VA Mental Health: Clearer Guidance on Access Policies and Wait-Time Data Needed
Published: 2015-10-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Between 2005 and 2013, the number of veterans receiving mental health care from VHA increased 63 percent, outpacing overall growth in veterans receiving any VHA health care. In fiscal year 2014, VHA spent more than $3.9 billion providing outpatient specialty mental health care (mental health care) to more than 1.5 million veterans.
GAO was asked to examine VHA's efforts to provide timely access to mental health care for veterans. This report examines, among other things, (1) veterans' access to timely mental health care, and (2) VHA's related oversight. GAO conducted site visits to five VAMCs selected to provide variation in factors such as location and mental health care utilization rates; reviewed a randomly selected, nongeneralizable sample of 100 medical records (20 from each of the five selected VAMCs) for veterans new to mental health care who received treatment between July 1, 2014, and September 30, 2014; and interviewed VHA and VAMC officials on VHA's measures and oversight of access to mental health care. GAO evaluated VHA's oversight of access to mental health care against relevant federal standards for internal control.
section_title: What GAO Found
paragraphs: The way in which the Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) calculates veteran mental health wait times may not always reflect the overall amount of time a veteran waits for care. VHA uses a veteran's preferred date (determined when an appointment is scheduled) to calculate the wait time for that patient's full mental health evaluation, the primary entry point for mental health care. Of the 100 veterans whose records GAO reviewed, 86 received full mental health evaluations within 30 days of their preferred dates. On average, this was within 4 days. However, GAO also found
veterans' preferred dates were, on average, 26 days after their initial requests or referrals for mental health care, and ranged from 0 to 279 days. Further, GAO found the average time in which veterans received their first treatment across the five VA medical centers (VAMC) in its review ranged from 1 to 57 days from the full mental health evaluation.
conflicting access policies for allowable wait times for a full mental health evaluation—14 days (according to VHA's mental health handbook) versus 30 days (set in response to recent legislation) from the veteran's preferred date—created confusion among VAMC officials about which policy they are expected to follow. These conflicting policies are inconsistent with federal internal control standards and can hinder officials' ability to ensure veterans are receiving timely access to mental health care.
VHA monitors access to mental health care, but the lack of clear policies on wait-time data precludes effective oversight. GAO found VHA's wait-time data may not be comparable over time and between VAMCs. Specifically
data may not be comparable over time. VHA has not clearly communicated the definitions used, such as how a new patient is identified, or changes made to these definitions. This limits the reliability and usefulness of the data in determining progress in meeting stated objectives for veterans' timely access to mental health care.
data may not be comparable between VAMCs. For example, when open-access appointments are used, data are not comparable between VAMCs. Open-access appointments are typically blocks of time for veterans to see providers without a scheduled appointment. GAO found inconsistencies in the implementation of these appointments, including one VAMC that manually maintained a list of veterans seeking mental health care outside of VHA's scheduling system. Without guidance stating how to manage and track open-access appointments, data comparisons between VAMCs may be misleading. Moreover, VAMCs may lose track of patients referred for mental health care, placing veterans at risk for negative outcomes.
section_title: What GAO Recommends
paragraphs: GAO recommends that VHA issue clarifying guidance on (1) access policies; (2) definitions used to calculate wait times; and (3) how open-access appointments are to be managed. VHA concurred with GAO's recommendations but disagreed with certain of its findings, for example, GAO's calculation of overall wait-times. GAO maintains its findings, as discussed in the report, are valid.

section_title: Letter
paragraphs: The Veterans Health Administration (VHA), within the Department of  Veterans Affairs (VA), has seen a significant increase in demand for  mental health services. Between 2005 and 2013, the number of veterans  who received mental health care from VHA increased 63 percent, more  than 3 times the rate of increase seen in the overall number of veterans  using any VHA health care services. VHA reported a significant portion of  this increase was due to an influx of veterans returning from the conflicts  in Iraq and Afghanistan, and to its proactive screening to identify veterans  with symptoms that may be associated with depression, post-traumatic  stress disorder (PTSD), substance abuse disorder, or who may have  experienced military sexual trauma.
In fiscal year 2014, VHA estimated that more than 1.5 million veterans  obtained outpatient mental health care for conditions such as PTSD,  depression, and substance abuse. VHA provides mental health care in  its more than 1,200 facilities in both specialty settings—those that  primarily provide mental health care—and in other settings, such as  primary care. Additionally, VHA may pay for mental health care provided  by non-VA providers in the community. In fiscal year 2014, VHA spent  more than $3.9 billion providing outpatient specialty mental health care in  its facilities, and more than $34 million for outpatient specialty mental  health care provided by non-VA providers.
In recent years, we and others have expressed concerns about veterans’  ability to access timely mental health care, and VHA’s oversight of patient  scheduling practices. For example, we previously identified the reliability  of reported wait times and patient scheduling oversight as areas for  improvement. Also, in 2012, the VA Office of Inspector General (OIG)  reported that VHA was not consistently providing new veterans with  timely access to comprehensive mental health evaluations, and had  overstated its success in providing veterans with timely new and follow-up  appointments for mental health treatment. An August 2012 Executive  Order directed VHA to improve mental health access by, among other  things, hiring additional staff and gauging the effectiveness of the use of  community-based providers by establishing a community provider pilot  program. In addition, the Veterans Access, Choice, and Accountability  Act of 2014 (Choice Act), enacted in August 2014, provided additional  non-VA care options for veterans facing long waits or lengthy travel  distances to obtain VHA health care services.
