................................................................................i
 

Issue K. Integrating Mental Health into Medical Care Settings and in the Care of 

Introduction ..........................................................................................................1 

Purpose............................................................................................................................. 1
 

Background...................................................................................................................... 1
 

Scope and Methodology .................................................................................................. 3
 

Results and Conclusions ....................................................................................6 

Issue A. Community Mental Health ................................................................................ 6
 

Issue B. Gender-Specific Care and Military Sexual Trauma .......................................... 6
 

Issue C. 24/7 and Emergency Department Care.............................................................. 7 

Issue D. Inpatient Care..................................................................................................... 8 

Issue E. Ambulatory Mental Health Care........................................................................ 8 

Issue F. Care Transitions ................................................................................................. 9 

Issue G. Specialized PTSD Services ............................................................................. 10 

Issue H. Substance Use Disorders ................................................................................. 11 

Issue I. Seriously Mentally Ill and Rehabilitation and Recovery Services ................... 13 

Issue J. Homeless Programs and Incarcerated Veterans................................................ 14 

Older Veterans ............................................................................................................... 15
 

Issue L. Suicide Prevention ........................................................................................... 16 

Issue M. Uniformity of PTSD Diagnosis and Evidence-Based Treatments ................. 17 

Conclusions.................................................................................................................... 20 

Appendixes 

A. Under Secretary for Health Comments..................................................................... 24
 

B. OIG Contact and Staff Acknowledgments................................................................ 26
 

C. Report Distribution.................................................................................................... 27
 

VA Office of Inspector General 
Implementation of VHA’s Uniform Mental Health Services Handbook 

Executive Summary 

Introduction 

As required by the Military Construction, Veterans Affairs, and Related Agencies 

Appropriation Bill, fiscal year 2009 (FY09), the VA Office of Inspector General (OIG) 

conducted a review of the Veterans Health Administration’s (VHA’s) progress in 

implementing the recommendations of the Mental Health Strategic Plan. Additionally, 

the Committee was concerned that VHA policy on the identification and treatment of 

post-traumatic stress disorder (PTSD) has not been applied uniformly and directed the 

OIG to include a review of the compliance to these policies in the report. 

The Mental Health Strategic Plan has over 200 initiatives; VHA’s Handbook 1160.01, 

Uniform Mental Health Services in VA Medical Centers and Clinics translates this into an 

operational, point of service, programmatic package of approximately 400 mental health 

services provided or available to eligible veterans at VA medical centers and community 

based outpatient clinics (CBOCs) of varying size. 

Results 

Given the dimension of the handbook, a comprehensive review of the extent of 

implementation is challenging. We limited the scope of our review to the medical center 

level. Implementation at CBOCs will be reviewed through OIG’s CBOC review process. 

In addition, we chose selected items from the handbook to evaluate for implementation. 

For each section, there may be items that were not chosen for which the extent of 

implementation is greater or less. In addition, implementation of the handbook is a 

dynamic and ongoing process during FY09 and the data presented in the findings do not 

capture partial implementation. We believe the items chosen reasonably estimate the 

present extent of handbook implementation at the medical center level at this time. A 

detailed table presents our findings, including findings on identifying and treating PTSD. 

We would anticipate the extent of implementation at medical centers to exceed that seen 

at the CBOC level. Smaller and rural CBOCs may face obstacles to implementation 

including geographic distance to care and ability to recruit mental health providers, 

among others. 

We found that some facilities were unclear as to facility level status and therefore were 

unclear whether onsite emergency department requirements have been met. 

At present we are unaware of a system by which VHA reliably tracks provision and 

utilization of evidence-based PTSD therapies on a national level. Development of a 

national system to track provision of evidence-based PTSD therapies and utilization by 

VA Office of Inspector General i 
Implementation of VHA’s Uniform Mental Health Services Handbook 

returning veterans would allow for a population based assessment of treatment outcomes 

with implications for the treatment of other veterans presenting for PTSD related care. 

The handbook is an ambitious effort to enhance the availability, provision, and 

coordination of mental health services to veterans. The handbook notes that metrics will 

be used to ensure implementation of requirements. Program evaluation and development 

of mental health outcome measures can be challenging. As implementation further 

progresses, VHA should develop metrics and outcome measures where feasible to allow 

for dynamic refinement of program requirements in order to meet changes in mental 

health needs and care utilization patterns of veterans. 

This inspection reports on the system-wide implementation status of VHA Handbook 

1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics. Because 

facilities have until the end of FY09 to fully meet the handbook requirements, we made 

no recommendations at this time. 

Comments 

The Under Secretary for Health concurred with our findings and stated that he was 

optimistic about forecasts for full implementation by the end of FY09, given VHA’s 

actions in process. See Appendix A, pages 24–25 for the full text of his comments. 

 (original signed by:)

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General ii 
 

Implementation of VHA’s Uniform Mental Health Services Handbook 

Introduction 

Purpose 

As requested in House Report 110-775, to accompany H.R. 6599, Military Construction, 

Veterans Affairs, and Related Agencies Appropriation Bill, fiscal year 2009 (FY09), the 

VA Office of Inspector General (OIG) conducted a review of the Veterans Health 

Administration’s (VHA’s) progress in implementing the recommendations of the Mental 

Health Strategic Plan. Additionally, the Committee was concerned that VHA policy on 

the identification and treatment of post-traumatic stress disorder (PTSD) has not been 

applied uniformly and directed the OIG to include a review of the compliance to these 

policies in the report. 

Background 

The VHA Mental Health Strategic Plan (MHSP)1 was finalized in 2004 in the context of 

a growing veteran population with unmet mental health care needs and the 

transformational emphasis of the 2003 report of the President’s New Freedom 

Commission on Mental Health.2

 The New Freedom Commission identified 6 broad 

goals: 

•	 Americans understand that mental health is essential to overall health. 

•	 Mental health care is consumer and family driven. 

•	 Disparities in mental health services are eliminated. 

•	 Early mental health screening, assessment and referrals to services are common 

practice. 

•	 Excellent mental health care is delivered and research is accelerated. 

•	 Technology is used to access mental health care. 

In 2003, the VA Under Secretary for Health convened a work group to review the 

President’s New Freedom Commission on Mental Health Report, to determine the 

relevance of the Commission’s goals and recommendations to veterans’ mental health 

programs, and to develop an action plan tailored to the special needs of the enrolled 

veteran population. In December 2003, this work group developed and published an 

action agenda report: Achieving the Promise: Transforming Mental Health Care in VA. 

The action agenda report prompted VHA to organize a workgroup to develop a 

comprehensive strategic plan for mental health care services. The workgroup ultimately 

incorporated multiple talking points into a 5-year strategic plan with more than 200 

1

 More formally known as A Comprehensive VHA Strategic Plan for Mental Health Services. 2 Achieving the Promise: Transforming Mental Health Care in America, The President’s New Freedom 

Commission on Mental Health, 2003. 

VA Office of Inspector General 1 
Implementation of VHA’s Uniform Mental Health Services Handbook 

initiatives. The MHSP was initially approved by the Under Secretary in July 2004, 

finalized in November 2004, and revised in May 2005. 

