Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Access to VA Mental Health Care for
 

Montana Veterans 

Report No. 08-00069-102 March 31, 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 
                 

           

Access to VA Mental Health Care for Montana Veterans

Contents 

Page 

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

I. Introduction .....................................................................................................1 

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

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

A. Access to Mental Health Care in Rural Areas ......................................................... 2 

B. Montana Demographics ........................................................................................... 2
 

C. VA Provided Care .................................................................................................... 3 

1. VAMHS Mental Health Care ............................................................................... 3
 

2. VAMHS Telemental Health................................................................................. 3
 

D. VA Paid Care ........................................................................................................... 4 

1. Contract Mental Health Care................................................................................ 4
 

2. Fee-Basis Mental Health Care.............................................................................. 5
 

E. Mental Health Care Available to Montana Veterans at VA Facilities in 

Neighboring States......................................................................................................... 5
 

F. VA Mental Health Care to American Indian Reservations in Montana................... 6
 

Scope and Methodology .......................................................................................7 

A. Interviews and Document Review ........................................................................... 7
 

B. Analytic Methodology.............................................................................................. 8
 

1. Study Population .................................................................................................. 8
 

2. Percentage Service-Connected Disability Ratings............................................... 8
 

3. Geo-Processing Montana Mental Health Providers and Veterans..................... 10
 

4. VA and DoD Treatment Information and Vital Status ...................................... 12
 

5. Statistical Analyses............................................................................................. 13
 

II. Results and Conclusions ............................................................................. 14 

Issue 1. Montana Veteran Characteristics and Geographic Access to Mental 

Health Care .................................................................................................................. 14
 

1. Characteristics of the Montana Veteran Population........................................... 18
 

2. Distribution of Disease Diagnostic Categories and Mental Disorder 

Diagnoses ............................................................................................................... 22
 

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Access to VA Mental Health Care for Montana Veterans

3. Characteristics of VA Users and Non-VA Users ............................................... 26 

4. Representativeness of Montana Veterans Included in the Access to Care 

Analyses ................................................................................................................ 30
 

5. Geographic Access to Mental Health Care in Montana..................................... 30
 

6. Travel Times and Utilization of VA Care in Montana....................................... 39
 

7. Impact of VA Paid Service on Geographic Access to Mental Health Care in 

Montana.................................................................................................................. 40
 

Conclusions for Issue 1 – Montana Veteran Characteristics and Geographic 

Conclusions for Issue 2 – Other VAMHS Specialized Mental Health Care 

Access to Mental Health Care ................................................................................ 45
 

Issue 2. Other VAMHS Specialized Mental Health Care Issues................................ 46
 

Issues ...................................................................................................................... 48
 

Issue 3. The Vet to Vet Program in Montana ............................................................. 48 

Conclusions for Issue 3 – The Vet to Vet Program in Montana ............................ 50 

Conclusions.................................................................................................................. 50
 

Recommendations........................................................................................................ 51 

Appendixes 

A. Contract and Fee-Basis Mental Health Sites and Locations of American Indian 

Reservations................................................................................................................... 52
 

B. ICD-9 CM Disease Categories................................................................................. 54
 

C. ICD-9 CM Mental Disorders (290–319).................................................................. 55
 

D. V-Codes Indicating a Psychosocial or Behavioral Problem.................................... 57
 

E. Under Secretary for Health Comments .................................................................... 61
 

F. VISN Director Comments ........................................................................................ 63
 

G. OIG Contact and Staff Acknowledgments .............................................................. 66
 

H. Report Distribution .................................................................................................. 67
 

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Access to VA Mental Health Care for Montana Veterans

Executive Summary 

Introduction 

In January 2008, U.S. Senator Jon Tester and U.S. Senator Max Baucus requested the VA 

Office of Inspector General (OIG) review the quality and availability of mental health 

services at Veterans Health Administration (VHA) facilities in Montana. It was decided 

that OIG would analyze: the access to VA provided and VA purchased mental health 

care in Montana by Montana veterans and the impact of peer-to-peer counseling 

programs. The availability of mental health providers, a geographically large area, and 

population dispersion are factors that pose challenges for Montana’s veterans in need of 

mental health services. 

The VA Montana Healthcare System (VAMHS) includes a 50-bed acute care, medicalsurgical facility at the main campus at Fort Harrison (Helena) and 12 community based 

outpatient clinics (CBOCs). Veterans Readjustment Counseling Centers (Vet Centers) 

are located in Billings and Missoula, and a 30-bed Community Living Center (nursing 

home) provides general and ventilator dependent care is located in Miles City. Acute 

inpatient psychiatric care and residential mental health treatment is provided at VA 

facilities in Sheridan, Wyoming, or Salt Lake City, Utah, or at a local community 

hospital. Outpatient VA mental health providers are available onsite at Fort Harrison and 

at 5 of the 12 CBOCs. VA telemental health is available at Fort Harrison and most VA 

CBOCs. Starting in 2001, VAMHS has contracted for mental health services with 

Montana’s regional community mental health centers; veterans are seen by mental health 

providers at 45 sites. In addition, VAMHS utilizes the services of 27 non-VA private 

mental health therapists on fee basis. Some veterans living close to the border of 

neighboring states receive VA mental health care at sites outside Montana. 

We used all Montana veterans in the LC database1

 for this review, with data updated 

through the end of fiscal year (FY) 2008. This review analyzed access in terms of travel 

time. We utilized geo-coding, that is the geographic coordinates of latitude and 

longitude. We geo-coded all VHA mental health care service providers and providers 

under VHA paid service; these were further categorized by whether they provided 

medications only, therapy only, or both medications and therapy. In addition, we 

identified all Montana veterans in the LC database for geo-coding, whether or not they 

are enrolled with VHA. We constructed travel time bands for each service provider’s 

physical service location. We determined veteran travel times from their home address to 

providers’ locations and considering the types of mental health services needed. 

1 Quantitative Assessment of Care Transition: The Population-Based LC Database, VAOIG report number 

07-00380-202, issued 9/13/2007, http://www.va.gov/oig/54/reports/VAOIG-07-00380-202.pdf 

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Results 

Over 82 percent of this veteran population had access to VHA providers and providers 

under VHA paid service offering at least medication management or therapy within 

15 minutes of travel. Access to a provider with half an hour of travel increased this to 

95 percent of the population. Almost all have access to a provider within an hour of 

travel. 

Over 70 percent of the population had access within 15 minutes of travel to a provider 

with both medications and therapy services, and over 88 percent had access within one 

hour. The marked exception was non-Operation Iraqi Freedom/Operation Enduring 

Freedom (OIF/OEF) reserve component veterans; 12 percent of them had to travel over 

an hour and 4 percent had to travel over 2 hours. 

The data set used permits analysis by demographic factors, medical treatment with 

Department of Defense and VA, VBA benefit status, and OIF/OEF participation. Our 

data show that in both the Montana and non-Montana LC population, alcohol and drug 

use were common mental health diagnoses, in addition to PTSD and related mental health 

disorders. At present, access to specialty substance use therapy is limited. 

We reviewed the Vet to Vet program in Montana. There was not sufficient data to 

analyze utilization or impact of such groups. However, it is reasonable for VAMHS to 

encourage further efforts at forming affiliated OIF/OEF-specific Vet to Vet groups as part 

of their ongoing, comprehensive outreach effort, including Vet Center outreach and VHA 

partnerships with community mental health organizations, non-VA providers, veterans 

groups, and the Montana National Guard. 

Recommendations 

Recommendation 1: We recommended that the VISN 19 Director ensure that the 

VAMHS Director takes steps to increase the availability of evidence-based treatment for 

PTSD for Montana veterans. 

Recommendation 2: We recommended that the VISN 19 Director ensure that the 

VAMHS Director takes steps to increase the availability of specialty substance use 

treatment for Montana veterans. 

Comments 

The Under Secretary for Health and VISN 19 Director concurred with our findings, and 

the VISN submitted appropriate implementation plans. (See Appendixes E and F, pages 

61–65 for the full text of their comments.) 

The VISN reports that an Evidence-Based Practice Coordinator has been hired to 

facilitate the implementation and expansion of evidence-based treatment (EBT) at VA 

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Montana Healthcare System. In addition, the VAMHS has sponsored EBT for contract 

and fee basis providers who serve Montana veterans. Also the newly proposed contract 

requires training in EBT. With regard to increasing the availability of specialty substance 

use treatment, the VA Montana Healthcare System has received additional VA positions 

for employees in an intensive outpatient program (IOP) of substance abuse services. 

They also report developing a contract agreement to provide IOP services and residential 

support. We will follow up on all planned actions until they are completed.

 (original signed by:)

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

 Assistant Inspector General for 

 Healthcare Inspections
 

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Access to VA Mental Health Care for Montana Veterans

Part I. Introduction 

Purpose 

On January 17, 2008, U.S. Senator Jon Tester and U.S. Senator Max Baucus requested 

the VA Office of Inspector General (OIG) review the quality and availability of mental 

health services at Veterans Health Administration (VHA) facilities in Montana. After 

further discussion in April 2008, it was decided that OIG Office of Healthcare 

Inspections would analyze: the impact of distance from mental health services on 

enrollment in VA mental health programs in Montana; the degree to which contracted 

mental health services for post-traumatic stress disorder (PTSD), depression, and 

substance use could be expanded to improve veteran access to mental health services; and 

the degree to which peer-to-peer counseling programs, such as the Vet to Vet program, 

help the VA reach out to veterans who are not enrolled in the VA but are in need of 

mental health services. 

Background 

The VA Montana Healthcare System (VAMHS) includes a 50-bed acute care, medicalsurgical facility at the main campus at Fort Harrison (Helena) and Community Based 

Outpatient Clinics (CBOCs) located in Anaconda, Billings, Bozeman, Cut Bank, 

Glasgow, Glendive, Great Falls, Havre, Kalispell, Lewistown, Missoula, and Miles City. 

Veterans Readjustment Counseling Centers (Vet Centers) are located in Billings and 

Missoula. A 30-bed Community Living Center (nursing home) that provides general and 

ventilator dependent care is located in Miles City. The system is part of Veterans 

Integrated Service Network (VISN) 19. Primary care is provided at the main campus in 

Fort Harrison and at the affiliated CBOCs. 

A May 2003 report from the VHA Office of the Medical Inspector (OMI) found that 

VAMHS had a plan for contracting mental health services with community practitioners 

around the state with the aim of providing better access to mental health services. The 

OMI report noted that specific programming for PTSD appeared “almost non-existent” 

and that discontinuation of an inpatient VA substance abuse program was not 

accompanied by a parallel increase in investment in an outpatient substance abuse 

program. 

A 2007 investigative report by a media outlet alleged that VAMHS lags behind the nation 

in the quality and availability of mental health services and specialized PTSD treatment 

programs for recent veterans. VAMHS asserted that health care needs in Montana are 

met not only by providers at VA clinics as described in the media report but also by 

contract and fee-basis providers throughout the state. 

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A. Access to Mental Health Care in Rural Areas 

Mental Health and Rural America: 1994–2005, a 2007 report by the Health Resources 

and Services Administration, Office of Rural Health Policy, notes “there is not one rural 

America. The rural United States is a place of great diversity, which is perhaps a surprise 

to many in the majority metropolitan population. Rural is many small places scattered 

across the vast landscape of America.” Rural can be a New England village, a 

Midwestern county, or the Western frontier. Rural areas share common characteristics of 

relatively few people living in the area, limited access to large cities, and considerable 

travel distances to market areas for work or every-day living activities.2

 No consistent 

definition is used across agencies or programs.3

 The most commonly used definitions are 

based on the Office of Management and Budget characterization of counties or the 

Census Bureau categorization of census blocks.4 According to the OMB definition, rural 

America comprises 17 percent (49 million) of the population, compared to 21 percent (59 

million) by the Census definition.5 

Over 85 percent of the 1,669 federally designated mental health professional shortage 

areas (MHPSAs) are rural. According to the Epidemiological Catchment Area (ECA) 

Study, which compared rural and urban prevalence rates for a large variety of psychiatric 

disorders, lifetime prevalence rate of the combined disorders was 32 percent in rural 

areas, and only slightly higher at 34 percent in urban areas. The rate of adults with severe 

mental illnesses is not significantly different in rural and urban areas. The overall 

prevalence of substance abuse among adults has also been shown to be comparable 

between rural and urban areas.6 

B. Montana Demographics 

According to the 2000 U.S. Census, Montana has a population of 902,195 and a land area 

of 145,552 square miles, with a 6.6 density-persons per square miles—the third-lowest in 

2 Ciarlo, James A. PhD, Wackwitz, John H., PhD, Wagenfeld, Morton O., PhD, Mohatt, Dennis F., MA, Focusing
 

on “Frontier”: Isolated Rural America, Letter to the Field No.2, Western Interstate Commission for Higher 

Education, Frontier Mental Health Services Resource Network, pp.1–14. 3 Mohatt, Dennis F., Bradley, Mimi M., Adams, Scott J., and Morris, Chad D., Mental Health and Rural America:
 

1994–2005, U.S. Department of Health and Human Services, Health Resources and Services Administration, Office 

of Rural Health Policy, p.1.

4 Coburn, Andrew F., MacKinney, A. Clinton, McBride, Timothy D., Mueller, Keith J., Slifkin, Rebecca T., and 

Wakefield, Mary K., Choosing Rural Definitions: Implications for Health Policy, Issue Brief #2, Rural Policy 

Research Institute Health Panel, March 2007.

5

 Mohatt, Dennis F., Bradley, Mimi M., Adams, Scott J., and Morris, Chad D., Mental Health and Rural America:
 

1994–2005, U.S. Department of Health and Human Services, Health Resources and Services Administration, Office 

of Rural Health Policy, p.2–3.

6 Mohatt, Dennis F., Bradley, Mimi M., Adams, Scott J., and Morris, Chad D., Mental Health and Rural America:
 

1994–2005, U.S. Department of Health and Human Services, Health Resources and Services Administration, Office 

of Rural Health Policy, p. 9.
 

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the U.S. Fifty-four percent of the population resides in urban areas and 46 percent in 

rural areas, the seventh-highest in the U.S.7 

The U.S. Department of Health and Human Services, Bureau of Health Professions, 

designates Health Professional Shortage areas for primary medical care, dentists, and 

mental health professionals. Within Montana’s 56 counties, part or all of 54 counties are 

designated mental health care shortage areas.8 

Montana has the second-highest veteran per capita population.9 According to the end of 

year 2006 enrollment file, Montana had a veteran population of 100,223 with 42,131 

veterans enrolled in VHA and 29,023 unique patients receiving care within the system. 

The availability of mental health providers, a geographically large area, and population 

dispersion are factors that pose challenges for Montana’s veterans in need of mental 

health services. 

C. VA Provided Care 

1. VAMHS Mental Health Care 

The VA facility at Fort Harrison does not have an inpatient acute psychiatric unit or a 

residential mental health treatment program. However, it does have an outpatient mental 

health clinic offering general mental health services including medication management 

and therapy for PTSD, depression, and other non-substance use conditions. Patients in 

need of inpatient psychiatric care are transferred to the VA Medical Center (VAMC) in 

Sheridan, Wyoming or Salt Lake City, Utah or a local community hospital. Patients in 

need of residential mental health care are admitted to programs at VAMCs in Sheridan, 

Salt Lake City, or Boise, Idaho. If a bed is not available in a VA facility or the 

community, patients are admitted temporarily to a medical floor at the Fort Harrison 

VAMC with consultation to a psychiatrist. 

Outpatient VA mental health providers are available onsite at Fort Harrison and the 

CBOCs in Anaconda, Billings, Great Falls, Kalispell, and Missoula. Mental health 

services are not available at the CBOCs in Cut Bank, Glasgow, Glendive, or Havre. 

2. VAMHS Telemental Health 

Telemental health networks have potential to provide a wide range of mental health 

services, enhance continuity of care for rural patients, and to facilitate family 

involvement and discharge planning for psychiatric inpatients. In addition, telemental 

health has been used to extend the service range of nurse practitioners, physician 

7

 mt.govTM Montana’s Official State Website, Montana Quickfacts.
 8

 Rural Policy Research Institute, State Economic and Demographic Profile Series, Montana.
 9

 Testimony of Joe Foster, Administrator, [State of] Montana Veterans Affairs Division before the U.S. Senate
 

Veterans’ Affairs Committee Field Hearing, Great Falls, Montana, July 21, 2007.
 