The purpose of the MHSP was to present a new approach to mental health care, focused 

on recovery versus pathology and the integration of mental health care into overall health 

care for veteran patients. The MHSP action items were grouped to align with the goals 

and recommendations of the New Freedom Commission Report. 

Since the MHSP is organized by New Freedom Commission Goals and 

Recommendations rather than by mental health program or operational focus, some 

MHSP initiatives do not clearly delineate what specific actions should be carried out to 

achieve these goals and are not easily measureable. In addition, several items are 

administrative in nature, such as establishing a workgroup. Although implementation of 

these items may indirectly facilitate provision of care, point of service delivery is not 

directly addressed. 

VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and 

Clinics (the handbook), issued on June 11, 2008, and updated in September 2008 

establishes minimum clinical requirements for VHA mental health services. The 

handbook specifies the essential components of the mental health program to be 

implemented nationally to ensure that all veterans have access to needed mental health 

services. The handbook delineates those services that must be provided at each VA 

medical facility and at very large, large, mid-sized, and small community based 

outpatient clinics (CBOCs). 

Mental health services required by the handbook represent the next step in the process 

that began with approval of the MHSP in 2004 and the allocation of funding through the 

Mental Health Enhancement Initiative. As an extension of the MHSP, the handbook was 

also developed to further implement the goals of the New Freedom Commission Report. 

Objectives of the handbook include: 

• Expanding access and capacity. 

• Integrating MH and primary care. 

• Transformation toward a recovery and rehabilitation model. 

• Implementing evidence-based care. 

• Returning veterans. 

• Suicide prevention. 

Although there is overlap between MHSP items and the handbook items, the handbook 

more clearly defines specific requirements for services that must be provided (those 

services that must be delivered when clinically needed to patients receiving health care at 

a facility by appropriate staff located at that facility) and those that must be available 

(those that must be made accessible when clinically needed to patients receiving health 

VA Office of Inspector General 2 
Implementation of VHA’s Uniform Mental Health Services Handbook 

care from VHA). In contrast to the MHSP, the handbook has an operational focus and 

action items are organized by mental health program areas (e.g., Ambulatory Mental 

Health Care, Homeless Programs, and Substance Use Disorders, etc.) rather than by less 

specific New Freedom Commission goals. 

Although the handbook contains over 400 elements, it does not intend to describe all 

mental health programming that could be effective, and it encourages sites to go beyond 

the specifications. In addition, specifications are not delineated with such detail as to 

preclude adjustments for local variation in clinical issues. The handbook stipulates that 

every veteran seen in mental health services will be assigned a principal mental health 

provider to help with continuity, care coordination, and treatment plan implementation 

and monitoring. 

Overall, facilities are expected to implement handbook requirements by the end of FY09. 

Potential barriers to implementation include: space limitations within facilities; difficulty 

recruiting mental health clinicians in some rural areas; limited availability of community 

providers with whom to arrange a sharing or contract agreement and/or the time needed 

to forge such agreements; and distance to travel to VA care. Each Veterans Integrated 

Service Network (VISN) must request approval from the Deputy Under Secretary for 

Health for Operations and Management for modifications and exceptions for 

requirements that cannot be met in FY09 with available and projected resources. 

The handbook notes that “when fully implemented these requirements will complete the 

patient care recommendations of the Mental Health Strategic Plan, and its vision of a 

system providing ready access to comprehensive, evidence-based care.” 

Scope and Methodology 

The scope of this review was limited to implementation at the VA medical facility level. 

VA facilities likely pursue full implementation at the facility level prior to the CBOC 

level. Accordingly, the extent of implementation presented in the findings likely 

represents the highest level currently attained for the system as a whole. OIG plans are 

that the Office of Healthcare Inspections, CBOC Project Group will inspect 

implementation at the CBOC level at a later date. Pursuant to Public Law 110-387, the 

OIG is presently conducting a review of VHA residential treatment programs. 

Implementation items related to residential programs were therefore excluded from the 

scope of this review. This review does include some items related to suicide prevention. 

As part of onsite visits for OIG combined assessment program (CAP) reviews, OIG 

inspectors have been conducting a focused, chart based review of implementation of 

suicide prevention related items from the handbook. This focused review began in 

January 2009 and will run through June 2009, after which a roll-up report will be issued. 

We interviewed VA Central Office, Office of Mental Health Services leadership. In 

addition we spoke to several VISN mental health liaisons/directors. We obtained VHA 

VA Office of Inspector General 3 
Implementation of VHA’s Uniform Mental Health Services Handbook 

Deputy Under Secretary for Health for Operations and Management monitor data 

pertaining to timely access for all new veterans who need mental health care, mental 

health care transitions follow-up to inpatient mental health hospitalization, and follow-up 

for high risk hospitalized mental health patients. We obtained data from the VHA Office 

of Mental Health Services monthly tracking report for Suicide Prevention Coordinators, 

VISN Homeless Health Care for Reentry Veterans Specialists, and VISN homeless 

coordinator positions. This report monitors filling by the field of positions funded from 

the Office of Mental Health Services for specific initiatives (e.g., suicide prevention 

coordinators, re-entry specialists, network homeless coordinators). We obtained a list of 

facilities with greater than 1,500 seriously mentally ill patients from the VA Serious 

Mental Illness Treatment and Evaluation Center (SMITREC). We obtained data on 

locations, clinical staffing, and case load on the mental health case management program 

(MCHIM) and on MCHIM-RANGE (Rural Access Network for Growth Enhancement) 

units from the VA Northeast Program Evaluation Center (NEPEC). In addition, data and 

information on dissemination of training in evidence-based psychotherapies was obtained 

from the Office of Mental Health Services. 

From August 11, 2008, to September 25, 2008, we conducted a web based mental health 

point of service inventory survey to be completed by all VA medical facilities. We 

received responses from 149 of 171 VA medical center campus sites. If a VA facility 

had more than one campus, then both campuses were individually surveyed. The 

inventory included questions related to availability of certain specific clinical mental 

health services or clinics (e.g., an Operation Iraqi Freedom/Operation Enduring Freedom 

(OIF/OEF) specialty clinic, evening mental health clinic hours) at VA medical facilities 

and CBOCs; location of CBOCs, satellite, and contract sites; and availability of evidencebased treatments. 

From March 5–19, 2009, we conducted structured phone interviews with mental health 

directors and/or designees at 138 VA medical centers. The structured interview tool 

consisted of select items from VHA Handbook 1160.01, Uniform Mental Health Services 

in VA Medical Centers and Clinics. Some sections of the handbook were omitted 

because we obtained data from other sources pertaining to implementation of items from 

these sections or because of exclusions (e.g., residential programs) described in the scope 

of this report. Each interview consisted of 39 index questions. OIG inspectors asked 

intermittent follow-up queries to enhance clarity and validity of interviewee responses. 

For facilities with more than one campus, only the mental health director responsible for 

the facility as a whole was interviewed. In addition, the interview process afforded the 

opportunity for mental health directors to apprise our inspectors on their progress on 

initiatives that are in process but not yet implemented. Also, we had the opportunity to 

obtain feedback and to hear about potential barriers to implementation. 

From the VA-OIG Data Center in Austin, Texas, we obtained national patient treatment 

data on all unique clinical encounters at each VA facility and associated CBOCs and the 

VA Office of Inspector General 4 
Implementation of VHA’s Uniform Mental Health Services Handbook 

total number of these unique encounters with a primary ICD-9 diagnostic code of 309.81 

(PTSD). We also obtained the number of all unique encounters for PTSD stop codes 

(516,540,561,519,542,562,580,581) and all unique encounters for PTSD stop codes for 

which the primary diagnosis was PTSD. This data was aggregated by VISN. 

The inspection was performed in accordance with Quality Standards for Inspections 

published by the President’s Council on Integrity and Efficiency. 

VA Office of Inspector General 5 
 

 

Implementation of VHA’s Uniform Mental Health Services Handbook 

Results and Conclusions 

Issue A: Community Mental Health 

According to the handbook, VISNs and facilities must collaborate with Vet Centers in 

outreach to returning veterans. Outreach can include presentations at National Guard and 

Reserve sites and Post Deployment Health Reassessment events as well as outreach 

involving veteran families.3 

During the structured interview, we were looking for evidence of active, 

collaborative outreach activities. We found that 87 percent of facilities affiliated 

with at least one Vet Center reported activities consistent with the handbook item. 

Five percent of facilities were not affiliated with a Vet Center and the question 

was therefore non-applicable.4 

Issue B: Gender-Specific Care and Military Sexual Trauma 

The handbook states that all inpatient and residential care facilities must provide separate 

and secured sleeping accommodations for women. Mixed gender units must ensure safe 

and secure sleeping and bathroom arrangements, including door locks and proximity to 

staff. 

Of the facilities with inpatient mental health units, 97 percent reported providing 

separate and secure sleeping and bathroom arrangements. 

According to the handbook, a nationwide tracking system should be used to ensure 

consistent data on screening and treatment of victims of Military Sexual Trauma (MST). 

While facilities uniformly indicated that they perform MST screening and referral, 

82 percent reported informally tracking the treatment of affected patients. 

The handbook also requires that each Medical Center Director is responsible for ensuring 

that evidence-based mental health care is available to all veterans diagnosed with mental 

health conditions resulting from MST. 

In response to the web based mental health point of service inventory, 96 percent 

of medical centers reported availability of outpatient treatment for MST. 

3

 Note that in this section, the material which begins at the left margin is what is stated or required in VHA’s 

Handbook; the indented material which follows is what we found during this review. 

4 The importance of collaboration between medical centers and Vet Centers was raised in a January 2008 OIG
 

report: Healthcare Inspection, Alleged Premature Discharge of a Veteran, VA Pittsburgh Healthcare System, 

Pittsburgh, Pennsylvania, No. 07-01622-62, 1/24/2008. All OIG reports and testimony cited in this report are 

available on http://www.va.gov/oig/. 

VA Office of Inspector General 6 
Implementation of VHA’s Uniform Mental Health Services Handbook 

Issue C: 24/7 Care and Emergency Department Care 

The handbook requires that all VHA emergency departments have mental health 

coverage by an independent, licensed mental health provider either onsite or on-call, on a 

24/7 basis. For level 1A VA medical centers (those facilities that have higher utilization, 

higher risk patients, specialized intensive care units, and research, educational, and 

clinical missions) mental health coverage must at a minimum be onsite from 7am to 

11pm. For non level 1A facilities, coverage must be onsite or on-call at all times. VA 

facilities with urgent care centers must have mental health coverage during their times of 

operation; the coverage may be onsite or on-call. 

Approximately 79 percent of facilities interviewed have emergency departments. 

Of the facilities with an emergency department of any level, 98 percent had at 

least 24/7 on-call coverage. For the number of facilities with urgent care centers, 

88 percent reported onsite coverage and 100 percent had at least on-call coverage 

during their times of operation. 

Although we initially attempted to ascertain the extent of 1A facilities with onsite 

emergency department coverage from 7am to 11 pm, it became clear that many 

facilities do not have level 1A emergency departments. Although most facility 

mental health directors were aware of the facility level, some mental health 

directors were unsure of the facility level or the level had recently changed. One 

mental health director commented that it would be helpful for central office to 

send all facility mental health directors a list of up to date facility level 

designations in order to ensure that mental health directors are meeting the 

emergency department onsite requirements. 

The handbook notes that all medical centers with emergency departments must have 

resources to allow extended observations or evaluations for up to 23 hours when 

clinically necessary. Observation beds offer an opportunity to further evaluate patients 

initially presenting in states of intoxication. This may be accomplished through 

observation beds in the emergency department or, when consistent with State and 

accreditation standards, through use of observation beds on inpatient units. 

We found that 54 percent of facilities with emergency departments had 

observation beds. Some facilities reported working toward implementation of this 

item. Some reported space as a notable barrier to implementation. One facility 

reported having had observation beds in the past, but converted the beds back to 

regular inpatient status because the patients in these beds were nearly uniformly 

admitted on subsequent evaluation. 

VA Office of Inspector General 7 
Implementation of VHA’s Uniform Mental Health Services Handbook 

Issue D: Inpatient Care 

According to the handbook, inpatient care must be available to all veterans who require 

hospital admissions for a mental disorder, either at the VA medical center where they 

usually receive care, a nearby VA, or by contract, sharing agreement, or non-VA feebasis referral to a community facility to the extent that the veteran is eligible. In addition, 

secured inpatient units in VA medical centers must be prepared when it is feasible to 

accept involuntary hospitalizations resulting from civil commitments for veterans for 

whom VHA provides health care services. 

From the structured interview, 79 percent of facilities reported providing inpatient 

mental health care onsite. Ninety-two percent of the facilities with inpatient units 

also admit involuntary patients. A few facilities with inpatient units that do not 

admit involuntary patients reported either having arrangements in place with other 

VA medical centers or private community facilities. At least one facility that does 

not admit involuntary patients and one facility that does not have an inpatient unit 

reported the de facto use of state facilities to provide for involuntary 

hospitalization. 

Issue E: Ambulatory Mental Health Care 

The handbook specifies that all new patients requesting or referred for mental health 

services must receive an initial evaluation within 24 hours and a more comprehensive 

diagnostic and treatment planning evaluation within 14 days. 

In FY09, the Office of Mental Health Services, within the Office of Patient Care 

Services (PCS), established expectations for timely access to mental health 

specialty care consistent with the goals of the mental health strategic plan and the 

handbook. Veterans defined as new to mental health are to have further evaluation 

and the initiation of mental health care within 15 days of an initial trigger 

encounter. Based on the PCS monitor, for February 2009, 96.7 percent of new 

patients were seen within the 15 day time frame. The monitor target is 

90 percent. The preliminary data for March 2009 indicate a range between VISNs 

of 89–98 percent. PCS and the Office of Quality and Performance state that they 

are collaborating to further develop and refine performance metrics (including 

formal Performance Measures for accountability, and monitors for ongoing 

tracking) to support system-wide goals. 