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Access to VA Mental Health Care for Montana Veterans

assistants, and psychiatric clinical nurse specialists who serve rural areas and who 

practice in consultation with off-site psychiatrists who provide medication review. 

However, telemental health services may not be appropriate for every patient. An 

example would be a patient with serious mental illness who has delusions focused on 

being electronically monitored by others.10 

Telemental health care is provided at the Fort Harrison VAMC and the CBOCs in 

Anaconda, Billings, Great Falls, Kalispell, Missoula, Bozeman, Lewistown, and Miles 

City utilizing video-conferencing systems in which patient and provider see and 

communicate with each other in real time. Equipment is reportedly in place in Cut Bank, 

Glendive, and Havre, with plans for utilization within the next few months. 

D. VA Paid Care 

1. Contract Mental Health Care 

For non-VA community mental health services, Montana is divided into four regions: the 

Eastern Montana Community Mental Health Centers (EMCMHC), the South Central 

Regional Mental Health Centers (SCRMHC), the Centers for Mental Health (CMH), and 

the Western Montana Mental Health Centers (WMMHC). Each region consists of a 

regional mental health center and several satellite offices. 

VAMHS contracted with the SCRMHS in 2001 to provide mental health care to veterans 

at their various satellites/clinics. In 2003, VAMHS contracted with WMMHC and CMH 

for mental health services, and the EMCMHC clinical sites were sub-contracted under the 

SCRMHC contract. In FY 2003, approximately 870 veterans were treated at these 

contract facilities. In FY 2007, the number of veterans treated under contract increased to 

approximately 2,081 for 22,420 visits. 

Under these contracts, veterans are seen by mental health providers at 45 sites including 

11 EMCMHS sites, 12 CMH sites, 8 SCRMH sites, and 14 WMMHC sites. (See 

Appendix A.1.) 

Patients access contract care through the Ft. Harrison VAMC Access to Care Unit. If the 

patient has not been seen within 24 months by a VA mental health professional a phone 

assessment will be done within 24 hours. An assigned provider completes the phone 

assessment and a written note is sent to Access to Care Unit clinicians who then set up a 

referral to an appropriate contract provider nearest to the patient. The choice of contract 

provider depends on the type of clinical services required. 

10 Smith Henry A., LCSW, and Ronald A. Allison MA, Telemental Health: Delivering Mental Health Care at a 

Distance; A Summary Report, U.S. Department of Health and Human Services, Substance Abuse and Mental Health 

Services Administration Center for Mental Health Services, Health Resources and Services Administration, 1998. 

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A contract provider may be utilized for one service while a VA provider may be utilized 

for a different mental health service. For example, a patient may be seen for therapy by a 

contract psychologist at a contract community mental health center site and for 

medication management by a VA psychiatrist in Fort Harrison. 

When a contract provider sees a VA patient, progress notes are mailed to Access to Care 

Unit clinicians at Fort Harrison, who scan the notes into the VHA computerized patient 

record system (CPRS). On a monthly basis, Access to Care Unit staff review a 5 percent 

sample of progress notes and treatment plans. 

The contracts specify provision of initial visits, psychiatric care, case management, 

interactive group psychotherapy, and other outpatient visits for evaluation and 

management. According to VAMHS leadership, the contracts are in the process of renegotiation. In 2008, the VAMHS conducted a survey of services provided at each 

contracted community mental health center. Community mental health centers were 

interested in adding additional services to the contracts. 

VHA has a performance mandate that Operation Iraqi Freedom/Operation Enduring 

Freedom (OIF/OEF) veterans be scheduled for an initial intake with a mental health 

provider within 2 weeks of contact/referral to the system. Although not specified in the 

present contracts, the VAMHS reported that mental health centers have previously 

pledged to see these veterans on a priority basis and contract providers have been 

compliant with the VA mandate. 

2. Fee-Basis Mental Health Care 

In addition to the community mental health center contracts, but to a lesser extent, the 

VAMHS utilizes the services of 27 non-VA private mental health therapists on fee-basis. 

These fee-basis arrangements are set up on an individual basis. VAMHS leadership 

reports that in FY 2007, there were 257 VAMHS patients seen for 3,213 visits under fee 

basis. (See Appendix A.2.) 

E. Mental Health Care Available to Montana Veterans at VA Facilities 

in Neighboring States 

Some Montana veterans live in areas close to the border of neighboring states. Veterans 

may access mental health care at VHA sites located in a neighboring state, especially if 

the neighboring site is more proximate to the patient’s home. For example, a patient 

living near the North Dakota border may seek care at the CBOC in Dickinson, North 

Dakota, as an alternative to care at the Miles City, Montana site. At the time of our 

inspection, mental health care was available via telemental health or on-site care at the 

CBOCs in Dickinson and Williston, North Dakota; the satellite clinic in Salmon, Idaho; 

the CBOC in Powell, Wyoming, and the Sheridan VAMC; the Spokane VAMC in 

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Access to VA Mental Health Care for Montana Veterans

Washington; and at the VA Black Hills Health Care System–Fort Meade Campus in 

South Dakota. 

F. VA Mental Health Care to American Indian Reservations in Montana 

The 2004 U.S. Census Bureau American Community Survey indicated that American 

Indian and Alaska Native-alone and American Indian and Alaska Native-alone-or-in 

combination populations represented approximately 6.5 or 7.8 percent of Montana’s state 

population.11 (See Appendix A.3 for a map showing seven different American Indian 

reservations.) 

Mental health services to veterans residing on American Indian reservations in Montana 

(see Appendix) are provided via telemental health videoconferencing. The program is 

administratively based at the VA Salt Lake City Healthcare System and affiliated with 

the VHA Office of Rural Health. A psychiatrist and nurse practitioner at the VA Eastern 

Colorado Health Care System in Denver provide clinical care by telemental health. The 

program also serves veterans residing on American Indian reservations in Wyoming and 

South Dakota. Mental health clinicians work with Tribal telemental health outreach 

workers who serve as community liaisons, help arrange installation, and provide 

logistical support for use of the equipment. Funding for telemental health outreach 

workers is funded through VAMHS fee-basis. Tribal telemental health outreach workers 

partner with Tribal veteran representatives to liaison with veterans, their families, Tribal 

Councils, and the Indian Health Service, to facilitate access to care within a culturally 

sensitive framework. 

Provision of care requires having a facility where patients can use the telemental health 

equipment; having the equipment and associated technological infrastructure in place and 

operable; having an effective outreach worker who is knowledgeable and respectful of 

tribal customs and Tribal Council procedures; and having mental health clinicians in 

place at the other side of the transmission. Equipment may be located inside Vet Centers, 

IHS facilities, or other available and appropriate locations. 

In Montana, telemental health has been available at the Lame Deer and Crow sites. 

Telemental health began at the Fort Belknap site in November 2008. Telemental health 

recently became operable at the Rocky Boys site and is under development at the other 

sites. The Montana veteran population analyzed in the findings section of this report 

included American Indian veterans. However, because telemental health services at 

reservation sites are solely intended for use by those veterans residing on American 

Indian Reservations, we captured the data for these veterans but did not include these 

telemental health locations in the quantitative analysis of geographic access presented in 

the findings section. 

11 U.S. Census Bureau, The American Community—American Indians and Alaska Natives: 2004, May 2007, p.6. 

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Access to VA Mental Health Care for Montana Veterans

Scope and Methodology 

A. Interviews and Document Review 

We initially interviewed the VISN 19 Director, VAMHS leadership, the Director of 

Behavioral Health services for the VAMHS, VAMHS staff responsible for contract 

mental health care and fee-basis mental health care, and the VAMHS liaison to the Vet to 

Vet program12 by phone in February 2008. 

We obtained information regarding the address, number of providers, provider types, and 

services provided at VAMHS facilities and VAMHS mental health contract and fee-basis 

sites. We obtained data on when telehealth services began at CBOCs and whether 

contract and fee-basis sites provided service before and/or after March 2008. 

We visited multiple VAMHS sites during the week of August 25–29, 2008. At the Fort 

Harrison facility, we interviewed the facility director, and re-interviewed the Director of 

Behavioral Health services, staff responsible for contract mental health care, and the 

liaison to the Vet to Vet program. We interviewed mental health clinicians and the grantper-diem program manager at the Fort Harrison VAMC. We interviewed the program 

manager responsible for coordinating VISN 19 telemental health services to Indian 

Reservations. 

Inspectors visited and interviewed clinical and administrative staff at the CBOC and a 

contract mental health clinic site in Billings; the CBOC and a contract mental health site 

in Bozeman; and the CBOC, a Grant-Per-Diem residence, and a community shelter for 

the homeless in Missoula. We also visited the Missoula campus of the WMMHC. 

During the week of our visit we ultimately drove over 660 miles from Missoula to 

Dickinson, North Dakota, which provided an enhanced understanding of geography in 

relation to access issues. 

Additionally, we met with a group of Montana veterans who facilitate and participate in 

Vet to Vet groups. These veterans shared with us observations and experiences with the 

Vet to Vet program. In addition, we were provided with and reviewed the Fort Harrison 

Vet to Vet Missions Statement/Program Guide. We reviewed the June 2005 Vet to Vet 

Peer Support Manual authored by Moe and Naomi Armstrong. In addition, we 

ascertained the location of other Vet to Vet sites in Montana and schedules or flyers 

indicating days and times of meetings. 

We reviewed the October 2007 OIG report, Combined Assessment Program Review of 

the VA Montana Health Care System, Fort Harrison, Montana. We reviewed the May 

2003 OMI report, VA Montana Healthcare System, Ft. Harrison, MT, Review of Quality 

12 Vet to Vet is a non-VA program which offers peer-to-peer support to veterans of all eras; it is a self-help program 

of veterans helping veterans overcome both mental illness and substance abuse. 

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of Care. In addition, we reviewed VHA Handbook 1160.01, Uniform Mental Health 

Services in VA Medical Centers and Clinics, and a State of Montana Veterans Affairs 

Division, Division of Military Affairs, PDHRA Task Force Report. Further, we 

performed a literature search and reviewed selected research, public health, and public 

policy literature relevant to access to mental health care in rural areas. 

This inspection was performed in accordance with Quality Standards for Inspections 

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

B. Analytic Methodology 

1. Study Population 

We used the Montana veterans in the LC database for this review. The population-based 

LC database identifies all veterans who were discharged alive from active military duty 

during July 1, 2005 – September 30, 2006, whether or not they enrolled in VA healthcare 

or applied for VA benefits after discharge (VA users or non-VA users). The LC database 

was created and currently is maintained by the OIG. Derived from more than 30 files 

acquired from VA and Department of Defense (DoD), the LC database integrates details 

from both VA and DoD data on these nearly a half million discharged service members. 

The LC database is the first and, to date, the only available population-based, 

comprehensive analytic database that integrates both VA and DoD data on these recently 

discharged veterans. This population-based approach eliminates potential selection bias 

in the selection of veterans. For example, veterans who are VA users may differ from 

non-VA users in fundamental ways that impact policy, planning, and resource decisions. 

In addition, VA outreach efforts could be better targeted if more information were 

available about non-VA users. 

The OIG’s descriptive report on the LC database, Quantitative Assessment of Care 

Transition: The Population-Based LC Database,

13 was published in September 2007. 

The report describes the LC database in detail, including an overview of its structure, the 

methodology used to create it, data confidentiality issues, and the opportunity it provides 

for VA to make decisions using an evidence-based approach. Since publication of the 

report, we have updated the LC database with DoD and VA medical treatment files and 

vital status files and incorporated additional information. These updates are summarized 

below. 

2. Percentage Service-Connected Disability Ratings 

Disability compensation is part of the Veterans Benefits Administration (VBA) 

Compensation and Pension (C&P) program. It provides a tax-free monetary benefit paid 

to veterans who are disabled by injury or disease that was incurred or worsened during 

13 VAOIG report number 07-00380-202, issued 9/13/2007, http://www.va.gov/oig/54/reports/VAOIG-07-00380-

202.pdf 

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Access to VA Mental Health Care for Montana Veterans

their military service. This benefit compensates veterans for the average loss in earnings 

capacity in civilian occupations commensurate with the severity of the service-connected 

conditions. Generally, service-disabled veterans who were discharged from military 

service under other than dishonorable conditions are entitled to compensation benefits, 

regardless of their income or employment status. 

After a veteran submits a benefits claim to the VA Regional Office (VARO) of 

jurisdiction, a VARO veteran service representative (VSR) develops claim evidence by 

obtaining the veteran’s military service medical records and other relevant medical 

information. The veteran undergoes a medical examination (known as a C&P exam) by a 

VA or contract clinician. A VARO rating specialist evaluates the evidence to 

(1) determine if the claimed impairments are service-connected; (2) if service connected, 

apply the medical criteria of VA’s rating schedule to assign a degree of disability for each 

impairment; and (3) if there is more than one impairment, determine the veteran’s overall 

degree of service-connected disability. 

The VBA rating schedule classifies diagnostic codes (1) by body systems, such as 

musculoskeletal, mental, and cardiovascular; (2) by specific conditions, such as 

impairment of the knee, PTSD, and hypertensive disease; and (3) by the severity of the 

conditions. The degree of disability for both individual conditions and the overall 

disability is rated as a percentage in 10 percent increments from 0 percent (for conditions 

that are disabling but not to a compensable degree) to 100 percent (for conditions that are 

totally disabling). 

After the determination of service-connection and disability rating has been completed, 

the VSR processing the claim enters the pertinent claim and rating information into VA’s 

automated payment system to begin the veteran’s monthly compensation payments. 

These payments are usually retroactive to the date the VARO received the claim. If a 

service-connected condition worsens, a veteran can file a claim for an increase in 

disability rating and thus higher compensation payments. If VA denies a disability claim 

or assigns a rating lower than what the veteran feels is appropriate, the veteran may 

appeal the decision. 

The amount of monthly monetary compensation depends on the veteran’s degree of 

service-connected disability and the number of dependents (spouse, children, and 

parents). As of December 1, 2008, the basic monthly compensation payments ranged 

from $123 for a 10 percent-disabled veteran to $2,673 for a 100 percent-disabled veteran. 

For disability ratings of 30 percent or higher, VA pays additional benefits for veterans’ 

dependents. For example, if a 60 percent-disabled veteran has a spouse and one child, the 

monthly payment increases by $155, from $974 to $1,129. For very serious disabilities, 

such as the loss of limb(s), VA pays additional Special Monthly Compensation (SMC). 

VA also pays additional benefits if the veteran requires the regular aid and attendance of 

another person. 

VA Office of Inspector General 9
                 

           

Access to VA Mental Health Care for Montana Veterans

Compensation payment rates are not (linearly) proportional to the corresponding degrees 

of disability, with the higher disability ratings having disproportionally larger monetary 

benefits than the lower ratings. For example, the basic monthly 100 percent 

compensation payment rate of $2,673 is 21.7 times more than the 10 percent payment 

rate of $123. In contrast, the 100 percent payment rate is 3.5 times more than the 

50 percent payment rate of $770. 

Because of the compensation payment variation for a given disability rating, we chose to 

work with disability ratings directly. We added to the LC database up to 9 impairmentspecific disability ratings and the combined overall disability rating as of the end of FY 

2008. Note that the combined disability rating is not a simple sum of each specific 

disability rating. For example, multiple zero ratings of specific disability could result in a 

10 percent combined disability rating. These disability ratings were taken from both the 

extract of the Benefits Delivery Network (BDN) database (referred to as the C&P file) 

and from the extract of Corporate Data Warehouse’s VetsNet database (referred to as the 

Corporate file), as VBA is in transition from the BDN database to the Corporate one. 

3. Geo-Processing Montana Mental Health Providers and Veterans 

The geo-coding process translates addresses into geographic coordinates, that is, latitude 

and longitude. We identified all VHA mental health care service providers and providers 

under VHA paid service in Montana as of March 8, 2008. Through the remainder of this 

report, we use the term “VA providers” to indicate “VHA providers and providers under 

paid service.” VHA providers located near Montana state borders were included if they 

were within 2 hours of travel time of Montana veterans. VHA acquired paid service 

through both contractual arrangement and fee basis. We do not distinguish paid service 

by these two mechanisms in the quantitative analysis. Based on treatment service(s) 

offered, each of the care providers were classified into one of the three types of service: 

medications only, therapy only, and combination of medications and therapy. 