In order to enhance access to ambulatory mental health care, the handbook requires that 

clinics in medical centers must offer a full range of services during evening hours at least 

1 day per week. Additional morning, evening, or weekend hours need to be offered when 

required to meet the needs of a facility population. Evening hours may increase access 

for patients who work or attend college during usual business hours.

VA Office of Inspector General 8 
Implementation of VHA’s Uniform Mental Health Services Handbook 

In the OIG August–September 2008 mental health point of service inventory, we 

asked facilities if evening hours were available for at least one outpatient mental 

health clinic. Eighty-seven percent of the facilities reported having evening hours. 

Similarly we asked about weekend hours and 18 percent of facilities reported 

offering one or more outpatient Saturday or Sunday mental health clinics or 

groups. In the March 2009 structured interview we also asked if facilities provide 

evening or weekend onsite outpatient mental health services at least 1 day per 

week; 99 percent of facilities reported affirmatively. As an anecdotal trend, some 

facilities indicated that evening substance use programs seemed well attended but 

the turnout for evening PTSD clinics has been mixed. One mental health director 

reported that an evening OIF/OEF clinic at his facility initially had poor turnout 

for months but has become increasingly utilized. In terms of weekend hours, 

anecdotally a few respondents from facilities that have implemented weekend 

hours reported that younger patients have indicated the desire for weekend hours 

but the turnout has been poor. 

Issue F: Care Transitions 

As per the handbook, facilities must ensure continuity of care during transitions from one 

level of care to another. When veterans are discharged from inpatient or residential 

settings, they must be given appointments for follow-up at the time of discharge, receive 

information about how they can access mental health care on an emergency basis, and 

receive follow-up mental health evaluations at least by phone within 1 week of discharge 

and face-face within 2 weeks of discharge. 

From the structured interview, 97 percent of mental health directors of facilities 

with inpatient units reported giving patients mental health follow-up appointments 

at the time of discharge. A few facilities expressed the caveat that for unexpected 

discharges and discharges occurring during the weekend, this is not always 

possible. A few facilities reported having made wallet appointment cards which 

are given to patients along with the usual discharge paperwork. Of the facilities 

with inpatient units, 97 percent reported giving patients information about how to 

access mental health care on an emergency basis, including the number for the VA 

national suicide hotline. Some facilities also give patients cards with the suicide 

hotline number on it. 

Consistent with the handbook requirements for timely follow-up after discharge 

from a mental health inpatient unit, the VHA Office of Quality and Performance, 

Office of Patient Care Services, and Office of Mental Health Services introduced a 

new quality monitor for FY09. The monitor measures the percent of inpatient 

discharges that include at least a bed day of care in a mental health bed-section of 

care during which the patient received a face-to-face, telehealth, or telephone 

encounter within 7 days following the discharge date; and if the initial follow-up 

VA Office of Inspector General 9 
Implementation of VHA’s Uniform Mental Health Services Handbook 

encounter was by telephone, a face to face follow-up encounter must occur within 

14 days. VHA pulls the data for these measures from the VA National Patient 

Care Database Outpatient and Inpatient Workload files. In March 2008 prior to 

the handbook, 46 percent of total patient discharges were seen within 7 days. For 

February 2009, this increased to 57 percent. The monitor target is 85 percent. 

Issue G: Specialized PTSD Services 

Veterans with PTSD can be treated in specialized PTSD services, general mental health 

services, or primary care. The handbook requires that all VA medical centers have 

specialized outpatient PTSD programs, either a PTSD clinical team (PCT) or PTSD 

specialists based on locally determined patient population needs, and staff with training 

and expertise to serve the OIF/OEF veterans either through an OIF/OEF team or PTSD 

program staff. 

In the OIG point of service inventory, 80 percent of VA medical centers indicated 

having a PCT and 91 percent of respondents reported having a specialized clinic 

for patients with PTSD. In addition, 61 percent reported having an OIF/OEF 

PTSD specialty clinic. Some small facilities may have a single PTSD specialist 

available in general mental health clinic. 

From the structured interviews, mental health directors reported an OIF/OEF 

clinic with specialized mental health services at 65 percent of facilities. Even in 

the absence of a designated OIF/OEF clinic, 96 percent of facilities reported that 

they provide outpatient specialized PTSD services for OIF/OEF veterans. 

The handbook also states that all VISNs must have specialized residential or inpatient 

care programs to address the needs of veterans with severe symptoms and impairments 

related to PTSD and that each VISN must provide timely access to residential care 

services to address the needs of those veterans with severe conditions. 

Specialized inpatient PTSD programs are unusual, as most VA PTSD care was 

moved to a residential and outpatient basis. Mental health directors reported 

having a residential PTSD program or an inpatient PTSD program at 33 percent of 

facilities, excluding the stand alone facility in Columbus, Ohio, the Southeast 

Louisiana Veterans Hospital in New Orleans, and the medical center in Las Vegas 

which is presently in transition between locations. Of the facilities without a 

residential or inpatient PTSD program, 91 percent reported access to a program 

within the VISN (we counted as a positive response facilities in California that use 

another facility in California that is not within the VISN). Seventy-three percent 

reported the ability to reliably access the VISN program; some facilities reported 

VA Office of Inspector General 10 
 

 

 

 

 

Implementation of VHA’s Uniform Mental Health Services Handbook 

geographic distance to the VISN program and some reported that patients had to 

wait 4–8 weeks to start a program within the VISN.5 

The handbook specifies that all PTSD or specialist programs must be able to address the 

care needs of veterans with both PTSD and substance use disorders (SUD) by having 

either distinct PTSD dual diagnosis program tracks or tracks that include providers with 

specific expertise in both PTSD and SUD; or by putting in place formal mechanisms to 

support coordination of care for PTSD with that provided by SUD programs.6 

Mental health directors at 90 percent of facilities demonstrated efforts to address 

the care needs of veterans with concomitant PTSD and SUD and 76 percent 

described processes or mechanisms to support the coordination of care for PTSD 

with that provided in SUD programs. Several facilities have hired or are in the 

process of hiring a PTSD-SUD psychologist to spearhead efforts to bolster and 

coordinate PTSD-SUD care. 

Although not a handbook requirement, in the OIG web based point of service inventory, 

48 percent of facilities reported providing Seeking Safety/Seeking Strength groups. 

Seeking Safety is a specific form of therapy aimed at helping patients with co-morbid 

PTSD and SUD issues. 

Issue H: Substance Use Disorders 

The handbook notes that services addressing substance use conditions can be provided in 

VA facilities in SUD specialty care, primary care, programs integrating treatment for 

co-occurring mental health disorders and SUD, and other medical care settings. 

Regardless of setting, care must recognize the principle that SUDs are, in most cases, 

chronic or episodic, and recurrent conditions that require ongoing care. 

For SUD treatment reluctant patients, the handbook indicates that motivational 

counseling needs to be available to patients in all settings who need it to support the 

initiation of treatment. When patients are appropriate for admission and willing to be 

admitted to inpatient or residential treatment settings for SUD related conditions, but 

admission is not immediately available, interim services must be provided to ensure 

patient safety and promote treatment engagement. 

Motivational enhancement therapy is an empirically based psychosocial 

intervention that is more rigorous than motivational counseling. In the web based 

point of service inventory, 76 percent of facility respondents reported that they 

5

 Monitoring and evaluation of a patient with PTSD related issues who was awaiting treatment at a VA residential 

program was explored in a May 2007 OIG Report: Healthcare Inspection, Review of the Care and Death of a 

Veteran Patient, VA Medical Centers St. Cloud and Minneapolis, Minnesota, No. 07-01349-127, 5/10/2007. 6

 The import of concomitant and coordinated care for patients with PTSD and SUD was highlighted in OIG 

testimony in front of a May 6, 2008, Committee on Veterans’ Affairs, U.S. House of Representatives hearing. 

VA Office of Inspector General 11 
Implementation of VHA’s Uniform Mental Health Services Handbook 

provided some form of motivational enhancement therapy for patients with SUD 

who delay or resist treatment. 

From the structured interview, 16 percent of facilities reported no wait for patients 

starting residential SUD programs at their facility. For the remaining facilities 

with some wait, 94 percent reported providing treatment in the interim. 

The handbook also indicates that facilities must make medically-supervised withdrawal 

management available as needed, based on a systematic assessment of the symptoms and 

risks of serious adverse consequences related to the withdrawal process. Withdrawal 

management may take place at a VA facility, by referral to another VA medical center, or 

by a contract or fee-basis arrangement. 

Ninety-five percent of facility mental health directors reported that inpatient 

withdrawal management was available to their patients either on the medical unit, 

mental health unit, through referral to a nearby VA medical center, or through a 

non-VA arrangement. Several directors reported follow-up via transfer to a 

residential, mental health inpatient, or intensive outpatient treatment program 

(IOP) at discharge. 

The handbook specifies the provision of intensive outpatient services for SUD. Such 

programs must be at least 3 hours per day and at least 3 days per week. The nature of 

SUD related conditions including the risk for relapse and the frequent co-morbidity of 

other mental health conditions underscores the importance of available intensive 

outpatient services for SUD. 

From the web based point of service inventory in late 2008, 62 percent of facilities 

reported having intensive outpatient services available for patients with SUD. By 

the time of the structured interview in March 2009, 71 percent of facilities 

reported having these services. Some facilities reported that for patients who live 

a considerable distance from the facility, temporary housing is arranged to 

facilitate participation in the program. 

The handbook requires that a monitored pharmacotherapy program with approved, 

appropriately-regulated opioid agonists (e.g., buprenorphine, methadone) be an available 

option for appropriate patients diagnosed with opioid dependence for whom there are no 

medical contraindications. 

Approximately half of facility respondents to the web based point of service 

inventory indicated that an opiate substitution program was available at the 

medical center. Outpatient buprenorphine agonist therapy was available at 

38 percent of medical centers and outpatient methadone maintenance was 

available at 20 percent of sites. Some medical centers have both available. In 

VA Office of Inspector General 12 
Implementation of VHA’s Uniform Mental Health Services Handbook 

addition, some provide these services within a residential program which was not 

captured in this data. 

Issue I: Seriously Mentally Ill and Rehabilitation and 

Recovery Services 

The handbook states that based upon the evidence for the effectiveness of Assertive 

Community Treatment services as modified for use in the VA, Mental Health Intensive 

Case Management (MHICM) programs must be available to patients at all facilities with 

more than 1,500 patients on the Serious Mental Illness Research and Evaluation Center 

(SMITREC) psychosis registry. At least four full-time “on the street” employees are 

needed for each MHICM team. “On the street” staff are those who are nonadministrative and are out seeing patients in the community. 

MHICM is an intensive interdisciplinary, coordinated team approach to management of 

patients with severe mental illness, primarily psychosis. MHICM differs from usual case 

management in that clinician-patient interactions occur primarily in the community rather 

than in the office, a higher clinician to patient ratio, around the clock fixed responsibility 

over time for the team assigned to a patient, and multiple patient visits per week if 

needed. 

We compared the data list from SMITREC of parent facilities with more than 

1,500 seriously mentally ill (SMI) veterans based on the FY07 National Psychosis 

Registry with NEPEC data indicating staffing and caseload for sites with MHICM 

teams. We found that all 61 parent facilities with more than 1,500 SMI veterans 

had MHICM teams. In addition, there were 50 additional MHICM teams at 

several sites with less than 1,500 SMI veterans and some sites have more than one 

MHICM team. 

We inspected filled clinical FTE data for December 2008 from NEPEC’s MHICM 

monthly FTE Caseload Report. Of the 111 programs, there were 24 with less than 

4 “on the street” FTE. For the 61 parent facilities with more than 1,500 SMI 

patients, 7 had less than 4 “on the street” FTE. 

The handbook directs each medical center to maintain the Local Recovery Coordinator 

Position first authorized in FY07 to help transform local VA mental health services to a 

recovery-oriented model. The Local Recovery Coordinator’s responsibilities include 

leading the integration of recovery principles into all mental health services, promoting 

activities to eliminate stigma, providing training and consultation to staff, veterans, and 

family members, and being directly involved in the provision of recovery-oriented 

clinical services. 

VA Office of Inspector General 13 
Implementation of VHA’s Uniform Mental Health Services Handbook 

Ninety-three percent of mental health directors reported that a local recovery 

coordinator was in place at their facility. 

According to the handbook, medical centers with more than 1,500 SMI patients on the 

National Psychosis Registry must have a Psychosocial Rehabilitation and Recovery 

Center (PRRC). These programs are ambulatory, non-residential day treatment programs 

aimed at providing a therapeutic and supportive learning environment to facilitate 

maximization of function. PRRCs provide a menu of daily treatment programming 

alternatives from which patients can choose to assist in their attainment of treatment 

goals. PRRC programs must provide an array of services including individual 

psychotherapy, social skills training, illness management and recovery groups, peer 

support services, and family educational programs, among others. 

Mental health directors reported having a PRRC in place at 51 percent of the 

medical centers with more than 1,500 SMI patients. 

The handbook specifies that Social Skills training, an evidence-based psychosocial 

intervention aimed at enhancing social functioning in patients affected by SMI and 

individual or group peer counseling from peer support technicians must be provided 

when clinically indicated at all medical centers. In addition, compensated work therapy 

with transitional work experience and supported employment services must be offered. 

VHA recently began a rollout of system-wide provider training in the delivery of 

formal, evidence-based Social Skills training. In the interim, mental health 

directors reported providing a more general form of Social Skills training at 

74 percent of medical centers. SMI peer counseling was in place at 60 percent of 

facilities and CWT at 90 percent. 

Issue J: Homeless Programs and Incarcerated Veterans 

The handbook indicates that each facility must develop and maintain collaborative formal 

or informal agreements with community providers for shelter, temporary housing, or 

basic emergency services. Also, each VA medical center with an estimated 100 or more 

homeless veterans in their primary service area must have one Grant and Per Diem 

Program or alternative residential care setting for homeless veterans. 

Ninety-three percent of mental health directors interviewed reported having 

collaborative agreements in place with community providers for homeless 

veterans. Although not required, 52 percent of the facilities with agreements 

reported having at least one written agreement. 