All Montana veterans in the LC database were identified for geo-coding, irrespective of 

their use of VHA services or VA benefits, in order to derive their travel time to VA 

mental healthcare providers. The Planning Systems Support Group (PSSG) of the VHA 

Policy Analysis and Forecasting (PA&F) Division in the Office of the Assistant Deputy 

Under Secretary for Health (ADUSH) for Policy and Planning (10A5) is charged with 

geo-coding all VHA providers and enrolled veterans (VHA users). Thus, for veterans 

who were VHA users and for VHA mental health providers, we captured their geo-data 

directly. 

For non-VA mental health providers under VA auspices (paid service) and non-VHA 

users, we first assembled their addresses. The listing and addresses for non-VA mental 

health providers were acquired from the VAMC at Fort Harrison, Montana. For Montana 

non-VHA users in the LC database, their addresses were determined from the BDN file, 

Veterans Assistance Discharge System (VADS) file, and finally the VA/DoD Identity 

VA Office of Inspector General 10
                 

           

                                                           

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Repository (VADIR) file, if missing from a previous file in this hierarchical order. The 

BDN address information was gathered from the mini SAS C&P dataset created on 

February 26, 2008. The mini file is created bi-monthly on the VA mainframe. VADS 

addresses were pulled from the most current information on the mainframe’s quarterly 

VADS file that was gathered on April 24, 2008. The VADIR addresses were obtained 

from the VADIR file that was extracted on January 25, 2008. 

We sent the addresses file of these non-VHA users and non-VHA mental health providers 

under VA auspices to PA&F in the Office of the ADUSH for Policy and Planning for 

geo-coding. These addresses were first checked against the National Change of Address 

(NCOA) data from the US Postal Service to insure best match in geo-processing. The 

positional accuracy of the geo-coded addresses was summarized into 5 categories that 

include: (1) street match, which is the most accurate geo-coding level; (2) ZIP+4 (or 

ZIP9) match, which is the next most accurate geo-coding level, indicating that every part 

of an address (street, city, State and ZIP) was matched except for the house number 

which is typically on the wrong side or between two known house numbers of a street; 

(3) ZIP+2 (ZIP7) match, which denotes a sector or neighborhood match within a ZIP 

code; (4) ZIP (or ZIP5) match, in which the location of an address is as certain only as 

the center (centroid) of mass delivery or the location of the post office of a ZIP code, 

which can encompass several neighborhoods or sectors; and (5) non-geo-coded, which 

indicates insufficient or invalid address information and thus cannot be geo-processed. 

After geo-coding, PA&F constructed travel time bands around each of these VA health 

care providers. The 5 travel time bands are: (1) 15-minutes – travel time is within 

15 minutes (inclusive), (2) 30-minutes – travel time is over 15 minutes but within 

30 minutes, (3) 1 hour – travel time is over 30 minutes but within 1 hour, (4) 90-minutes 

– travel time is over one hour but within 90 minutes, and (5) 2 hours – travel time is over 

90 minutes but within 2 hours. 

The road network used in deriving travel time included freeways, primary, secondary and 

access roads, except for those roads in residential neighborhoods. Where available, ferry 

routes were also used.14 To account for the travel conditions on these different types of 

roads, the 2001 Urban Mobility Report of the Texas Transportation Institute (Texas 

A&M University System) was used to derive average speeds for each type of road in 

different types of urban areas. In addition, the 2000 Census population density of the 

Census tracks was used to adjust the travel time on the each type of road. For more 

details, see National Travel Time Analysis Methodology of the Planning Systems Support 

Group, VHA Office of ADUSH for Policy and Planning.15 

14 FY 2006 Geographic Access to Veterans Health Administration, Healthcare Analysis & Information Group, 

Office of the ADUSH for Policy and Planning, U.S. Department of Veterans Affairs; April 2008.

15 http://vaww.pssg.med.va.gov/PSSG/PSSG_TravelTime.pdf.

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Travel times between veterans and health care providers were corroborated based on the 

geo-coordinates of the veterans and the travel bands around the providers. We derived 

travel times to nearest providers by service type (medication management, therapy, or 

both) and by VHA providers and providers under paid services. In the report, the travel 

times from veterans to nearest providers are presented in the upper limits of 15 minutes, 

30 minutes, 1 hour, 90 minutes, 2 hours, and over 2 hours. 

4. VA and DoD Treatment Information and Vital Status 

Veterans’ vital status information was updated through October 2008. All medical 

treatment information was updated to the end of FY 2008 (September 30, 2008). In 

addition, we added DoD treatment information from FY2002 and FY2003, so that the 

current LC database covers DoD treatment information from FY2002 through FY2008. 

VA treatment information covers the period from the beginning of FY2004 through the 

end of FY2008. 

In addition to updating the original 11 diagnostic-specific indicators in the LC database, 

we added new diagnostic-specific indicators. These indicators were created based on 

patients’ specific diagnostic codes of the International Classification of Diseases, Ninth 

Revision, Clinical Modification (ICD-9-CM), using the same business rules detailed in 

the 2007 OIG report.

16 ICD-9-CM groups these disease diagnostic codes into 17 broad 

categories. We created an indicator for each of the 16 broad ICD-9-CM categories, 

except for Neoplasms (140-239) that used 2 indicators, one for Malignant Neoplasms 

(140-208) and another for Benign Neoplasms (210-239). 

Mental Disorders were defined as any ICD-9-CM diagnosis from 290.0 to 319.0, which 

corresponds to the Diagnostic and Statistical Manual of Mental Disorders, Fourth 

Edition, Revised (DSM-IV-R). Indicators were also created for each individual category 

of mental disorders, based on the first 3 digits of the ICD-9-CM codes. 

The category “Psychosocial or Behavioral Problems” were defined based on selected 

ICD-9-CM V-codes, a supplementary classification used to describe problems that are a 

focus for mental health treatment but are not considered mental health diagnoses.17 180 19 

The specific V-codes included for defining this category are: V15.40 – V15.49; V60.0 – 

V60.2; V60.4; V61.0 – V61.22; V61.80 – V61.83; V61.90; V62.0; V62.2; V62.5; V62.80 

– V62.89; V63.0; V63.9; V65.2; V65.5; V69.2 – V69.8; V70.1 – V70.2; V71.0 – V71.01; 

16 Quantitative Assessment of Care Transition: The Population-Based LC Database, 

http://www.va.gov/oig/54/reports/VAOIG-07-00380-202.pdf.
 17 Prophet S., V codes: supplementary classification of factors influencing health status and contact with health 

services, Journal of AHIMA (American Health Information Management Association), 1996; 67:16-25.
 18 Hoge CW, Lesikar SE, Guevara R, et al., Mental disorders among U.S. military personnel in the 1990s: 

association with high levels of health care utilization and early military attrition, American Journal of Psychiatry, 

2002; 159:1576-1583.
 19 Karen.

VA Office of Inspector General 12
                 

           

Access to VA Mental Health Care for Montana Veterans

V71.5; V71.81; and V79.0 – V79.1. Descriptions of these V-codes are shown in 

Appendix C of this report. 

5. Statistical Analyses 

Analyses included service members in the LC database who were discharged alive from 

active military duty during July 1, 2005 – September 30, 2006. Veterans whose age at 

separation was under 17 or over 65 were excluded. Age at separation was calculated 

based on date at separation and date of birth. 

A veteran was considered to be a Montana veteran if residing in the State of Montana. 

All veterans other than Montana veterans were termed non-Montana veterans, including 

those with unknown states of residency. 

A service member was considered as having served in a Reserve/National Guard unit if 

Reserve/National Guard status was indicated in any of the Reserve Affairs roster, 

OEF/OIF, or VADIR Reserve files before their separation date. 

The “Other” category of service combined all branches other than Army, Navy, Air 

Force, and Marine Corps, including missing branch information. 

Pay Grade was grouped into 5 categories: E1–E4, E5–E9, O1–O3, O5–O10, and “Other.” 

The “Other” group included W1–W5, codes other than specified above, and missing Pay 

Grade information. 

Service Character was re-categorized as follows: 

•	 Honorable/General incorporates “Honorable” and “General, Under Honorable 

Conditions.” This category also includes those judged “Honorable for VA 

Purposes” by VBA. 

•	 Other than Honorable. 

•	 Bad Conduct/Dishonorable includes “Bad Conduct” and “Dishonorable” 

discharges. It also includes those judged “Dishonorable for VA Purposes” by 

VBA. 

•	 Uncharacterized consists of those without character of service listed. 

Both DoD and VA treatment comprised only clinical encounters (that is, with at least one 

ICD-9 diagnosis code), excluding “occasions of services” (no ICD-9 codes). 

The Indicator of Mental Health Diagnosis combined the Mental Disorder (ICD-9-CM) 

and Psychosocial or Behavioral Problems (ICD-9-CM V-codes). 

Because of the large size of the population of interest, nearly all comparisons between 

subgroups were likely to be statistically significant, even though differences between 

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9.2.20 

Access to VA Mental Health Care for Montana Veterans

subgroups were very small and thus likely not of practical importance. For this reason, 

we did not report statistical significance. 

All data analyses were performed using SAS statistical software (SAS Institute, Inc., 

Cary, North Carolina), version 9.2 (TS1M0). Maps were produced using ArcGIS 

software (Environmental Systems Research Institute (ESRI), Redlands, CA), version 

Part II. Results and Conclusions 

Issue 1: Montana Veteran Characteristics and Geographic Access to 

Mental Health Care 

The LC database currently incorporates details about all 493,935 service members 

discharged or released alive from active military duty during the period July 1, 2005– 

September 30, 2006. Because of delays in reporting deaths, the total number discharged 

alive (493,935) in the current database differs from that (494,147) in the 2007 report 

Quantitative Assessment of Care Transition: The Population-Based LC Database.

21 

Of the 493,935 veterans in the LC database (Figure 1), we excluded from our analyses 

(1) 20 whose date of birth were unknown and (2) 16 veterans coded as under age 17 and 

55 over age 65 at their time of separation from active military duty. A total of 93 

veterans were excluded, which was less than 0.02 percent (93/493,935) of the entire 

population. Thus, our analyses included 493,842 service members whose ages at 

separation were between 17 and 65, inclusive. Among these, 3,224 (0.65 percent) were 

Montana veterans. 

20 GIS stands for geographic information systems. 21 http://www.va.gov/oig/54/reports/VAOIG-07-00380-202.pdf.

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Access to VA Mental Health Care for Montana Veterans

Figure 1: Pathway from LC database to study populations: service members discharged from active

military service during 7/1/2005 ‐ 9/30/06.

Of the 3,224 Montana veterans, 42 (1.3 percent) of them had moved out of the state or 

had invalid addresses. Among the 3,183 geo-coded addresses, 659 (21 percent) were 

coded at the accuracy of ZIP level. We excluded them from geo-analyses because of 

considerable uncertainty in their travel times to care providers since Montana is such a 

geographically vast state with low population density. Therefore, the number of Montana 

veterans included in the analysis of access to mental health care was 2,523, which 

represented 78 percent (2,523/3,224) of the Montana veterans. 

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There were 86 mental health provider sites, 79 of them within Montana. The other 

7 VHA provider sites were located within a 2-hour travel zone of geo-coded Montana 

veterans. At 6 sites medication management only was available; at 55 sites therapy only 

was available; and at 25 sites both medication management and therapy were available. 

VHA does not provide therapy only service, and paid service does not provide 

medication only service. (See Table 1) 

Table 1. Distribution of mental health providers as of March 2008, by mental health service type and provider type.

# of Sites # of Sites With # of Sites # of Sites With

Only With Only Both Meds &

Medication Therapy Therapy

Management

Mental health providers in the state of Montana

VHA Provider

VAMC 1 0 0 1

CBOC/Satellite 7 4 0 3

Paid Service Provider

Fee‐Basis 26 0 26 0

Contract 45 0 29 16

Total 79 4 55 20

Mental health providers in bordering states

VHA Provider

VAMC 3 0 0 3

CBOC/Satellite 4 2 0 2

Total 7 2 0 5

Map 1 on the next page depicts the geographic distribution of (geo-coded) veterans and 

mental health care providers in Montana included in our analyses of access to care. 

VA Office of Inspector General 16
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Access to VA Mental Health Care for Montana Veterans

1. Characteristics of the Montana Veteran Population 

Figure 2 shows that at the time of their separation, 55 percent (1,758/3,224) of Montana 

service members were serving in the active component compared to 71 percent 

(349,421/490,618) of non-Montana veterans. By the time of separation, more than twice 

the service members in the reserve component had served in OIF/OEF than those in the 

active component: 78 percent (1,142/1,466) vs. 34 percent (593/1,758) for Montana, and 

81 percent (114,525/141,197) vs. 37 percent (130,862/349,421) for non-Montana. 

Figure 2: Montana and non‐Montana (all U.S., excluding Montana) veterans discharged from active

military service during 7/1/2005 ‐ 9/30/06 (17‐65 years old at discharge), by military component and

OIF/OEF status.

Table 2 shows the socio-demographic and military service related characteristics, health 

service utilization, and service-connected disability ratings of Montana veterans, by 

military component (active or reserve) and OIF/OEF status. Compared to their reserve 

counterparts at the time of separation from military duty, service members in the active 

component were more than 5 years younger on average; less than half had served in the 

Army; more than 54 percent were in the E1–E4 pay grade; and they were more likely to 

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Access to VA Mental Health Care for Montana Veterans

have had a mental health diagnosis (mental disorder and/or psychosocial or behavioral 

problems). 

Regardless of military component, compared to their non-OIE/OEF counterparts, 

Montana OIF/OEF veterans were twice as likely to use VA health care; over three times 

as likely to have had a VA mental health diagnosis; and more than twice as likely to be 

receiving VA compensation. 

These patterns were similar to those of the non-Montana (All U.S. other than Montana) 

veteran population (See Table 3). 

Compared to their non-Montana counterparts, Montana veterans were younger when they 

separated from active military service: the median discharge age of Montana service 

members was 1 year younger, except for non-OIF/OEF Montana reserve service 

members, whose median age at separation was 4 years younger (32 vs. 36). The median 

age of 32 means half of them were younger and half of them older than 32 at their 

discharge time. Average ages were greater than median ages, indicating distributions of 

age at separation were more skewed towards younger service members than elderly ones. 

More Montana reserves had served in the Army than non-Montana reserves. Most of the 

veterans (94 percent or more), Montana or non-Montana, had at least one disease 

diagnosed while serving their active military duty (from July 1, 2002 until their 

separation). However, the percentage of Montana veterans who had at least one disease 

diagnosed by DoD (including TriCare) after separation was at least 9 points lower than 

their non-Montana counterparts, indicating fewer Montana veterans sought DoD health 

care after separation. 

In contrast, the percent of OIF/OEF Montana veterans who sought VA care was over 

10 points higher than their non-Montana counterparts after discharge from active duty 

(54 percent and 63 percent for Montana OIE/OEF active and reserve component, 

respectively; compared with 43 percent and 47 percent for non-Montana OIE/OEF active 

and reserve component, respectively). For those who had not served in OIF/OEF, the 

percentages of seeking VA care were similar, irrespective of their residency. 

Percentages of mental health diagnoses (combined ICD-9-CM mental disorder and Vcodes for psychosocial or behavioral problems) were generally comparable among 

Montana and non-Montana veterans, regardless of whether diagnosed by DoD or VA and 

before or after separation, although Montana tended a bit lower. The noticeable 

exception was OIF/OEF veterans who served in the reserve component: the mental health 

diagnosis by VA after separation was much higher among Montana veterans (38 percent) 

than non-Montana (26 percent), mostly for mental disorders (37 percent vs. 24 percent). 

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Access to VA Mental Health Care for Montana Veterans

Table 2: Distributions of socio‐demographic and military service characteristics, health service utilization and

service‐connected disability ratings of 3,224 Montana veterans discharged from active military service during

7/1/2005 ‐ 9/30/06 (who were 17‐65 years old at discharge), by military component and OIF/OEF status.

Active Component Reserve/Guard

[1,758] [1,466]

OIF/OEF Not OIF/OEF OIF/OEF Not OIF/OEF

[593] [1,165] [1,142] [324]

Age (years)

Mean 27.0 26.4 32.7 33.6

Median 24 23 31 32

Sex (%)

Male 88.0 76.5 92.1 85.8

Female 11.6 22.6 6.8 12.4

Missing 0.3 0.9 1.1 1.9

Branch (%)

Army 41.5 48.8 86.4 91.1

Navy 17.2 14.9 1.3 0.3

Air Force 21.9 27.0 9.3 7.7

Marines 19.1 6.1 3.0 0.9

Other 0.3 3.2 0.0 0.0

Character of Service (%)

Honorable/General 94.6 82.9 90.6 97.5

Other than Honorable 3.0 3.2 0.2 0.0

BC/Dishonorable 0.0 0.2 0.0 0.0

Uncharacterized/Missing 2.4 13.7 9.2 2.5

Pay Grade (%)

E1‐E4 54.3 68.2 34.7 33.0

E5‐E9 36.9 24.2 53.2 52.5

O1‐O3 6.2 3.6 4.9 7.7

O4‐O10 2.0 3.3 4.1 6.5

Other 0.5 0.7 3.1 0.3

DoD Diagnosed (FY2002‐FY2008) (%) 99.5 95.1 97.7 98.2

Before Discharge 99.3 94.2 96.9 97.8

After Discharge 18.0 28.5 26.5 26.2

VA Diagnosed (FY2004‐FY2008) (%) 56.2 25.8 65.2 32.1

Before Discharge 10.1 7.3 9.0 9.6

After Discharge 53.6 22.6 63.1 29.0

DoD Diagnosed (FY2002‐FY2008) (%)

Mental Health (Mental Disorders + V‐codes)

Before Discharge 46.5 35.9 11.7 22.5

After Discharge 6.1 8.3 5.4 6.2

Mental Disorders (ICD‐9‐CM: 290‐319)

Before Discharge 35.6 28.8 9.4 19.8

After Discharge 4.9 5.7 4.9 5.9

V‐codes for Psychosocial/Behavioral Problems

Before Discharge 30.5 22.8 4.6 7.1

After Discharge ‐ 4.0 1.7 ‐

VA Diagnosed (FY2004‐FY2008) (%)

Mental Health (Mental Disorders + V‐codes)

Before Discharge 1.7 0.8 2.3 2.2

After Discharge 26.5 7.6 38.1 6.5

Mental Disorders (ICD‐9‐CM: 290‐319)

Before Discharge 1.2 ‐ 2.3 ‐

After Discharge 26.0 7.0 36.8 6.2

V‐codes for Psychosocial/Behavioral Problems

Before Discharge ‐ ‐ ‐ ‐

After Discharge 5.9 1.4 8.9 ‐

Percent with Service Connected Disability 45.0 21.2 39.2 17.6

Overall Disability Rating, Mean 41.4 39.7 35.9 26.8

Overall Disability Rating, Median 40 40 30 20

Percent with Service Connected PTSD 13.5 ‐ 19.8 ‐

Overall Disability Rating, Mean 52.3 ‐ 47.0 ‐

Overall Disability Rating, Median 50 ‐ 40 ‐

‐ Not reported because there were fewer than 10 veterans.

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Table 3: Distributions of socio‐demographic and military service characteristics, health service utilization and

service‐connected disability ratings of 493,842 non‐Montana (U.S. excluding Montana) veterans discharged from active

military service during 7/1/2005 ‐ 9/30/06 (who were 17‐65 years old at discharge), by military component and OIF/OEF

status.

Active Component Reserve/Guard

[349,421] [141,197]

OIF/OEF Not OIF/OEF OIF/OEF Not OIF/OEF

[130,862] [218,559] [114,525] [26,672]

Age (years)

Mean 28.1 27.4 33.1 35.9

Median 25 24 32 36

Sex (%)

Male 88.1 78.1 89.2 80.7

Female 11.4 20.1 9.0 16.8

Missing 0.5 1.9 1.9 2.5

Branch (%)

Army 42.0 45.9 77.5 72.4

Navy 22.5 20.0 4.6 4.4

Air Force 15.9 19.0 10.9 11.4

Marines 19.4 12.1 6.9 6.7

Other 0.2 3.0 0.1 5.2

Character of Service (%)

Honorable/General 94.4 82.2 86.6 84.1

Other than Honorable 3.3 4.7 0.2 0.6

BC/Dishonorable 0.1 0.2 0.0 0.0

Uncharacterized/Missing 2.3 12.8 13.2 15.3

Pay Grade (%)

E1‐E4 51.0 63.4 32.3 25.7

E5‐E9 40.1 26.0 53.8 53.8

O1‐O3 5.1 4.7 5.4 8.1

O4‐O10 3.1 5.1 7.0 10.5

Other 0.8 0.8 1.5 2.0

DoD Diagnosed (FY2002‐FY2008) (%) 99.5 96.6 95.5 94.6

Before Discharge 99.3 95.6 93.5 92.7

After Discharge 27.4 38.2 45.7 53.9

VA Diagnosed (FY2004‐FY2008) (%) 46.3 25.9 50.6 30.9

Before Discharge 8.5 7.1 13.1 13.1

After Discharge 43.2 22.4 47.3 26.2

DoD Diagnosed (FY2002‐FY2008) (%)

Mental Health (Mental Disorders + V‐codes)

Before Discharge 45.0 38.2 16.6 22.5

After Discharge 6.3 10.1 8.7 11.5

Mental Disorders (ICD‐9‐CM: 290‐319)

Before Discharge 33.3 30.5 10.5 17.3

After Discharge 5.4 7.3 7.5 9.7

V‐codes for Psychosocial/Behavioral Problems

Before Discharge 29.0 22.9 9.6 11.0

After Discharge 1.9 4.5 3.1 4.2

VA Diagnosed (FY2004‐FY2008) (%)

Mental Health (Mental Disorders + V‐codes)

Before Discharge 1.1 1.1 3.2 2.9

After Discharge 23.1 8.2 26.3 10.2

Mental Disorders (ICD‐9‐CM: 290‐319)

Before Discharge 0.8 0.9 2.6 2.3

After Discharge 20.7 7.0 23.5 8.9

V‐codes for Psychosocial/Behavioral Problems

Before Discharge 0.4 0.5 1.2 1.0

After Discharge 9.6 3.3 11.1 4.0

Percent with Service Connected Disability 34.0 21.4 18.0 14.6

Overall Disability Rating, Mean 39.1 40.4 37.3 37.5

Overall Disability Rating, Median 40 40 30 30

Percent with Service Connected PTSD 7.0 0.5 5.4 0.7

Overall Disability Rating, Mean 56.9 63.9 57.9 64.3

Overall Disability Rating, Median 60 60 60 60

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As of September 2008, more Montana veterans received VA compensation, especially for 

those who had served in OIF/OEF: 45 percent for active component and 39 percent for 

reserve component Montana veterans, compared to 34 percent for active component and 

18 percent for reserve component among non-Montana veterans. The overall disability 

ratings were quite similar. For the overall disability ratings which included any 

component for PTSD, the percentage of Montana OIF/OEF veterans receiving 

compensation was more than twice as high as for their non-Montana counterparts. The 

median PTSD disability rating was 50 percent for Montana active component and 40 for 

reserve; it was 60 percent for non-Montanans. 

2. Distribution of Disease Diagnostic Categories and Mental Disorder Diagnoses 

Table 4 details the distribution of 17 broad ICD-9-CM diagnostic categories and the Vcodes for psychosocial or behavioral problems, by military component and OIF/OEF 

status for Montana veterans. The neoplasm category was split into two subcategories, 

malignant or benign neoplasm. These diagnoses are combined from both DoD (during 

FY2002 – FY2008) and VA (during FY2004 – FY2008). 

Table 4: Distributions of ICD‐9‐CM broad disease categories of DoD and VA diagnoses (from October 1, 2001 to September 30, 2008) of

3,224 Montana veterans discharged from active military service during 7/1/2005 ‐ 9/30/06 (who were 17‐65 years old at discharge), by

military component and OIF/OEF status.

Active Component Reserve/Guard

ICD‐9 CM Categories [1,758] [1,466]

OIF/OEF Not OIF/OEF OIF/OEF Not OIF/OEF

[593] [1,165] [1,142] [324]

Infectious and Parasitic Disease (001‐139) 42.0 32.4 20.3 26.2

Malignant Neoplasm (140‐208) 1.7 1.0 0.9 ‐

Benign Neoplasm (210‐239) 11.1 8.2 6.5 10.8

Endocrine, Nutritional and Metabolic Disease, and Immunity Disorders (240‐279) 26.0 20.8 19.4 20.4

Diseases of the Blood and Blood Forming Organs (280‐289) 2.5 2.7 2.3 ‐

Mental Disorders (290‐319) 48.7 34.9 43.1 26.9

Diseases of the Nervous System and Sense Organs (320‐389) 73.9 60.4 64.0 63.6

Diseases of the Circulatory System (390‐459) 20.2 13.9 14.9 14.8

Diseases of the Respiratory System (460‐519) 59.2 55.3 36.2 67.6

Diseases of the Digestive System (520‐579) 37.3 26.4 34.8 29.9

Diseases of the Genitourinary System (580‐629) 21.8 19.3 9.2 13.0

Complications of Pregnancy, Childbirth, and the Puerperium (630‐677) 20.7 18.1 7.8 11.7

Diseases of the Skin and Subcutaneous Tissue (680‐709) 39.6 31.7 19.6 25.6

Diseases of the Musculoskeletal System and Connective Tissue (710‐739) 70.7 56.1 58.1 60.2

Congenital Anomalies (740‐759) 7.1 5.0 2.2 ‐

Certain Conditions Originating in the Perinatal Period (760‐779) ‐ ‐ ‐ ‐

Symptoms, Signs, and Ill‐Defined Conditions (780‐799) 64.8 50.1 49.8 51.2

Injury and Poisoning (800‐999) 72.3 50.9 43.9 55.3

V‐Codes Indicating a Psychosocial or Behavioral Problem1 34.7 25.8 14.1 9.6

‐ Not reported because there were fewer than 10 veterans.

1See Appendix D for specific codes.

More than half of Montana veterans had a diagnosis of disease of the nervous system and 

sense organs, and disease of the musculoskeletal system and connective tissues, 

VA Office of Inspector General 22
                 

           

                                           

                       

                         

   

     

           

      

             

         

         

                     

                     

         

                     

               

   

   

               

                   

                   

                     

         

                   

               

           

                 

      

                 

Access to VA Mental Health Care for Montana Veterans

regardless of their active or reserve, OIF/OEF status. However, more than 70 percent of 

veterans separated from active OIF/OEF service had the diagnoses. Veterans served in 

OIF/OEF were more likely to have a mental disorder diagnosis (49 percent for active 

component and 43 percent for reserve), compared to their non-OIF/OEF counterparts (35 

percent for active and 27 percent for reserve). Veterans separated from active component 

were 2.5 times more like to have a psychosocial/behavioral problem than their reserve 

counterparts. 

Similar patterns were observed for non-Montana veterans (Table 5) although the absolute 

magnitude fluctuated. 

Table 5: Distributions of ICD‐9‐CM broad disease categories of DoD and VA diagnoses (from October 1, 2001 to September 30, 2008) of

490,618 non‐Montana veterans (U.S. excluding Montana) veterans discharged from active military service during 7/1/2005 ‐ 9/30/06

(who were 17‐65 years old at discharge), by military component and OIF/OEF status.

Active Component Reserve/Guard

ICD‐9 CM Categories [349,421] [141,197]

OIF/OEF Not OIF/OEF OIF/OEF Not OIF/OEF

[130,862] [218,559] [114,525] [26,672]

Infectious and Parasitic Disease (001‐139) 43.5 37.8 21.3 27.5

Malignant Neoplasm (140‐208) 1.4 1.6 1.2 1.9

Benign Neoplasm (210‐239) 11.0 10.3 6.9 11.1

Endocrine, Nutritional and Metabolic Disease, and Immunity Disorders (240‐279) 28.0 24.1 22.1 27.1

Diseases of the Blood and Blood Forming Organs (280‐289) 4.5 4.9 2.7 4.1

Mental Disorders (290‐319) 44.7 37.1 33.3 28.2

Diseases of the Nervous System and Sense Organs (320‐389) 67.7 60.6 47.4 55.1

Diseases of the Circulatory System (390‐459) 20.9 18.5 17.2 23.5

Diseases of the Respiratory System (460‐519) 60.3 61.3 41.7 49.9

Diseases of the Digestive System (520‐579) 38.5 32.2 29.4 30.0

Diseases of the Genitourinary System (580‐629) 22.8 22.5 13.3 20.8

Complications of Pregnancy, Childbirth, and the Puerperium (630‐677) 20.8 20.6 10.2 16.1

Diseases of the Skin and Subcutaneous Tissue (680‐709) 41.8 36.7 25.2 30.5

Diseases of the Musculoskeletal System and Connective Tissue (710‐739) 69.5 61.9 52.9 58.8

Congenital Anomalies (740‐759) 6.2 6.0 3.1 5.3

Certain Conditions Originating in the Perinatal Period (760‐779) 0.3 0.3 0.1 0.2

Symptoms, Signs, and Ill‐Defined Conditions (780‐799) 66.0 58.5 48.8 56.1

Injury and Poisoning (800‐999) 68.1 57.9 42.2 51.3

V‐Codes Indicating a Psychosocial or Behavioral Problem1 35.7 27.5 21.8 17.7

1See Appendix D for specific codes.

Table 6 shows the distribution of each individual category of mental disorders (based on 

the first 3 digits of ICD-9-CM codes from 290.0 to 319.0), PTSD, and adjustment 

reaction excluding PTSD for Montana veterans. 

VA Office of Inspector General 23
                 

           

                                         

                                 

       

   

       

           

      

                         

               

                   

     

           

     

       

             

                   

         

                 

   

                 

               

           

       

              

                        

                              

Access to VA Mental Health Care for Montana Veterans

Table 6: Distributions of VA and DoD mental disorder diagnoses (from October 1, 2001 to September 30, 2008) of 3,224 Montana

veterans discharged from active military service during 7/1/2005  ‐ 9/30/06 (who were 17‐65 years old at discharge), by military

component and OIF/OEF status.

Active Component Reserve/Guard

Mental Disorders (ICD‐9‐CM: 290‐319) [1,758] [1,466]

OIF/OEF Not OIF/OEF OIF/OEF Not OIF/OEF

[593] [1,165] [1,142] [324]

Alcohol and Drug induced mental disorders (Alcohol & drug psychoses) (291 & 292) 1.7 0.8 1.1 ‐

Episodic mood disorders (Affective psychosis) (296) 8.8 6.4 7.4 3.7

Anxiety, dissociative and somatoform disorders (Neurotic Disorders) (300) 12.0 9.0 9.6 4.3

Personality disorders (301) 2.7 4.3 0.8 ‐

Sexual and gender identity disorders (302) 2.5 1.6 1.5 ‐

Alcohol dependence syndromes (303) 8.9 2.8 5.3 ‐

Drug dependence (304) 2.0 1.2 ‐ ‐

Non‐dependent abuse of drugs (305) 29.7 14.9 21.4 16.1

Special symptoms or syndromes, not elsewhere classified (307) 7.8 5.3 5.1 3.1

Acute reaction to stress (308) 2.7 2.0 3.0 ‐

Adjustment reaction excluding PTSD (309 excluding 309.81) 14.5 14.2 10.1 4.9

PTSD (309.81) 18.4 2.4 25.2 ‐

Specific non‐psychotic mental disorders due to brain damage (310) ‐ ‐ 1.5 ‐

Depressive disorder, not elsewhere classified (311) 18.0 11.0 19.7 7.1

Disturbance of conduct, not elsewhere classified (312) ‐ ‐ ‐ ‐

Other mental disorder diagnoses1 6.1 3.7 4.3 ‐

‐ Not reported because there were fewer than 10 veterans.

1Other ICD‐9‐CM codes for mental disorders (290‐319) than those already listed in the table.

For Montana veterans, the most common mental disorder diagnoses were non-dependent 

abuse of drugs, PTSD, and depressive disorders. While diagnoses of non-dependent 

abuse of drugs were similar for the non-OIF/OEF active components (15 percent) and 

non-OIF/OEF reserve components (16 percent), they were considerably lower than for 

both the OIF/OEF active (30 percent) and reserve (21 percent) counterparts. For PTSD, 

there is a marked difference when comparing the OIF/OEF active (18 percent) and 

OIF/OEF reserve component veterans (25 percent). Two percent of the non-OIF/OEF 

active component veterans had at least one PTSD diagnosis. The number of nonOIF/OEF reserve service members diagnosed with PTSD was too small to report (fewer 

than 10 veterans). Depressive disorder was also lower in the non-OIF/OEF active (11 

percent) and reserve components (7 percent) than their OIF/OEF counterparts. 