We also found that without taking into consideration (eliminating) facilities with 

less than an estimated 100 homeless veterans in the primary service area, 

VA Office of Inspector General 14 
Implementation of VHA’s Uniform Mental Health Services Handbook 

87 percent of facilities reported having a Grant and Per Diem arrangement in 

place. 

A full-time VISN Health Care for Reentry Veterans Specialist (HCRV Specialist) to 

support veterans being released from prisons is mandated by the handbook. The HCRV 

Specialist is to work with point of contacts to engage with veterans being released from 

prison who are in need of mental health care. 

We obtained monthly HCRV Specialist position tracking data (filled, date filled, 

mental health discipline etc) from the Office of Mental Health Services. As of the 

end of January 2009, 20 of 21 VISNs had filled the open HVCR positions with full 

time social workers. The remaining VISN filled the HVCR position with a Health 

Science Specialist and is advertizing for a social worker to be a HVCR specialist 

also. In addition, 15 VISNs had a supplemental HCRV Specialist in place at a 

second site. 

Issue K: Integrating Mental Health into Medical Care Settings 

and in the Care of Older Veterans 

As per the handbook, VA medical centers must have integrated mental health services 

that operate in primary care clinics on a full-time basis. The services need to utilize a 

blend of co-located collaborative care and care management. Integration of mental health 

services in primary care clinics directly facilitates access for patients and indirectly by 

reducing stigma and supporting the New Freedom Commission and MHSP goal of 

helping patients understand that mental health is an essential component to overall health. 

Seventy-eight percent of mental health directors reported the presence of 

integrated mental health services at primary care clinics. 

VA Community Living Centers (CLCs), previously known as Nursing Home Care Units, 

are required to have integrated mental health services, including at minimum 1 FTE 

psychologist, to provide services (cognitive testing, psychological assessment and 

treatment) for facilities with at least 100 beds. The handbook also specifies that each VA 

Home-Based Primary Care (HBPC) team must have a full-time psychologist or 

psychiatrist as a core member of the team. 

Slightly more than 45 percent of facilities do not have either a CLC or one that is bigger 

than 100 beds. Of the sites with a CLC to which the requirement applies, two-thirds met 

the requirement at the time of the interview. From the structured interview, 81 percent of 

facilities reported having a full-time psychologist or psychiatrist as a core member of the 

HBPC team. 

VA Office of Inspector General 15 
 

 

 

Implementation of VHA’s Uniform Mental Health Services Handbook 

Issue L: Suicide Prevention 

Suicide prevention and VHA’s implementation of suicide prevention related items from 

the mental health strategic plan are discussed in detail in a May 2007 OIG report.7 

According to the handbook, all patients on inpatient units must be evaluated as clinically 

indicated for warning signs of self-destructive and dangerous behaviors, including risks 

of suicide and violence. 

As expected, all facilities with inpatient units reported evaluating for risks of 

suicide. To explore the issue of evaluation for suicide risk further, we asked how 

many both completed and documented a formal, multifactor risk assessment on 

admission, to which 95 percent responded affirmatively. Several mental health 

directors reported the use of templates, some of which were being used by 

facilities in their VISN or are used at other VA facilities. Some referenced a 

template documented in the admission nursing assessment. Although VHA 

clinicians have developed some formalized risk assessment templates, health care 

evaluations research is ongoing. At present there is not a uniform, standard “best 

practices” VHA suicide risk assessment template in use throughout the system.8 

As discussed in the scope of this report, during onsite visits for OIG CAP reviews, 

OIG inspectors have been conducting a focused, chart based review of 

implementation of suicide prevention related items from the handbook. These 

chart based reviews began in January 2009 and are scheduled to run through June 

2009. 

Because most suicide prevention related elements in the handbook are linked to 

the functions of facility suicide prevention coordinators (SPCs), we obtained 

monthly SPC position tracking data (filled, date filled, mental health discipline, 

etc.) from the Office of Mental Health Services. As of the end of January 2009, 

146 of 154 positions were filled; 1 facility was awaiting human resources 

processing, 4 were interviewing applicants, 2 were recruiting, and 1 had recently 

posted the position. 

7

 VAOIG Report: Healthcare Inspection, Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide 

Prevention, No. 06-03706-126, 5/10/2007. 8

 A July 2007 OIG report reviewed a suicide that occurred on a VA inpatient unit. OIG Report: Healthcare 

Inspection, Patient Suicide, VAMC Augusta, Georgia, No. 07-00561-167, 7/11/2007.
 

VA Office of Inspector General 16 
Implementation of VHA’s Uniform Mental Health Services Handbook 

Issue M: Uniformity of PTSD Diagnosis and Evidence-Based 

Treatments 

We were asked to review the uniformity of compliance with VHA policies regarding the 

identification and treatment of post-traumatic stress disorder (PTSD). Initially, we 

obtained data on unique patient encounters with a primary diagnosis of PTSD for all 

unique patient encounters at medical centers and affiliated very large CBOCs (greater 

than 10,000 annual visits) within each VISN. Figure 1 depicts the percentage of unique 

patients with a primary encounter diagnosis of PTSD, by VISN, seen as a percentage of 

all unique patients seen at facilities with greater than 10,000 annual encounters. VISN 

percentages ranged from 4 to 8.8 percent of unique patients seen. 

Figure 1. Patients with a primary encounter diagnosis of PTSD, by VISN, as a 

percentage of all patients seen at facilities with greater than 10,000 annual encounters. 

To explore this issue further, we looked at data pertaining to PTSD clinic stop codes. 

These are clinics or programs that largely serve patients with PTSD and at which we 

would expect a high concentration of patients with a PTSD diagnosis. Figure 2 depicts 

patients with a primary encounter diagnosis of PTSD at clinics with PTSD stop codes, by 

VISN, as a percentage of all patients seen at clinics with PTSD stop codes, for facilities 

with greater than 10,000 annual encounters. 

VA Office of Inspector General 17 
 

 

Implementation of VHA’s Uniform Mental Health Services Handbook 

Figure 2. Patients with a primary encounter diagnosis of PTSD at clinics with PTSD 

stop codes, by VISN, as a percentage of all patients seen at clinics with PTSD stop 

codes, for facilities with greater than 10,000 annual encounters. 

Among VISNs the percentage of unique encounters with a primary diagnosis of PTSD 

ranged from 71–88 percent. In a recent OIG report, we reviewed multiple charts from a 

facility’s PCT clinic. We found that most patients had more than one diagnosis from 

encounter to encounter. In addition, although most unique patients seen in the PCT clinic 

had a diagnosis of PTSD, not all patients had this diagnosis. Some patients had clinical 

presentations and encounter diagnoses consistent with major depression, adjustment 

disorders, generalized anxiety disorder, and other non-PTSD anxiety disorders.9 

There are a few important considerations to keep in mind when interpreting the PTSD 

diagnosis proportions. It is expected that there is some underlying variation across 

VISNs in terms of what patients are treated for and their propensity for a PTSD 

diagnosis. This is likely to be a function of differences in age distribution, gender, and 

service era, among other major factors. Thus, proportions of patients seen for a PTSD 

diagnosis are likely to vary as a result of a range of factors, and are not exclusively a 

function of differences in diagnostic consistency among mental health providers. The 

analysis is subject to and limited by confounding factors, and interpretation of PTSD 

9 Healthcare Inspection, Allegations of Mental Health Diagnosis Irregularities at the Olin E. Teague VA Medical 

Center, Temple Texas, No. 08-02089-59, 1/28/2009. 