VA Office of Inspector General 24
                 

           

                                       

                                   

             

   

       

           

  

                         

           

               

     

           

     

   

         

               

         

             

   

               

           

             

       

              

                                

Access to VA Mental Health Care for Montana Veterans

Table 7 shows that for non-Montana veterans, the most common mental disorder 

diagnoses were also non-dependent abuse of drugs, although it was lower in the nonOIF/OEF than in the OIF/OEF, as was the case with Montana veterans. Noticeably, 

among the non-Montana veterans this diagnosis was 5 points lower in both OIF/OEF 

active and reserve components compared with their Montana counterparts. As with 

Montana veterans, a marked difference was noted in the percentage of PTSD in OIF/OEF 

veterans compared with their non-OIF/OEF counterparts. PTSD and depressive disorder 

percentages were higher in the Montana OIF/OEF active and reserve components 

compared with non-Montana OIF/OEF active and reserve components. 

Table 7: Distributions of VA and DoD mental disorder diagnoses (from October 1, 2001 to September 30, 2008) of 490,618 non‐Montana

veterans (U.S. excluding Montana) veterans discharged from active military service during 7/1/2005 ‐ 9/30/06 (who were 17‐65 years old at

discharge), by military component and OIF/OEF status.

Active Component Reserve/Guard

Mental Disorders (ICD‐9‐CM: 290‐319) [349,421] [141,197]

OIF/OEF Not OIF/OEF OIF/OEF Not OIF/OEF

[130,862] [218,559] [114,525] [26,672]

Alcohol and Drug induced mental disorders (Alcohol & Drug Psychoses) (291 & 292) 1.6 1.1 0.9 0.9

Episodic mood disorders (Affective psychosis) (296) 7.9 6.3 5.7 4.5

Anxiety, dissociative and somatoform disorders (Neurotic Disorders) (300) 12.5 10.0 9.1 7.1

Personality disorders (301) 2.8 4.3 1.0 1.3

Sexual and gender identity disorders (302) 2.1 1.9 2.3 2.9

Alcohol dependence syndromes (303) 6.4 3.4 2.8 2.2

Drug dependence (304) 1.9 1.3 1.0 0.9

Non‐dependent abuse of drugs (305) 24.0 15.5 16.1 13.5

Special symptoms or syndromes, not elsewhere classified (307) 5.8 6.2 3.4 3.9

Acute reaction to stress (308) 2.8 1.9 2.0 1.4

Adjustment Reaction Excluding PTSD (309 Excluding 309.81) 14.2 13.7 11.0 7.7

PTSD (309.81) 13.8 2.5 13.6 3.4

Specific non‐psychotic mental disorders due to brain damage (310) 1.6 0.6 1.6 0.7

Depressive disorder, not elsewhere classified (311) 13.0 10.1 10.2 7.5

Disturbance of conduct, not elsewhere classified (312) 0.6 0.5 0.4 0.3

Other mental disorder diagnoses1 4.7 4.1 3.4 2.8

1Other ICD‐9‐CM codes for mental disorders (290‐319) than those already listed in the table.

VA Office of Inspector General 25
                 

           

                         

                         

                 

                       

Access to VA Mental Health Care for Montana Veterans

3. Characteristics of VA Users and Non-VA Users 

Figure 3 shows that 28 percent (901/3,224) of Montana veterans were diagnosed with 

mental health issues (mental disorders and/or psychiatric disabilities) by DoD before their 

separation, compared with 34 percent of non-Montana veterans (167,294/490,618). 

Montana veterans were more likely to become VA care users after separation (43 percent 

of those without DoD mental health diagnoses and 45 percent of those with diagnoses) 

than non-Montana veterans (31 percent of those without DoD mental health diagnoses 

and 39 percent of those with diagnoses). The VA care included care provided both by 

VHA providers and by providers under VA auspices (paid service). 

Figure 3: Montana and non‐Montana (all U.S., excluding Montana) veterans discharged from active
 

military service during 7/1/2005 ‐ 9/30/06 (17‐65 years old at discharge), stratified by DoD mental
 

health1 diagnoses before discharge and VA users and non‐users.
 

1ICD‐9‐CM mental disorders (290‐319) and v‐codes indicating a psychosocial or behavioral problem.

VA Office of Inspector General 26
                 

           

Access to VA Mental Health Care for Montana Veterans

Table 8 gives the socio-demographic and military service related characteristics, mental 

health service utilization, and VA compensation and disability ratings of Montana 

veterans by users of VA care after separation and non-users, stratified by DoD mental 

health diagnoses before discharge. For Montana veterans who were diagnosed with 

mental health issues (mental disorder and/or psychosocial or behavioral problems) by 

DoD before separation, users of VA care tended to be older than non-users; a higher 

percentage were male, served in the Army and OIF/OEF, earned honorable character of 

service, were in the E5–E9 pay grade, and were receiving VA compensation. Note that 

Bad Conduct and Dishonorable discharges issued by general courts martial may bar VA 

benefits. Veterans separated administratively under “Other Than Honorable” conditions 

may request that their discharge be reviewed for possible re-characterization for the 

purpose of obtaining VA benefits. 

Although different somewhat in magnitude, similar patterns were observed for Montana 

veterans who were not diagnosed with mental health issues and who were users of VHA. 

The distributions of characteristics of Montana VA and non-VA users were quite similar 

to those of non-Montanans (See Table 9). One noticeable difference was that lower 

percentages of non-Montana VA users were receiving compensation as of September 

2008 (65 percent for DoD mental health diagnosed and 46 percent for not diagnosed vs. 

corresponding 78 percent and 63 percent in Montana), but percentages of non-Montana 

non-VA users were somewhat higher (11 percent for DoD mental health diagnosed and 

7 percent for not diagnosed vs. corresponding 5 percent and 4 percent in Montana). In 

addition, 22 percent of Montana VA users were receiving compensation that included a 

component for PTSD, regardless of DoD mental health diagnoses; but the percentages for 

non-Montana VA users were lower, 13 percent for those with DoD mental health 

diagnoses and 7 for those without. 

VA Office of Inspector General 27
                 

           

                       

                         

                                 

       

                 

                   

  

               

   

               

   

         

     

                 

       

   

       

   

           

       

         

       

       

       

     

     

              

                      

                       

Access to VA Mental Health Care for Montana Veterans

Table 8: Distributions of socio‐demographic and military service characteristics, military components and

service‐connected disability ratings of 3,224 Montana veterans discharged from active military service during

7/1/2005  ‐ 9/30/06 (who were 17‐65 years old at discharge) of VA users and non‐users, stratified by DoD mental

health1 diagnoses before discharge.

Not DoD MH Diagnosed DoD MH Diagnosed

[2,323] [901]

Not VA Treated VA Treated Not VA Treated VA Treated

[1,331] [992] [497] [404]

Age (years)

Mean 27.7 33.3 25.7 30.5

Median 24 31 23 27

Sex (%)

Male 84.8 92.0 75.1 81.4

Female 13.9 7.4 23.7 18.4

Missing 1.4 0.6 1.2 0.3

Branch (%)

Army 63.0 78.1 47.7 60.6

Navy 8.3 6.0 16.5 9.9

Air Force 19.8 8.2 29.8 20.8

Marines 7.4 7.3 3.8 7.9

Other 1.5 0.5 2.2 0.7

Character of Service (%)

Honorable/General 86.1 93.6 83.7 96.0

Other than Honorable 1.4 0.1 7.0 0.7

BC/Dishonorable 0.1 0.0 0.2 0.0

Uncharacterized/Missing 12.5 6.4 9.1 3.2

Pay Grade (%)

E1‐E4 55.1 34.3 69.6 49.8

E5‐E9 34.2 52.8 24.6 44.1

O1‐O3 5.8 5.7 2.6 3.5

O4‐O10 3.8 4.7 2.6 1.7

Other 1.1 2.5 0.6 1.0

Active Component (%)

OIF/OEF 11.5 16.5 24.6 38.1

Not OIF/OEF 46.5 12.9 56.9 33.4

Reserve Component (%)

OIF/OEF 28.3 63.6 8.9 22.3

Not OIF/OEF 13.7 7.0 9.7 6.2

DoD MH Diagnosis after Discharge1 (%) 5.7 3.8 10.1 12.6

VA Mental Health Diagnosis1 (%)  ‐ 47.3  ‐ 59.7

Before Discharge  ‐ 2.2  ‐ 5.9

After Discharge  ‐ 46.7  ‐ 58.9

Percent with Service Connected Disability 4.1 63.0 5.2 77.5

Overall Disability Rating, Mean 30.0 35.7 31.2 43.8

Overall Disability Rating, Median 30 30 20 40

Percent with Service Connected PTSD  ‐ 22.2  ‐ 22.3

Overall Disability Rating, Mean  ‐ 46.0  ‐ 54.9
 

Overall Disability Rating, Median  ‐ 40  ‐ 60
 

‐ Not reported because there were fewer than 10 veterans.
 

1ICD‐9‐CM mental disorders (290‐319) and v‐codes indicating a psychosocial or behavioral problem.
 

VA Office of Inspector General 28
                 

           

                       

                     

                               

                     

                 

                   

  

               

   

               

   

         

     

                 

       

   

                 

   

           

         

   

   

         

       

         

       

              

                      

                     

Access to VA Mental Health Care for Montana Veterans

Table 9: Distributions of socio‐demographic and military service characteristics, military components and

service‐connected disability ratings of 490,618 non‐Montana veterans (U.S. excluding Montana) veterans

discharged from active military service during 7/1/2005 ‐ 9/30/06 (who were 17‐65 years old at discharge) of VA

users and non‐users, stratified by DoD mental health1 diagnoses before discharge.

Not DoD MH Diagnosed DoD MH Diagnosed

[323,324] [167,294]

Not VA Treated VA Treated Not VA Treated VA Treated

[222,510] [100,814] [101,437] [65,857]

Age (years)

Mean 28.7 32.1 27.1 31.0

Median 25 29 24 27

Sex (%)

Male 85.4 86.9 78.6 79.2

Female 12.6 11.7 20.2 20.0

Missing 2.0 1.5 1.2 0.8

Branch (%)

Army 51.0 62.7 47.5 58.7

Navy 16.0 12.1 21.6 15.0

Air Force 16.6 10.4 19.5 16.3

Marines 14.0 13.8 10.3 9.3

Other 2.5 1.1 1.2 0.7

Character of Service (%)

Honorable/General 83.8 91.0 82.5 95.7

Other than Honorable 3.1 0.2 7.4 0.8

BC/Dishonorable 0.1 0.0 0.3 0.0

Uncharacterized/Missing 13.1 8.9 9.7 3.5

Pay Grade (%)

E1‐E4 51.2 39.1 63.6 47.5

E5‐E9 34.6 48.9 28.7 45.0

O1‐O3 6.6 4.7 3.8 3.0

O4‐O10 6.5 5.8 3.3 3.6

Other 1.0 1.6 0.6 1.0

Active Component (%)

OIF/OEF 20.0 27.2 29.3 44.2

Not OIF/OEF 49.3 25.1 59.0 35.9

Reserve Component (%)

OIF/OEF 23.5 42.9 8.0 16.6

Not OIF/OEF 7.2 4.7 3.7 3.4

DoD MH Diagnosis after Discharge1 (%) 6.6 6.8 12.5 14.0

VA Mental Health Diagnosis1 (%) 0.3 43.1 1.3 59.2

Before Discharge 0.3 2.7 1.3 5.1

After Discharge ‐ 42.3 ‐ 58.4

Percent with Service Connected Disability 7.1 45.7 10.7 65.3

Overall Disability Rating, Mean 31.1 35.9 36.9 46.4

Overall Disability Rating, Median 30 30 30 40

Percent with Service Connected PTSD 0.2 7.1 0.5 12.9

Overall Disability Rating, Mean 48.4 53.7 50.5 62.0
 

Overall Disability Rating, Median 50 50 50 60
 

‐ Not reported because there were fewer than 10 veterans.
 

1ICD‐9‐CM mental disorders (290‐319) and v‐codes indicating a psychosocial or behavioral problem.
 

VA Office of Inspector General 29
                 

           

Access to VA Mental Health Care for Montana Veterans

4. Representativeness of Montana Veterans Included in the Access To Care 

Analyses 

After excluding 701 from the Montana veteran population of 3,224 (42 of them had 

moved out of the state or had invalid addresses and 659 were geo-coded at the accuracy 

of ZIP level), 78 percent (2,523/3,224) of this population were included in the analysis of 

access to care (geo-coded Montana veterans). We compared the distribution of selected 

characteristics among the geo-coded Montana veterans with that of the Montana veteran 

population to check for the representativeness of these geo-coded veterans. 

Comparing Tables 10–13 with corresponding Tables 2, 4, 6, and 8, the magnitude of the 

differences was very small. Thus, the population of geo-coded Montana veterans 

included in the analyses of access to care can be considered to be reasonably 

representative of the Montana population from which they were drawn, in terms of their 

characteristics, disease diagnoses, and becoming VA users after separation from military 

active duty. 

5. Geographic Access to Mental Health Care in Montana 

Table 14 shows travel times to the nearest VA mental health care providers (including 

paid services) in Montana by military component and OIF/OEF status. Over 82 percent 

of this veteran population had access to a VA mental health provider (offering at least 

medication management or therapy service) within 15 minutes of travel. Access to a 

provider within half an hour of travel increased this to 95 percent of the population. 

Almost all have access to a provider within an hour of travel. As a result, distributions of 

travel times to nearest mental health providers were very similar across military 

component and OIF/OEF status. The distributions of travel times to a nearest provider 

offering at least therapy service were very similar to those of access to the nearest VA 

mental health provider as observed above. 

Over 70 percent of the population had access within 15 minutes of travel to a nearest 

provider with both medications and therapy services, and over 88 percent of veterans had 

access within one hour. The marked exception was non-OIF/OEF reserve component 

veterans; 12 percent of them had to travel over 1 hour, and 4 percent had to travel over 2 

hours. Similar travel time distributions were observed for access to providers offering at 

least medication service. 

VA Office of Inspector General 30
                 

           

                         

                               

                                 

     

   

           

      

               

   

   

          

   

   

   

               

   

   

       

   

   

         

   

         

   

   

                 

   

   

   

   

   

           

       

       

           

       

       

       

             

       

       

         

       

       

       

       

                   

                       

   

       

                   

   

       

                   

   

       

             

           

   

         

       

              

                        

Access to VA Mental Health Care for Montana Veterans

Table 10: Distributions of socio‐demographic and military service characteristics, health service utilization and service‐connected

disability ratings of 2,523 Montana geo‐coded veterans (excluding veterans geo‐coded at zip‐code level) discharged from active

military service during 7/1/2005 ‐ 9/30/06 (who were 17‐65 years old at discharge), by military component and OIF/OEF status.

Active Component Reserve/Guard

[1,382] [1,141]

OIF/OEF Not OIF/OEF OIF/OEF Not OIF/OEF

[455] [927] [908] [233]

Age (years)

Mean 27.0 26.7 32.8 33.8

Median 24 23 31 32

Sex (%)

Male 88.6 76.9 92.2 85.8

Female 11.0 22.3 6.7 12.5

Missing 0.4 0.8 1.1 1.7

Branch (%)

Army 39.8 48.2 86.1 88.8

Navy 17.1 13.6 1.2 0.4

Air Force 22.9 28.8 9.9 9.4

Marines 20.0 6.4 2.8 1.3

Other 0.2 3.0 0.0 0.0

Character of Service (%)

Honorable/General 94.3 84.3 91.2 96.6

Other than Honorable 3.3 2.8 0.1 0.0

BC/Dishonorable 0.0 0.2 0.0 0.0

Uncharacterized/Missing 2.4 12.7 8.7 3.4

Pay Grade (%)

E1‐E4 53.4 67.6 33.6 32.2

E5‐E9 36.3 24.9 53.5 51.1

O1‐O3 7.0 3.2 5.4 7.7

O4‐O10 2.6 3.5 4.5 8.6

Other 0.7 0.8 3.0 0.4

DoD Diagnosed (FY2002‐FY2008) (%) 99.6 94.6 97.5 97.9

Before Discharge 99.3 93.6 96.7 97.4

After Discharge 18.5 28.5 27.2 27.9

VA Diagnosed (FY2004‐FY2008) (%) 57.4 26.1 65.4 32.6

Before Discharge 9.9 8.3 8.9 8.6

After Discharge 55.0 22.7 63.1 29.6

DoD Diagnosed (FY2002‐FY2008) (%)

Mental Health (Mental Disorders + V‐codes)

Before Discharge 44.0 36.3 10.9 24.0

After Discharge 6.4 8.5 5.5 6.4

Mental Disorders (ICD‐9‐CM: 290‐319)

Before Discharge 32.5 28.7 8.8 21.9

After Discharge 5.1 5.8 5.0 6.0

V‐codes for Psychosocial/Behavioral Problems

Before Discharge 29.2 23.7 4.2 6.4

After Discharge ‐ 3.9 1.8 ‐

VA Diagnosed (FY2004‐FY2008) (%)

Mental Health (Mental Disorders + V‐codes)

Before Discharge ‐ ‐ 2.4 ‐

After Discharge 25.7 7.8 36.8 7.3

Mental Disorders (ICD‐9‐CM: 290‐319)

Before Discharge ‐ ‐ 2.4 ‐

After Discharge 25.3 7.4 35.6 6.9

V‐codes for Psychosocial/Behavioral Problems

Before Discharge ‐ ‐ ‐ ‐

After Discharge 5.7 1.3 8.6 ‐

Percent with Service Connected Disability 45.5 22.8 38.7 17.2

Overall Disability Rating, Mean 41.7 39.5 36.3 27.3

Overall Disability Rating, Median 40 40 30 20

Percent with Service Connected PTSD 14.1 ‐ 20.0 ‐

Overall Disability Rating, Mean 52.3 ‐ 46.8 ‐

Overall Disability Rating, Median 50 ‐ 40 ‐

‐ Not reported because there were fewer than 10 veterans.

VA Office of Inspector General 31
                 

             

                                         

                                 

                           

   

           

    

             

       

         

                     

               

         

                     

               

   

   

               

                   

                   

                     

     

             

               

           

                 

      

                       

         

                                         

                           

                         

   

       

           

      

                              

           

                   

         

           

     

   

             

               

         

                 

   

             

               

           

       

         

                       

                              

Access to VA Mental Health Care for Montana Veterans

Table 11: Distributions of ICD‐9‐CM broad disease categories of DoD and VA diagnoses (from October 1, 2001 to September 30, 2008)

of 2,523 Montana geo‐coded veterans (excluding veterans geo‐coded at zip‐code level) discharged from active military service during

7/1/2005 ‐ 9/30/06 (who were 17‐65 years old at discharge), by military component and OIF/OEF status.

Active Component Reserve/Guard

ICD-9 CM Categories [1,382] [1,141]

OIF/OEF Not OIF/OEF OIF/OEF Not OIF/OEF

[455] [927] [908] [233]

Infectious and Parasitic Disease (001‐139) 41.5 32.6 20.0 27.0

Malignant Neoplasm (140‐208) ‐ 1.1 ‐ ‐

Benign Neoplasm (210‐239) 11.0 8.9 6.8 9.0

Endocrine, Nutritional and Metabolic Disease, and Immunity Disorders (240‐279) 24.6 20.9 19.6 22.8

Diseases of the Blood and Blood Forming Organs (280‐289) ‐ 2.7 1.9 ‐

Mental Disorders (290‐319) 46.8 34.6 41.5 28.3

Diseases of the Nervous System and Sense Organs (320‐389) 74.7 61.5 64.8 60.9

Diseases of the Circulatory System (390‐459) 20.9 13.9 14.4 15.5

Diseases of the Respiratory System (460‐519) 61.1 55.6 37.0 67.4

Diseases of the Digestive System (520‐579) 37.8 27.5 34.8 30.0

Diseases of the Genitourinary System (580‐629) 22.0 20.4 8.5 11.6

Complications of Pregnancy, Childbirth, and the Puerperium (630‐677) 20.4 18.5 8.4 9.9

Diseases of the Skin and Subcutaneous Tissue (680‐709) 40.9 31.6 19.8 27.5

Diseases of the Musculoskeletal System and Connective Tissue (710‐739) 71.0 56.6 57.7 62.2

Congenital Anomalies (740‐759) 7.3 5.0 2.4 ‐

Certain Conditions Originating in the Perinatal Period (760‐779) ‐ ‐ ‐ ‐

Symptoms, Signs, and Ill‐Defined Conditions (780‐799) 64.8 50.7 50.1 50.2

Injury and Poisoning (800‐999) 72.3 51.6 44.3 56.2

V‐Codes Indicating a Psychosocial or Behavioral Problem1 33.9 26.4 13.8 8.6

‐ Not reported because there were fewer than 10 veterans.
 

1See appendix for specific codes.
 

Table 12: Distributions of VA and DoD mental disorder diagnoses (from October 1, 2001 to September 30, 2008) of 2,523 Montana

geo‐coded veterans (excluding veterans geo‐coded at zip‐code level) discharged from active military service during 7/1/2005 ‐ 9/30/06

(who were 17‐65 years old at discharge), by military component and OIF/OEF status.

Active Component Reserve/Guard

Mental Disorders (ICD‐9‐CM: 290‐319) [1,382] [1,141]

OIF/OEF Not OIF/OEF OIF/OEF Not OIF/OEF

[455] [927] [908] [233]

Alcohol and Drug induced mental disorders (Alcohol & Drug Psychoses) (291 & 292) ‐ ‐ ‐ ‐

Episodic mood disorders (Affective Psychosis) (296) 8.1 6.2 7.1 ‐

Anxiety, dissociative and somatoform disorders (Neurotic Disorders) (300) 12.3 8.5 9.0 4.7

Personality disorders (301) 2.9 4.3 ‐ ‐

Sexual and gender identity disorders (302) 2.9 1.7 1.5 ‐

Alcohol dependence syndromes (303) 8.4 2.5 4.9 ‐

Drug dependence (304) ‐ 1.4 ‐ ‐

Non‐dependent abuse of drugs (305) 28.4 15.2 20.4 17.6

Special symptoms or syndromes, not elsewhere classified (307) 8.1 5.7 5.6 ‐

Acute reaction to stress (308) 3.3 1.8 2.9 ‐

Adjustment reaction excluding PTSD (309 excluding 309.81) 12.8 13.8 9.6 6.4

PTSD (309.81) 18.7 2.4 24.2 ‐

Specific non‐psychotic mental disorders due to brain damage (310) ‐ ‐ 1.8 ‐

Depressive disorder, not elsewhere classified (311) 17.6 11.4 18.8 7.7

Disturbance of conduct, not elsewhere classified (312) ‐ ‐ ‐ ‐

Other mental disorder diagnoses1 5.9 3.9 4.1 ‐

‐ Not reported because there were fewer than 10 veterans.
 

1Other ICD‐9‐CM codes for mental disorders (290‐319) than those already listed in the table.
 

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Table 13: Distributions of socio‐demographic and military service characteristics, military components and

service‐connected disability ratings of 2,523 Montana geo‐coded veterans (excluding veterans geo‐coded at zip‐code level)

discharged from active military service during 7/1/2005 ‐ 9/30/06 (who were 17‐65 years old at discharge) of VA users and

non‐users, stratified by DoD mental health1 diagnoses before discharge.

Not DoD MH Diagnosed DoD MH Diagnosed

[1,832] [691]

Not VA Treated VA Treated Not VA Treated VA Treated

[1,036] [796] [385] [306]

Age (years)

Mean 28.0 33.1 26.0 30.8

Median 24 31 23 27

Sex (%)

Male 84.7 92.5 74.8 82.4

Female 14.1 6.8 24.2 17.7

Missing 1.3 0.8 1.0 0.0

Branch (%)

Army 62.1 77.4 44.9 60.5

Navy 7.9 5.9 15.1 9.5

Air Force 21.3 8.7 33.8 20.6

Marines 7.1 7.7 4.4 8.8

Other 1.6 0.4 1.8 0.7

Character of Service (%)

Honorable/General 86.3 94.4 84.4 95.8

Other than Honorable 1.4 0.1 6.5 0.7

BC/Dishonorable 0.1 0.0 0.3 0.0

Uncharacterized/Missing 12.3 5.5 8.8 3.6

Pay Grade (%)

E1‐E4 54.0 34.7 68.1 50.0

E5‐E9 34.7 51.5 25.5 43.8

O1‐O3 6.0 5.8 2.6 3.6

O4‐O10 4.3 5.3 3.4 2.0

Other 1.2 2.8 0.5 0.7

Active Component (%)

OIF/OEF 11.5 17.1 22.3 37.3

Not OIF/OEF 47.3 12.7 59.0 35.6

Reserve Component (%)

OIF/OEF 29.1 63.8 8.8 21.2

Not OIF/OEF 12.2 6.4 9.9 5.9

DoD MH Diagnosis after Discharge1 (%) 6.0 3.9 11.2 12.1

VA Mental Health Diagnosis1 (%)  ‐ 45.6  ‐ 59.5

Before Discharge  ‐ 2.1  ‐ 5.6

After Discharge  ‐ 45.1  ‐ 59.2

Percent with Service Connected Disability 4.2 63.3 5.7 78.4

Overall Disability Rating, Mean 29.8 36.4 31.8 43.6

Overall Disability Rating, Median 30 30 20 40

Percent with Service Connected PTSD  ‐ 23.4  ‐ 20.9

Overall Disability Rating, Mean  ‐ 46.4  ‐ 54.7
 

Overall Disability Rating, Median  ‐ 40  ‐ 60
 

‐ Not reported because there were fewer than 10 veterans.
 

1ICD‐9‐CM mental disorders (290‐319) and v‐codes indicating a psychosocial or behavioral problem.
 

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Table 14: Distributions of travel times to VHA mental health facilities and paid services1 of 2,523 Montana

geo‐coded veterans (excluding veterans geo‐coded at zip‐code level) discharged from active military service

during 7/1/2005 ‐ 9/30/06 (who were 17‐65 years old at discharge), by military component and OIF/OEF status.

Active Component Reserve/Guard

[1,382] [1,141]

OIF/OEF Not OIF/OEF OIF/OEF Not OIF/OEF

[455] [927] [908] [233]

Access to any MH provider (%)

Travel Time: within 15 min 82.6 82.3 82.3 85.0

15+ to 30 min 13.4 13.6 13.1 11.6

30+ to 60 min 3.7 3.6 4.4 3.4

60+ to 90 min 0.0 0.3 0.2 0.0

90+ to 120 min 0.2 0.2 0.0 0.0

MH Facility with both meds and therapy (%)

Travel Time: within 15 min 72.5 73.6 76.1 70.0

15+ to 30 min 15.2 12.5 13.7 9.9

30+ to 60 min 8.8 9.1 6.6 8.2

60+ to 90 min 2.0 2.3 2.4 1.7

90+ to 120 min 0.4 1.5 0.9 6.0

120+ 1.1 1.1 0.3 4.3

MH Facility with access to meds (%)

Travel Time: within 15 min 73.4 74.3 76.8 70.0

15+ to 30 min 15.4 12.9 13.8 9.9

30+ to 60 min 7.7 7.9 5.8 8.2

60+ to 90 min 2.0 2.4 2.4 1.7

90+ to 120 min 0.7 1.4 0.9 6.0

120+ 0.9 1.1 0.3 4.3

MH Facility with access to therapy (%)

Travel Time: within 15 min 82.4 82.2 82.3 85.0

15+ to 30 min 13.6 13.7 13.1 11.6

30+ to 60 min 3.7 3.6 4.4 3.4

60+ to 90 min 0.0 0.3 0.2 0.0

90+ to 120 min 0.0 0.2 0.0 0.0

120+ 0.2 0.0 0.0 0.0

1Paid services including both under fee basis and contractual agreement.

Maps 2 – 5 display Montana veteran travel times to VA mental health providers, one 

map for each provider service type. 

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6. Travel Times and Utilization of VA Care in Montana 

We investigated the impact of travel times (to nearest mental health care providers) on 

becoming users of VA care after discharge from active military duty, separately, for 

veterans who were diagnosed with mental health issues by DoD before separation and for 

veterans without DoD mental health diagnoses. 

Table 15 gives distributions of travel times to nearest VA mental health care providers by 

users of VA care after separation and non-users, stratified by DoD mental health 

diagnoses before discharge. For a given type of mental health care service, no 

differences (all p-values were greater than 0.05) were observed in travel time 

distributions across those with or without mental health diagnoses and whether or not VA 

users. This could be explained, at least in part, by the fact that over 93 percent of 

Montana veterans were within 30 minutes of travel time to a nearest mental health 

provider and virtually all of them had access to a provider within an hour of travel. 

Table 15: Distributions of travel times to VHA mental health facilities and paid services1 of 2,523 Montana

geo‐coded veterans (excluding veterans geo‐coded at zip‐code level) discharged from active military service during

7/1/2005 ‐ 9/30/06 (who were 17‐65 years old at discharge) of VA users and non‐users, stratified by DoD mental

health2 diagnoses before discharge.

Not DoD MH Diagnosed DoD MH Diagnosed

[1,832] [691]

Not VA Treated VA Treated Not VA Treated VA Treated

[1,036] [796] [385] [306]

Access to any MH provider (%)

Travel Time: within 15 min 83.1 82.4 82.1 82.0

15+ to 30 min 13.2 13.4 14.0 11.4

30+ to 60 min 3.4 3.9 3.1 6.5

60+ to 90 min 0.1 0.3 0.5 0.0

90+ to 120 min 0.2 0.0 0.3 0.0

MH Facility with both meds and therapy (%)

Travel Time: within 15 min 73.4 74.6 74.6 73.5

15+ to 30 min 13.3 13.8 12.5 11.8

30+ to 60 min 7.7 7.8 9.1 8.5

60+ to 90 min 2.4 1.8 1.3 3.9

90+ to 120 min 1.5 1.1 2.1 2.0

120+ 1.7 0.9 0.5 0.3

MH Facility with access to meds (%)

Travel Time: within 15 min 74.0 75.0 75.8 74.2

15+ to 30 min 13.5 14.3 12.7 11.4

30+ to 60 min 6.9 6.9 7.5 8.2

60+ to 90 min 2.5 1.8 1.3 3.9

90+ to 120 min 1.4 1.1 2.3 2.0

120+ 1.7 0.9 0.3 0.3

MH Facility with access to therapy (%)

Travel Time: within 15 min 83.0 82.4 81.8 82.0

15+ to 30 min 13.3 13.4 14.3 11.4

30+ to 60 min 3.4 3.9 3.1 6.5

60+ to 90 min 0.1 0.3 0.5 0.0

90+ to 120 min 0.2 0.0 0.0 0.0

120+ 0.0 0.0 0.3 0.0

1Paid services including both under fee basis and contractual agreement.
 

2ICD‐9‐CM mental disorders (290‐319) and v‐codes indicating a psychosocial or behavioral problem.
 

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7. Impact of VA Paid Service on Geographic Access to Mental Health Care in 

Montana 

To explore whether VA paid service improved geographic access to mental health care in 

Montana, we recalculated travel times to nearest VHA mental health providers after 

excluding those providers under VA paid service. 

Table 16 reports what the distributions of travel times would have been if the paid 

service not been acquired, by military component and OIF/OEF status. Because VA paid 

service did not include providers with only medication management service, travel times 

to VHA providers with only medication management service and travel times to VHA 

providers with only therapy coincided with travel times to nearest VHA providers 

offering at least medications or therapy. 

Table 16: Distributions of travel times to VHA mental health facilities of 2,523 Montana geo‐coded veterans (excluding

veterans geo‐coded at zip‐code level) discharged from active military service during 7/1/2005 ‐ 9/30/06 (who were

17‐65 years old at discharge), by military component and OIF/OEF status.

Active Component Reserve/Guard

[1,382] [1,141]

OIF/OEF Not OIF/OEF OIF/OEF Not OIF/OEF

[455] [927] [908] [233]

Access to any MH provider (VHA) (%)

Travel Time: within 15 min 55.4 56.1 57.4 47.6

15+ to 30 min 19.8 19.7 24.7 19.7

30+ to 60 min 10.6 8.5 8.3 8.6

60+ to 90 min 8.6 7.6 5.7 8.6

90+ to 120 min 2.6 4.4 1.7 6.4

120+ 3.1 3.7 2.3 9.0

MH Facility with both meds and therapy (VHA) (%)

Travel Time: within 15 min 43.1 45.7 44.3 39.1

15+ to 30 min 11.2 11.9 18.2 15.5

30+ to 60 min 8.4 7.0 7.5 7.3

60+ to 90 min 11.9 10.8 7.8 9.4

90+ to 120 min 9.0 7.9 12.8 10.3

120+ 16.5 16.7 9.5 18.5

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Comparing Table 16 with Table 14 showed that without paid service, percentages of 

travel within 15 minutes to nearest providers would have been reduced by at least 25 

points and would have been reduced by at least 28 points to nearest providers with both 

medications and therapy services. Over 35 percent of veterans would have had to travel 

more than an hour to seek care for their need of both medications and therapy. Table 17 

indicated that over 10 percent of VHA users and over 16 percent of non-users would have 

had to travel more than 2 hours in order to get care from VHA providers offering both 

medications and therapy treatment. 