VA Office of Inspector General 18 
 

 

Implementation of VHA’s Uniform Mental Health Services Handbook 

diagnosis proportions should be conducted in the context of underlying variability in the 

patient populations. 

A section of the handbook addresses access to specific evidence-based psychotherapies 

and somatic therapies. It should be noted however, that attention to evidence-based care 

is present throughout the handbook. The handbook states that all veterans with PTSD 

must have access to Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) 

and medical centers must provide adequate staff to allow the delivery of evidence-based 

psychotherapy when clinically indicated. Additionally, all veterans with depression must 

have access to Cognitive Behavioral Therapy (CBT), Acceptance and Commitment 

Therapy (ACT), or Interpersonal Therapy. 

The Office of Mental Health Services began a system-wide effort to train VA clinicians 

in core mental health disciplines in CPT in the summer of 2007 and in PE starting in the 

fall of 2007. System-wide training in CBT and ACT began in the summer of 2008. The 

Office of Mental Health Services has also begun a formalized system-wide training for 

social skills therapy. Although mental health clinicians have often been trained in some 

of the therapies like CBT during their doctoral education or post-doctoral residency 

training, and may use these therapies in their practices, the Office of Mental Health 

Service’s intent is to provide a more comprehensive training and to promote fidelity to 

principles and delivery of specific evidence-based psychotherapies. The first step in the 

training process entails provider participation in experientially based workshops. The 

second step in the process involves weekly phone consultation with training consultants 

who are experts in that therapy. 

CPT can be delivered in a group or individual format and PE therapy on an 

individual basis. In the web based point of service inventory, 89 percent and 63 

percent of respondent facilities reported that CPT and PE were available for 

patients with stress related disorders. 

Evidence-based PTSD therapies are relatively time and labor intensive. For example PE 

sessions may last 90 minutes, and CPT and PE require regular session visits for multiple 

weeks. At a given facility, factors limiting provision and/or utilization of available 

evidence-based PTSD therapies may include the number of providers with at least step 1 

training; availability of provider time, especially at medical centers in areas where there 

is a high concentration of returning OIF/OEF veterans; geographic distance to care, 

availability of mental health providers in rural areas, and patient preference (some 

patients may opt for other treatment choices.)10 

10 Evidence-based PTSD therapy is discussed further in an August, 2008 OIG report: Healthcare Inspection PostTraumatic Stress Disorder Program Issues, VA San Diego Healthcare System, San Diego California, 

No. 08-01297-187, 8/26/2008. In this report, we commented on the need for the medical center to develop a 

mechanism to track whether returning OIF/OEF veterans are being offered and provided evidence-based PTSD 

VA Office of Inspector General 19 
 

Implementation of VHA’s Uniform Mental Health Services Handbook 

At present we are unaware of a system by which VHA reliably tracks provision and 

utilization of these therapies on a national level. We are aware of at least one residential 

PTSD program that enters a special progress note template into the electronic medical 

record that denotes the type of PTSD therapy provided and the session number for each 

visit. Development of a national system to track provision of evidence-based PTSD 

therapies and utilization by returning veterans (via template electronic note, special stop 

code, or other mechanism) would allow for a population based assessment of treatment 

outcomes with implications for the treatment of other veterans presenting for PTSD 

related care.11 

Conclusions: 

The President’s New Freedom Commission Report laid the conceptual groundwork for 

the transformation of Mental Health Care in America. The 2004 VHA Mental Health 

Strategic Plan adopted the goals and strategies of the New Freedom Commission Report, 

adapted these to the VA system, and developed over 200 related initiatives. Handbook 

1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics attempts to 

further translate the New Freedom Commission Goals and MHSP initiatives into an 

operational, point of service, programmatic package of approximately 400 mental health 

services provided or available to eligible veterans at VA medical centers and CBOCs of 

varying size. 

Given the dimension of the handbook, a comprehensive review of the extent of 

implementation is challenging. We limited the scope of our review to the medical center 

level. In addition, we chose selected items from the handbook to evaluate for 

implementation. For each section, there may be items that were not chosen for which the 

extent of implementation is greater or less. In addition, implementation of the handbook 

is a dynamic and ongoing process during FY09 and the data presented in the findings do 

not capture partial implementation. We believe the items chosen reasonably estimate the 

present extent of handbook implementation at the medical center level at this time. 

The following table summarizes our system-wide findings regarding the level of 

implementation of handbook items at the medical center level: 

therapies, whether they opt for treatment with these therapies, how many sessions are utilized by returning veterans, 

and whether those who start evidence-based therapies complete them. 11 A recent OIG report: Healthcare Inspection, Access to VA Mental Health Care for Montana Veterans, 

No. 08-00069-102, 3/31/2009, reviews the provision of general mental health treatment, substance use treatment, 

and evidence-based PTSD therapies to veterans in a large rural state. 

VA Office of Inspector General 20 
Implementation of VHA’s Uniform Mental Health Services Handbook 

VHA Mental Health Services Extent of 

Implementation 

(%) 

Community Mental Health 

Collaboration with Vet Centers for Outreach 87 

Gender-Specific Care and MST 

Separate and Secure Sleeping and Bathroom 97 

Tracking of MST Treatment 82 

Availability of evidence-based care for MST 96 

24 Hours a Day, 7 Days a Week (24/7) 

Care 

24/7 ED On-Call MH Coverage 98 

Urgent Care On-Call Coverage 100 

Availability of 23 Hour Observation Beds 54 

Inpatient Care 

Onsite Inpatient Care 

Ability to Admit Involuntary Patients 

79 

92 

Ambulatory Mental Health Care 

Follow-Up for new MH Patients 

Evening MH Clinic Hours 

97 

99 

Care Transitions 

Set MH Appointment Provided at Discharge 

Seen for Follow-Up within 1 Week Post- Discharge 

97 

57 

Specialized PTSD Services 

PCT or Specialized Clinic for Patients with PTSD 91 

OIF/OEF Outpatient Clinic Specialized MH Clinic 65 

(or) Specialized PTSD Services for OIF/OEF 96 

Access to a VISN Specialized PTSD Program 91 

Ability to Reliably Access the VISN Program 73 

Efforts to Address Concomitant PTSD and SUD 90 

Coordination of PTSD and SUD Care 76 

Substance Use Disorders 

Available Motivational Counseling 

Treatment of Patients Awaiting Admission to 

76 

Residential SUD Settings 94 

Inpatient Withdrawal Management 95 

Intensive Outpatient Services for SUD 71 

Buprenorphine Opioid Agonist Therapy 38 

(or) Methadone Opiate Substitution Therapy 20 

VA Office of Inspector General 21 
Implementation of VHA’s Uniform Mental Health Services Handbook 