Table 17: Distributions of travel times to VHA mental health facilities of 2,523 Montana geo‐coded veterans (excluding

veterans geo‐coded at zip‐code level) discharged from active military service during 7/1/2005  ‐ 9/30/06 (who were

17‐65 years old at discharge) of VA users and non‐users, stratified by DoD mental health1 diagnoses before discharge.

Not DoD MH Diagnosed DoD MH Diagnosed

[1,832] [691]

Not VA Treated VA Treated Not VA Treated VA Treated

[1,036] [796] [385] [306]

57.2

17.7

9.2

8.8

3.3

3.9

Access to any MH provider (VHA) (%)

Travel Time: within 15 min 52.9 56.7 59.7

15+ to 30 min 22.2 24.8 16.1

30+ to 60 min 8.8 8.7 8.8

60+ to 90 min 7.5 5.4 8.6

90+ to 120 min 4.3 1.6 4.2

120+ 4.3 2.9 2.6

MH Facility with both meds and therapy (VHA) (%)

Travel Time: within 15 min 42.2 42.6 48.8 48.7

15+ to 30 min 14.4 17.5 9.9 11.8

30+ to 60 min 7.5 7.0 7.5 8.2

60+ to 90 min 10.8 7.3 9.6 13.1

90+ to 120 min 9.0 13.4 7.8 7.8

120+ 16.1 12.2 16.4 10.5

1ICD‐9‐CM mental disorders (290‐319) and v‐codes indicating a psychosocial or behavioral problem.

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Access to VA Mental Health Care for Montana Veterans

Figure 4 plots the percentage of this Montana veteran population by travel times to the 

nearest VA mental health care providers, with and without paid services. It shows clearly 

a marked improvement in geographic access to care providers after adding the paid 

service. 

Figure 4: Cumulative percentage of travel times to VHA‐only mental health facilities, and VHA mental

health facilities & paid services1 combined, for 2,523 Montana geo‐coded veterans (excluding veterans

geo‐coded at zip‐code level) discharged from active military service during 7/1/2005  ‐ 9/30/06

(17‐65 years old at discharge).

82.6% of Montana geo‐coded veterans are within 15 minutes of any mental health

service provider (medication and/or therapy), 95.8% are within 30 minutes, 99.7% are

within 60 minutes, 99.9% are within 90 minutes, and 100% are within 120 minutes.

1Paid services including both under fee basis and contractual agreement.

Maps 6 and 7 separately depict what Montana veterans’ travel times to VA mental health 

providers would be had VA paid services not been acquired for provider sites offering 

medication management and/or therapy and for provider sites offering both medication 

management and therapy. 

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Access to VA Mental Health Care for Montana Veterans

Conclusions for Issue 1 – Montana Veteran Characteristics and 

Geographic Access to Mental Health Care 

We characterized the Montana veteran population who were discharged from active duty 

during July 1, 2005 – September 30, 2006 and compared them with their non-Montana 

veteran counterparts, with a total population of nearly half a million recently discharged 

veterans. We examined this Montana veteran population’s access to VA mental health 

care. 

This is the first report that examines an entire veteran population, whether or not they 

were users of VA care. This population-based approach eliminates potential bias of using 

only veterans who are VA users, because VA users may differ from non-VA users in a 

fundamentally different way that impacts their choices and utilization of health care. 

Because of the lack of population-based veteran data, previous studies on veteran access 

to and/or utilization of VA care were largely based on VA users, including those 

published in peer-reviewed journals. The LC database makes this population-based 

approach feasible. 

We pioneered using veterans’ travel times from their home addresses to providers’ 

physical service locations. Traditionally, travel distances were measured as straightlinear distances between the location of providers’ central administrative office and the 

centroid of the zip codes of veterans’ residency. Real travel distances depend on 

availability of road network and are certainly longer than straight-linear distances. 

Health care providers’ physical service locations can be a hundred miles apart from their 

central administrative office location, so can veterans’ home addresses from the centroid 

of the zip codes of their residency because of the dispersed Montana population. We 

excluded Montana veterans with accuracy of their residency geographic coordinates at 

ZIP level, to eliminate the likely considerable uncertainty in their travel times. 

In addition, we derived veterans travel times by provider’s available services to address 

their geographical access. A veteran residing within 15 minutes of travel to a nearest 

provider offering only medication management would not have met his/her need for 

therapy if the nearest therapy providers were located more than 2 hours away. 

The VA paid service (fee basis and contractual agreement) clearly improved Montana 

veterans’ geographic access to VA mental health care. This signaled that strategies such 

as paid service or mobile units could be vital to improving veterans’ access to VA care in 

highly rural areas where building VA care facilities may not be a cost-effective choice. 

In addition to geographic access, availability of specialized mental health services (such 

as prolonged exposure therapy for PTSD or buprenorphine substitution therapy for opiate 

addiction), patient satisfaction, and waiting time are some other aspects of access to care. 

It would be important to examine how improved access impacts utilization of VA care 

and the coordination of care. 

VA Office of Inspector General 45
                 

           

 

Access to VA Mental Health Care for Montana Veterans

The mapping of access to health care providers allowed us to visualize accessibility of 

providers, to identify geographic inequities, and to pinpoint specific communities in need. 

We excluded from geographic access to care analyses of those Montana veterans whose 

accuracy of residency geographic coordinates was coded at the ZIP level. It is 

foreseeable that these excluded Montana veterans may be more likely to live in areas 

from where their travel times to mental health care are longer than those included in the 

analyses. If all of these excluded veterans had been living in a place of more than 2-hour 

travel to a mental health care, the absolute percentage of Montana veterans with access to 

care within an hour would reduce from over 99 percent to about 80 percent in Table 14. 

However, the relative patterns of Montana veterans’ characteristics, disease diagnoses, 

and becoming VA users after separation from military active should not be altered, as 

demonstrated by the representative of geo-coded Montana veterans in our analyses. 

Our findings may not be generalizable to Montana veterans who were discharged from 

the military during time periods other than July 1, 2005 – September 30, 2006. We had 

no data on these veterans who were not included in the LC database. Studies based on all 

veterans would allow for better strategic planning and resource decisions, improved 

targeting of specific veteran groups for outreach, and identification of required legislative 

and policy changes. The House Committee on Veterans’ Affairs requested continued 

efforts to expand the LC database by including all veterans discharged from FY 2002 

onwards. We are working collaboratively with other VA staff on this endeavor. 

Issue 2: Other VAMHS Specialized Mental Health Care Issues 

Within the past year, the facility has received approval from VA Central Office to build a 

24 bed acute inpatient mental health unit comprised of 8 acute psychiatry beds, 8 beds for 

a specialized PTSD program, and 8 specialized substance use beds. VAMHS mental 

health leadership reported that they hope to break ground on the new unit in 2009. 

The September 2008 VHA Handbook 1160.01, Uniform Mental Health Services in VA 

Medical Centers and Clinics, from VA Central Office specifies by VAMC and CBOC 

size, Mental Health Services that are to be available to all enrolled veterans at these sites 

by the end of FY 2009. 

According to the handbook, VAMCs will be expected to provide general mental health 

services including consultation about special emphasis problems. Some of the specialty 

mental health services that are to be provided at VAMCs include specialized outpatient 

PTSD programs, evidence-based psychotherapy, and either a PTSD Clinical Team or 

alternatively PTSD specialists, based on locally-determined patient population needs. In 

the absence of another VA facility nearby, smaller CBOCs must provide needed PTSD 

services by referral to other VA facilities, telemental health, or by referral to communitybased providers using sharing arrangements, contracts, or non-VA fee-basis to the extent 

that the veteran is eligible. 

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Substance use services at VAMCs include the expectation that coordinated, intensive 

substance use treatment programs will be available for all veterans who require them to 

establish early remission from the substance use disorder. Coordinated services can be 

provided either through intensive outpatient services at least 3 hours per day and at least 

3 days per week in a designated program delivered by staff with documented training and 

competencies addressing substance use disorders, or through availability of a mental 

health residential rehabilitation treatment program (MHRRTP) that specializes in 

substance use disorders or availability of a substance use track within another MHRRTP 

such as one with a PTSD emphasis.22 In addition, the handbook indicates that all PTSD 

or Specialist programs must be able to address the care needs of veterans with both PTSD 

and substance use disorders (SUD).23 These needs can be addressed through distinct 

PTSD dual diagnosis programs or tracks that include providers with specific expertise in 

both PTSD and SUD, or structures, processes, and formal mechanisms to support the 

coordination of care for PTSD with that provided in SUD programs. 

VA established a National Suicide Prevention Hotline (NSPH) in 2007. From October 

2008 through January 2009, they received 1024 calls from VISN 19. On 12/28/2008, 

NSPH started organizing data by area code. From that date to 2/07/2009 there have been 

107 total calls from the Montana (406) area code to the hotline. 

At the Fort Harrison VAMC, general mental health services including medication 

management and therapy for PTSD, depression, and other non-substance use conditions 

are available in the outpatient mental health clinic. Therapists use cognitive behavioral 

therapy and other therapeutic modalities to treat patients with PTSD and depression. 

Although some VAMHS clinicians have undergone VA training in specific evidencebased therapies for PTSD, cognitive processing therapy and prolonged exposure therapy 

are not consistently available for Montana veterans. The VAMHS is presently recruiting 

a clinician to serve as an evidence-based practices coordinator. The coordinator will be 

responsible for training CBOC personnel in specialized evidence based treatments for 

PTSD, depression, and other mental health conditions, and for monitoring and 

standardization of delivery of evidence based modalities across the VAMHS’s mental 

health system. 

General mental health services including treatment for PTSD, depression and other nonsubstance use conditions are available at the CBOCs in Anaconda, Billings, Great Falls, 

Kalispell, and Missoula. At the CBOCs in Bozeman, Lewistown, and Miles City mental 

health care is solely available via telehealth transmission to mental health providers at the 

Fort Harrison VAMC. Mental health services are not presently available in person or by 

telehealth at the CBOCs in Cut Bank, Glasgow, Glendive, or Havre. There are now 

two therapists at the CBOCs in Missoula, Great Falls, and Billings; one therapist at the 

22 Department of Veterans Affairs, Veterans Health Administration, VHA Handbook 1160.01, Uniform Mental
 

Health Services in VA Medical Centers and Clinics, Washington, D.C., September 2008.
 23 What was formerly termed substance abuse disorders is now frequently termed substance use disorders.
 

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CBOC in Kalispell, and the VAMHS is presently recruiting a therapist for the Bozeman 

CBOC. 

Substance abuse therapists are available at the Fort Harrison VAMC, and CBOCs in 

Missoula, Great Falls, Kalispell, and Billings. VAMHS has recruited an American 

Society of Addiction Medicine certified internal medicine physician to provide intensive 

outpatient substance use treatment. In addition, two mental health nurse practitioners 

have been recruited to facilitate coordination of substance use disorder related care. 

At contract and fee-basis sites, general mental health services including treatment for 

PTSD, depression, and other non-substance use conditions, and case management are 

available. Cognitive behavioral therapy is generally available at these sites. Other 

specialized mental health therapies such as cognitive processing therapy for PTSD and 

specialized therapy for substance use conditions are available to veterans at only a few of 

the contract and fee-basis sites. 

Conclusions for Issue 2 – Other VAMHS Specialized Mental Health 

Care Issues 

Although some VAMHS clinicians have undergone VA training in specific evidencebased therapies for PTSD, cognitive processing therapy and prolonged exposure therapy 

have limited availability for Montana veterans. 

Our data (Tables 6 and 7) show that in both the Montana and non-Montana LC 

population, alcohol and drug use (ICD-9-CM 303-305) were the most common mental 

health disorders. At present, access to specialty substance use therapy is only provided at 

a few CBOCs and contract or fee-basis sites. 

Issue 3: The Vet to Vet Program in Montana 

Vet to Vet was formed in West Haven, Connecticut by a veteran, Mo Armstrong, whose 

vision has been the starting point for chapters in at least 29 states.24 Vet to Vet is self 

directed and does not include use of VHA or other professional counselors, although 

professionals may be invited to present information at chapter meetings. The Vet to Vet 

program is not intended as a substitute or alternative to professional mental health care 

but is an adjunctive source of peer-to-peer support, peer-to-peer education, and a channel 

for outreach. Meetings are led by veteran group members who act as facilitators or cofacilitators. Some chapters affiliated with VHA hold meetings at VHA facilities; other 

affiliated chapters hold meetings at non-VHA sites. Some chapters are not affiliated with 

VHA and may have non-VHA affiliations. Funding for Vet to Vet programs does not 

come from VHA. 

24 Vermont Vet to Vet brochure from website, http://www.vtvettovvet.org/. 

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In Montana, a VAMHS staff member acts as a liaison to Vet to Vet chapters. Veterans 

may come to Vet to Vet spontaneously, through outreach, or through referral from VHA 

providers. In certain circumstances, referral by peers to the VA for professional therapy 

or other services may be suggested to an individual attending a group. If a group member 

expresses suicidal and/or homicidal ideation, efforts will be made to assist the individual 

in receiving immediate professional help.25 

Leadership at Fort Harrison reported that facilitators for the groups try to get vets who 

appear in need of formal mental health services to access the VAMHS system. Mental 

health leadership observed that OIF/OEF veterans seemed less inclined than other era 

veterans to seek help early on for problems. 

At present there are regular meetings of VAMHS affiliated Vet to Vet chapters for 

veterans from all service eras at Fort Harrison, Missoula, Great Falls, and Townsend. 

There are non-affiliated chapters in Kalispell, Polson, and Miles City. At the time of our 

visit to Montana, there were attempts to form new OIF/OEF specific Vet to Vet groups at 

Fort Harrison, Bozeman, and Missoula. Subsequently, we were informed that turnout for 

the proposed OIF/OEF-specific groups was poor and the groups did not launch. 

We were told that most Vet to Vet participants come to Fort Harrison for at least one 

meeting or training. Participants have included veterans of all service eras but OIF/OEF 

veterans were reported to be under-represented. We were told that almost all participants 

in Fort Harrison have enrolled in VHA for care prior to attending Vet to Vet groups. 

Additionally, most have reportedly been seen by a VAMHS mental health provider prior 

to attending Vet to Vet groups. We were told that there have been few participants who 

attended Vet to Vet groups prior to accessing mental health care through VAMHS and 

that a few participants attend only Vet to Vet groups without seeking mental health care 

at VAMHS. These trends were reported to be consistent between VAMHS affiliated Vet 

to Vet sites. 

The Vet to Vet program provides an opportunity to facilitate acceptance and utilization of 

VHA mental health clinical services by those in the group in need of care from mental 

health professionals. For confidentiality purposes, signing an attendance sheet is 

voluntary and some groups do not have attendance sheets. Therefore, analysis of data 

trends regarding utilization of Vet to Vet groups and the ability of Vet to Vet groups to 

help the VAMHS to reach out to veteran populations that are not enrolled in the VA but 

are in need of mental health services is limited to observations that the Vet to Vet group 

facilitators and the VAMHS Vet to Vet liaison shared with us. 

We met with a group of Vet to Vet facilitators who shared their experiences with Vet to 

Vet, the VAMHS, and other issues. One concern expressed was that because of space 

25 Mission statement and program description for Fort Harrison Vet to Vet chapter. 

VA Office of Inspector General 49
                 

           

 

Access to VA Mental Health Care for Montana Veterans

issues the location and schedule for meetings had been disrupted. Plans are to have a 

group room available to the Vet to Vet program during the spring of 2009. 

Conclusions for Issue 3 – The Vet to Vet Program in Montana 

It would appear reasonable for VAMHS to encourage further efforts at forming affiliated 

OIF/OEF-specific Vet to Vet groups as part of their ongoing, comprehensive outreach 

effort, including Vet Center outreach and VHA partnerships with community mental 

health organizations, non-VA providers, veterans groups, and the Montana National 

Guard. 

Conclusions 

We characterized the Montana veteran population who were discharged from active duty 

during July 1, 2005 – September 30, 2006 and compared them with those of their nonMontana veteran counterparts, with a total of nearly one half million recently discharged 

veterans. We examined this Montana veteran population’s access to VA mental health 

care. This is the first report that examines an entire veteran population, whether or not 

they were users of VA care. This population-based approach eliminates the potential bias 

of using only veterans who are VA users, because VA users may differ from non-VA 

users in a fundamentally different way that impacts their choices and utilization of health 

care. 

We pioneered using veterans’ travel times from their home addresses to providers’ 

physical service locations by provider’s available services to address their geographical 

access. Over 95 percent of Montana geo-coded veterans were within 30 minutes of a 

VHA or VHA paid mental health service provider. The VA paid service (fee basis and 

contractual agreement) clearly improved Montana veterans’ geographic access to VA 

mental health care over the access afforded by VA staff alone. This signaled that 

strategies such as paid service or mobile units could be vital to improving veterans’ 

access to VA care in highly rural areas. 

Specific evidence-based therapies for PTSD (cognitive processing therapy and prolonged 

exposure therapy) have limited availability for Montana veterans. Our data show that in 

both the Montana and non-Montana LC population, alcohol and drug use (ICD-9-CM 

303-305) were the most common mental health disorders in addition to PTSD and related 

mental health disorders. At present, access to specialty substance use therapy is limited. 

Our findings may not be generalizable to Montana veterans who were discharged from 

the military during time periods other than July 1, 2005 – September 30, 2006. We had 

no data on these veterans who were not included in the LC database. Studies based on all 

veterans would allow for better strategic planning and resource decisions, improved 

targeting of specific veteran groups for outreach, and identification of required legislative 

VA Office of Inspector General 50
                 

           

Access to VA Mental Health Care for Montana Veterans

and policy changes. We think the current data provide a reasonable sample of veterans 

for this analysis; now we are working to expand the data set. 

Recommendations 

Recommendation 1: We recommended that the VISN 19 Director ensure that the 

VAMHS Director takes steps to increase the availability of evidence-based treatment for 

PTSD for Montana veterans. 

Recommendation 2: We recommended that the VISN 19 Director ensure that the 

VAMHS Director takes steps to increase the availability of specialty substance use 

treatment for Montana veterans. 

VA Office of Inspector General 51
               

           

 

Access to VA Mental Health Care for Montana Veterans

Appendix A 

Contract and Fee-Basis Mental Health Sites and 

Locations of American Indian Reservations 

EMCMHC CMH SCRMH WMMHC 

Miles City Great Falls Billings Anaconda 

Baker Boulder Big Timber Bozeman 

Colstrip Browning Columbus Butte 

Forsyth Chinook Hardin Dillon 

Glendive Choteau Harlowtown Eureka 

Glasgow Conrad Lewistown Hamilton 

Malta Cut bank Red Lodge Kalispell 

Plentywood Havre Roundup Libby 

Scobey Helena Livingston 

Sidney Lincoln Missoula 

Wolf Point Shelby Polson 

Townsend Ronan 

Superior 

Thompson Falls 

Appendix A.1. Locations of mental health sites available under VAMHS contracts. 

Location Number of Providers Location Number of Providers 

Anaconda 2 Libby 1 

Belgrade 2 Livingston 1 

Billings 2 Missoula 2 

Bozeman 1 Polson 2 

Corvalis 1 Ronan 1 

Emigrant 1 Thompson Falls 2 

Great Falls 2 Townsend 1 

Hamilton 1 Valier 1 

Helena 1 Whitefish 1 

Kalispell 2 

Appendix A.2. Location of sites for fee-basis mental health therapists utilized by VAMHS 

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Appendix A 

Appendix A.3. Map of American Indian Reservations in Montana. 

(Source: mt.govTM, Montana’s Official Website). 

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Access to VA Mental Health Care for Montana Veterans

Appendix B 

ICD-9 CM Disease Categories 

1. Infectious and Parasitic Diseases (001-139) 

2. Neoplasms (140-239) 

 Malignant Neoplasms (140-208) 

 Benign Neoplasms (210-239) 

3. Endocrine, Nutritional and Metabolic Diseases, And Immunity Disorders (240-279) 

4. Diseases of the Blood and Blood-Forming Organs (280-289) 

5. Mental Disorders (290-319) 

6. Diseases of the Nervous System and Sense Organs (320-389) 

7. Diseases of the Circulatory System (390-459) 

8. Diseases of the Respiratory System (460-519) 

9. Diseases of the Digestive System (520-579) 

10. Diseases of the Genitourinary System (580-629) 

11. Complications of Pregnancy, Childbirth, and the Puerperium (630-677) 

12. Diseases of the Skin and Subcutaneous Tissue (680-709) 

13. Diseases of the Musculoskeletal System and Connective Tissue (710-739) 

14. Congenital Anomalies (740-759) 

15. Certain Conditions Originating in the Perinatal Period (760-779) 

16. Symptoms, Signs, and Ill-Defined Conditions (780-799) 

17. Injury and Poisoning (800-999) 

V. Supplementary Classification of Factors Influencing Health Status and Contact with 

Health Services (V01-V86) 

VA Office of Inspector General 54
               

 

           

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Appendix C 

ICD-9 CM Mental Disorders (290-319) 

Psychoses (290-299) 

 290 Dementias 

291 Alcohol-induced mental disorders (Alcohol Psychoses) 

292 Drug-induced mental disorders (Drug Psychoses) 

293 Transient mental disorders due to conditions classified elsewhere 

294 Persistent mental disorders due to conditions classified elsewhere 

295 Schizophrenic disorders 

296 Episodic mood disorders (Affective psychoses) 

297 Delusional disorders 

298 Other nonorganic psychoses 

299 Pervasive developmental disorders 

Neurotic Disorders, Personality Disorders, and Other Nonpsychotic Mental Disorders 

(300-316) 

300 Anxiety, dissociative and somatoform disorders (Neurotic Disorders) 

301 Personality disorders 

302 Sexual and gender identity disorders 

303 Alcohol dependence syndromes 

304 Drug dependence 

305 Nondependent abuse of drugs 

306 Physiological malfunction arising from mental factors 

307 Special symptoms or syndromes, not elsewhere classified 

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Appendix C 

308 Acute reaction to stress 

309 Adjustment reaction 

310 Specific nonpsychotic mental disorders due to brain damage 

311 Depressive disorder, not elsewhere classified 

312 Disturbance of conduct, not elsewhere classified 

313 Disturbance of emotions specific to childhood and adolescence 

314 Hyperkinetic syndrome of childhood 

315 Specific delays in development 

316 Psychic factors associated with diseases classified elsewhere 

Mental Retardation (317-319) 

317 Mild mental retardation 

318 Other specified mental retardation 

319 Unspecified mental retardation 

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Appendix D 

V-Codes Indicating a Psychosocial or 

Behavioral Problem 

V15.4 Psychological trauma 

Excludes: 

history of condition classifiable to 290-316 (V11.0-V11.9) 

V60 Housing, household, and economic circumstances 

V60.0 Lack of housing 

Hobos 

Social migrants 

Tramps 

Transients 

Vagabonds 

V60.1 Inadequate housing 

Lack of heating 

Restriction of space 

Technical defects in home preventing adequate care 

V60.2 Inadequate material resources 

Economic problem 

Poverty NOS 

V60.4 No other household member able to render care 

Person requiring care (has) (is): 

family member too handicapped, ill, or otherwise unsuited to render care 

partner temporarily away from home 

temporarily away from usual place of abode 

Excludes: 

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Appendix D 

holiday relief care (V60.5) 

V61 Other family circumstances 

Includes: 

when these circumstances or fear of them, affecting the person directly involved or 

others, are mentioned as the reason, justified or not, for seeking or receiving medical 

advice or care 

V61.0 Family disruption 

Divorce 

Estrangement 

V61.1 Counseling for marital and partner problems 

Excludes: 

problems related to: 

psychosexual disorders (302.0-302.9)
 

sexual function (V41.7)
 

V61.2 Parent-child problems 

counseling for non-parental abuser (V62.83) 

V61.21 Counseling for victim of child abuse 

Child battering 

Child neglect 

Excludes: 

current injuries due to abuse (995.50-995.59)
 

V61.22 Counseling for perpetrator of parental child abuse 

Excludes: 

counseling for non-parental abuser (V62.83)
 

V61.8 Other specified family circumstances 

Problems with family members NEC 

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Access to VA Mental Health Care for Montana Veterans

Appendix D 

Sibling relationship problem 

V61.9 Unspecified family circumstance 

V61.10 Counseling for marital and partner problems, unspecified 

Marital conflict 

Marital relationship problem 

Partner conflict 

Partner relationship problem 

V61.11 Counseling for victim of spousal and partner abuse 

Excludes: 

encounter for treatment of current injuries due to abuse (995.80-995.85)
 

V61.12 Counseling for perpetrator of spousal and partner abuse 

V62 Other psychosocial circumstances 

Includes: 

those circumstances or fear of them, affecting the person directly involved or others, 

mentioned as the reason, justified or not, for seeking or receiving medical advice or care 

Excludes: 

previous psychological trauma (V15.41-V15.49)
 

V62.0 Unemployment 

V62.2 Other occupational circumstances or maladjustment 

Career choice problem 

Dissatisfaction with employment 

Occupational problem 

V62.5 Legal circumstances 

Imprisonment 

Legal investigation 

Litigation 

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Access to VA Mental Health Care for Montana Veterans

Appendix D 

Prosecution 

V62.8 Other psychological 

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Access to VA Mental Health Care for Montana Veterans

Appendix E 

Under Secretary for Health Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 Mar 26, 2009 

From:	 Under Secretary for Health (10) 

Subject: Healthcare Inspection – Access to VA Mental Health Care 

for Montana Veterans (WebCIMS 424681) 

To:	 Assistant Inspector General for Healthcare Inspections 

(54) 

1. I appreciate the opportunity to review and comment on your report about 

access to mental health care for Montana Veterans. Your findings are 

interesting, and reflect broad-based public health issues in rural communities 

that directly impact not only Veterans living in these communities, but also all 

other rural residents. Your report also reflects innovative steps that the VA 

Montana Healthcare System (VAMHS) is taking to improve mental health care 

access by utilizing both community and technological resources. I have 

reviewed Veterans Integrated Service Network 19’s response to your 

recommendations, and believe that their detailed corrective actions 

appropriately address improvement options. 

2. I continue to differ with one of your conclusions, however, that previous 

Veteran access studies that focus only on the enrolled Veteran population are 

inherently biased. VHA is responsible for providing health care to the enrolled 

Veteran population, not just to those enrolled Veterans who are currently VA 

patients. VHA authorized services do not extend to the entire Veteran 

population, regardless of enrollment status. A portion of the non-enrolled 

Veteran population is Priority 8, and currently not eligible to enroll. These 

Priority 8 Veterans may actually comprise a significant segment of the nonOEF/OIF reserve component that you report as having “poorer” access to 

service. Therefore, by including the total Veteran population in the equation, 

your report might misstate the extent of access issues in the VAMHS. 

Nevertheless, the details of your findings are useful, and we will certainly 

reference them in our planning activities. 

VA Office of Inspector General 61
               

           

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Appendix E 

Under Secretary for Health Comments 

3. If additional information is required, please contact Margaret M. Seleski, 

Director, Management Review Service (10B5), at 461-8470. 

(original signed by:) 

Michael J. Kussman, MD, MS, MACP 

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Appendix F 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 March 16, 2009 

From:	 Director, VA Rocky Mountain Network (VISN 19) 

Subject: OIG Draft Report, Healthcare Inspection, Access to VA Mental Health 

Care for Montana Veterans (WebCIMS 424681) 

To:	 Director, Management Review Service (10B5) 

1. There were two recommendation for improvement from this in-depth 

report of VA Montana Healthcare Sustem provision of mental health care to 

veterans. The VISN 19 response is submitted for your review. 

2. Recommendation 1: We recommend that the VISN 19 Director ensures 

that the VAMHS Director takes steps to increase the availability of evidencebased treatment for PTSD throughout Montana 

As the implementation of evidence-based practice is a national effort, the hiring 

of qualified clinicians and training of these and currently employed therapists is a 

priority for VA Montana Health Care System (VAMHCS). An Evidence-Based 

Practice Coordinator has been hired to facilitate the implementation and 

expansion of evidence-based therapy (EBT). VA staff attend VA Central Office 

sponsored EBT trainings, they participate in supported consultation and are 

currently offering evidence-based treatment modalities. 

As indicated in the investigation, VA health care is augmented by contract 

providers throughout the state of Montana. The VAMHCS has sponsored 

trainings for contracted and fee basis mental health providers who serve 

Montana veterans. These EBT trainings included “Seeking Safety”, presented in 

October of 2008 and “Support and Family Education” (SAFE) presented in 

February of 2009. VAMHCS plans to provide additional training opportunities to 

contract providers. Also the newly proposed contract requires clinicians to be 

trained in evidence-based therapies with the expectation that veterans will be 

offered/receiving EBTs per VA standardized protocols. 

We are confident that these combined efforts meet recommendation 1. 

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Access to VA Mental Health Care for Montana Veterans

VISN Director’s Comments 

to Office of Inspector General’s Report 

3. Recommendation 2: We recommend that the VISN 19 Director ensures 

that the VAMHS Director takes steps to increase the availability of specialty 

substance use treatment throughout Montana 

June of 2008, VA Montana Healthcare System received 4.5 Intensive Outpatient 

Program (IOP) positions and is currently in the process of filling these positions. 

Position FTEE Status

Psychiatrist .5 Filled

Psychologist 1.0 To be selected

Addiction Counselor 2.5 .5 Filled

Program Support .5 Filled

The 0.5 Psychiatrist is American Society of Addiction Medicine (ASAM) certified, 

with extensive clinical background in chemical dependency. He will start May 1, 

2009. We are aggressively recruiting to fill the remaining positions. 

VA Central Office also awarded a 1.0 position for a Substance Abuse therapist 

for PTSD. This position has been filled. Additionally a 1.0 Nurse Practitioner has 

been hired and assigned to support substance abuse services and the IOP. 

Currently, we have contract IOP arrangements available for veterans in the 

Eastern part of the State. VA Montana Healthcare is in the process of 

developing a contract agreement with two community mental health centers 

which will provide IOP services and residential support as needed. VA 

Montana’s leadership has been actively developing and implementing a 

comprehensive expansion of specialty substance abuse services which include 

increased VA staffing and increased contract services throughout the state. 

4. The “Access to VA Mental Health Care for Montana Veterans” report 

completed by the OIG was thorough and accurate; however, the report did raise 

concern regarding the use of telehealth for some patients. The quote: “However, 

tele-mental health services may not be appropriate for every patient”. An 

example provided “would be a patient with serious mental illness who has 

delusions focused on being electronically monitored by others.[1]

” I want to 

assure you our veterans are offered services based on their individualized 

preferences. This service is tailored to meet the needs of the veteran. Generally 

[1] Smith Henry A., LCSW, and Ronald A. Allison MA, Telemental Health: Delivering Mental Health Care 

at a Distance; A Summary Report, U.S. Department of Health and Human Services, Substance Abuse and 

Mental Health Services Administration Center for Mental Health Services, Health Resources and Services 

Administration, 1998. 

VA Office of Inspector General 64
               

           

Access to VA Mental Health Care for Montana Veterans

VISN Director’s Comments 

to Office of Inspector General’s Report 

speaking, most veterans with serious and persistent mental illness are seen faceto-face; however, there are veterans, once stabilized on medications, that prefer 

telemental health over face-to-face appointments. The response we have 

received so far has been very positive from our veterans. Few have specifically 

requested to have face-to-face medication management and when they do 

arrangements are made to accommodate. 

5. If you have any questions, please contact Marcie Sardinta (303) 

639-6999. 

(original signed by:) 

Glen Grippen, FACHE 

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Appendix G 

OIG Contact and Staff Acknowledgments 

OIG Contact Limin X. Clegg, Ph.D. 

Director, Biostatistics 

202.461.4705 

Acknowledgments Michael L. Shepherd, M.D. 

Yurong Tan, Ph.D. 

Nathan McClafferty 

Patrick Smith 

Jerome Herbers, M.D. 

Dana L. Moore, Ph.D. 

Patricia Christ 

Richard C. Wright 

Joey Foley 

Jerry Goss 

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Access to VA Mental Health Care for Montana Veterans

Appendix H 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Veterans Benefits 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 

U.S. Senators: Max Baucus, Jon Tester 

U.S. Representative: Dennis Rehberg 

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

VA Office of Inspector General 67