SMI and Rehabilitation and Recovery 

Oriented Services 

MHICM Program if More than 1,500 SMI Patients 100 

At Least 4 FTE MHICM Team Members 88 

Presence of a Local Recovery Coordinator 93 

PRRC Program if More than 1,500 SMI Patients 51 

Social Skills Training 74 

SMI Peer Counseling 60 

Compensated Work Therapy 90 

Homeless Programs and Incarcerated 

Vets 

Arrangements with Community Providers for 

Temporary Housing 93 

At Least One Grant and Per Diem Arrangement 87 

VISN Health Care for Reentry Veterans Specialist 95 

Integrating Mental Health into Medical 

Care Settings and in the Care of Older 

Vets 

Integrated MH in Primary Care Clinics 78 

At least 1 FTE Psychologist for 100 Bed CLC 

FT Psychologist /Psychiatrist HBPC Core Team 

67 

Member 81 

Suicide Prevention 

Documentation of a Formal Risk Assessment 

Suicide Prevention Coordinator in Place 

95 

95 

Evidence Based Treatment 

Availability of CPT for PTSD 

Availability of PE for PTSD 

89 

63 

We would anticipate the extent of implementation at medical centers to exceed that seen 

at the CBOC level. Smaller and rural CBOCs may face obstacles to implementation 

including geographic distance to care and ability to recruit mental health providers, 

among others. 

We found that some facilities were unclear as to facility level status and therefore were 

unclear whether onsite emergency department requirements have been met. 

At present we are unaware of a system by which VHA reliably tracks provision and 

utilization of evidence-based PTSD therapies on a national level. Development of a 

national system to track provision of evidence-based PTSD therapies and utilization by 

VA Office of Inspector General 22 
Implementation of VHA’s Uniform Mental Health Services Handbook 

returning veterans would allow for a population based assessment of treatment outcomes 

with implications for the treatment of other veterans presenting for PTSD related care. 

The handbook is an ambitious effort to enhance the availability, provision, and 

coordination of mental health services to veterans. The handbook notes that metrics will 

be used to ensure implementation of requirements. Program evaluation and development 

of mental health outcome measures can be challenging. As implementation further 

progresses, VHA should develop metrics and outcome measures where feasible to allow 

for dynamic refinement of program requirements in order to meet changes in mental 

health needs and care utilization patterns of veterans. 

This inspection reports on the system-wide implementation status of VHA Handbook 

1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics. Because 

facilities have until the end of FY09 to fully meet the handbook requirements, we made 

no recommendations at this time. 

VA Office of Inspector General 23 
Implementation of VHA’s Uniform Mental Health Services Handbook 

Department of 

Veterans Affairs Memorandum 

Date:	 April 6, 2009 

From:	 Under Secretary for Health (10) 

Subject: OIG Draft Report, Implementation of VHA’s Uniform Mental 

Health Services Handbook, Project No. 2008-02917-HI-0179 

(WebCIMS 426570) 

To:	 Assistant Inspector General for Healthcare Inspections (54) 

1. I have reviewed the draft report, and I appreciate the thoughtful review of 

VHA's progress in implementing the Uniform Mental Health Services 

Handbook. I concur with the draft report and agree on the importance of the 

Handbook in ensuring that the initiatives outlined in the VHA Mental Health 

Strategic Plan are translated into providing the necessary comprehensive, 

evidence-based mental health services for our Nation's Veterans. 

2. Considering that VHA facilities have until the end of Fiscal Year (FY) 2009 to 

implement the handbook's requirements, I am generally encouraged by our 

progress as reported in your draft report. While acknowledging that VHA still 

needs to improve implementation in certain areas and ensure implementation 

of the Handbook at community-based outpatient clinics as well, I am optimistic 

about forecasts for full implementation. 

3. In regards to the report's finding that VHA lacks a system that reliably tracks 

provision and utilization of evidence-based post-traumatic stress disorder 

(PTSD) therapies on a national level, I want to emphasize that, currently, there 

is no standard mechanism for doing this in any health care system. 

Nonetheless, VA is taking actions at multiple levels to promote the 

dissemination of evidence-based psychotherapies (EBPs) throughout VHA, and 

I strongly agree with the report's conclusion on the importance of tracking the 

provision and utilization of EBPs. 

4. VHA is developing specific mechanisms to track the utilization and delivery 

of EBPs for PTSD and other mental disorders. Chief among these efforts is the 

development of EBP templates for different evidence-based therapies that will 

be input into the electronic medical record system. Clinicians will use the 

VA Office of Inspector General 24 
 

Implementation of VHA’s Uniform Mental Health Services Handbook 

Page 2 

OIG Draft Report, Implementation of VHA’s Uniform Mental Health Services 

Handbook, Project No. 2008-02917-HI-0179 (WebCIMS 426570) 

templates to enter progress notes when one of the EBPs is delivered, and the 

templates will mark the service being delivered as an EBP service. 

Additionally, the templates also provide a heuristic device to help guide clinical 

decision making for the clinician. Full availability of the templates at all sites is 

targeted for completion by the end of FY 2009. Moreover, VHA has placed a 

Local EBP Coordinator at each medical center that will facilitate the 

implementation of evidence-based psychotherapies at the local level. The 

Local EBP Coordinators will help to implement and track the use of these 

templates. In addition to the development of the EBP templates, VHA has 

initiated a survey process to track the availability and delivery of EBPs. 

5. I also agree with your report's statement that as implementation of the 

handbook progresses, VHA needs to further develop metrics and outcome 

measures where feasible to allow for program evaluation and dynamic 

refinement of program requirements. As your report mentions, VHA has 

multiple performance measures already in place related to implementation of 

the Uniform Mental Health Services Handbook. In addition to those you 

reviewed for the report, another relevant measure that VHA currently utilizes is 

an extensive check list capturing program coverage at all facilities and 

community-based outpatient clinics. This checklist was developed by the Office 

of Mental Health Services (OMHS) to provide formative evaluation for use in an 

extensive process of providing technical assistance to the Veterans Integrated 

Service Networks regarding implementation of the handbook. This checklist 

also will be used to monitor ongoing progress in implementation. Lastly, OMHS 

is currently working to develop additional measures to provide summative 

evaluation. 

6. In closing, my staff has informed me that they have already discussed and 

resolved certain issues with members of your review team. Thank you for the 

opportunity to review this report and your willingness to collaborate with my 

staff to ensure that the final report is accurate and clear. If you have any 

questions, please contact Margaret Seleski, Director, Management Review 

Service (10B5) at (202) 461-8470. 

 (original signed by:) 

Michael J. Kussman, MD, MS, MACP 

VA Office of Inspector General 25 
 

 

Implementation of VHA’s Uniform Mental Health Services Handbook 

Appendix A 

OIG Contact and Staff Acknowledgments 

OIG Contact Michael L. Shepherd, M.D. 

Senior Physician 

202 461-4705 

Acknowledgments Katherine Owens 

Audrey Collins-Mack 

Marnette Dhooghe 

Donna Giroux 

David Griffith 

Jeff Joppie 

Jeanne Martin 

Tishanna McCutchen 

Rayda Nadal 

Prabu Selvam 

Christa Sisterhen 

Roberta Thompson 

VA Office of Inspector General 26 
 

Implementation of VHA’s Uniform Mental Health Services Handbook 

Appendix B 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 27