You asked us to examine issues related to VHA’s efforts to provide timely  access to mental health care for veterans. This report examines  1.  veterans’ access to timely mental health care,  2.  VHA’s oversight of timely access to mental health care,  3.  VHA’s hiring of mental health staff since 2012 and the effects, if any,  of that hiring on access to mental health care, and  4.  VHA’s community provider pilot program’s effects, if any, on veterans’  access to mental health care.
We limited our scope to outpatient specialty mental health care, which we  refer to as mental health care for the purposes of this report, because the  majority of veterans with either a possible or a confirmed mental illness,  about 70 percent and 85 percent respectively, are treated by VHA  through outpatient mental health. To address all four objectives, we  conducted site visits to five VA medical centers (VAMC): Atlanta VAMC  (Decatur, Georgia); George H. O’Brien, Jr. VAMC (Big Spring, Texas);  Hunter Holmes McGuire VAMC (Richmond, Virginia); Portland VAMC  (Portland, Oregon); and Sioux Falls VA Health Care System (Sioux Falls,  South Dakota). These VAMCs were selected for variation in facility  complexity level, geographic location, mental health care utilization,  mental health appointment wait times, the number of mental health staff  hired since 2012, and participation in the community provider pilot  program. At each site, we visited the VAMC as well as one affiliated  community-based outpatient clinic (CBOC) that provided mental health  care. Additionally, at the two sites that participated in the community  provider pilot program, we visited two of the community-based providers  that participated in the program. The results from our five VAMC visits  cannot be generalized to all VHA facilities.
To examine veterans’ ability to access timely mental health care and  VHA’s oversight of this access, we reviewed relevant VHA and VAMC  documents, and interviewed staff from VHA’s central office, the five  selected VAMCs, and the five Veterans Integrated Service Networks  (VISN) that oversee the selected VAMCs about the current policies and  guidance for scheduling mental health appointments. We also  interviewed stakeholders from other key organizations, such as Vet  Centers and veteran service organizations, to gain their perspectives on  mental health care access. Further, for each of the five VAMCs we  visited, we reviewed a randomly selected sample of medical records to  assess the timeliness in which veterans received mental health  appointments. Our sample included 100 new veteran records, 20 for  each VAMC, generally composed of 10 records for veterans who had a  diagnosis of PTSD and 10 records for veterans who had any other (i.e.,  non-PTSD) mental health diagnoses. We considered veterans with PTSD  separately because PTSD is considered one of the signature injuries of  the conflicts in Iraq and Afghanistan. For new veterans, we examined the  timeliness in which they received comprehensive mental health  evaluations and follow-up mental health appointments as defined in  VHA’s policies, and, for new veterans with PTSD, we evaluated whether  or not they were referred to, and completed, evidence-based therapies for  PTSD—treatments specified by VHA as shown to be effective—in  accordance with VHA’s policies. Four of the five VAMCs we visited  offered inpatient mental health care. For those four VAMCs, we also  reviewed 20 records, 5 from each VAMC, of recently discharged  inpatients to assess the timeliness of their first follow-up mental health  appointments following discharge. Additionally, we reviewed a random  sample of 15 records from a list one of the VAMCs we visited used to  track veterans outside of VHA’s scheduling system. We reviewed these  records to see whether the veterans received mental health care. Due to  the small sample size of our medical record reviews, the results cannot  be generalized across any single VHA facility or to all VHA facilities.  Lastly, we evaluated VHA information on veteran wait times for mental  health appointments and VHA’s oversight of access to mental health care  against the federal internal control standards related to control activities,  information, and monitoring.
To examine VHA’s hiring of mental health staff since 2012 (the year of the  relevant Executive Order) and any effects on access to mental health  care, we analyzed national VHA mental health workforce data from fiscal  year 2010 through fiscal year 2014, as well as the number of full-time- equivalent staff providing outpatient mental health care, before and after  the hiring initiative. We also analyzed VHA data on hires by position type  to determine the number and types of mental health staff hired as a result  of the hiring initiative. Additionally, we reviewed vacancy rate data for  mental health staff at each of the five VAMCs we visited and across VHA  as of March 2015. We reviewed relevant VHA and VAMC documentation  related to staffing and hiring initiatives and interviewed VHA, VISN, and  VAMC officials about recruitment, hiring, and retention of outpatient  specialty mental health staff, any effects these initiatives had on access to  care, and the challenges to hiring or placing new staff. To determine the  reliability of the workforce and vacancy data, we reviewed related  documentation; performed manual and electronic tests of the data to  identify any outliers or anomalies; and followed up with officials as  necessary, incorporating the corrections we received. We determined that  the data were sufficiently reliable for the purposes of our review. Finally,  we reviewed a random, nongeneralizable sample of 30 records from  VAMC transfer lists—15 from each of the two VAMCs we visited that  were using them—that track veterans waiting for mental health care  appointments at preferred locations. We reviewed the records to identify  whether these veterans were receiving care while waiting to be  transferred to their preferred locations.
To examine the community provider pilot program’s effects, if any, on  veterans’ access to mental health care, we reviewed relevant VHA  documents related to the pilot program and other non-VA care programs  and interviewed VHA, VISN, and VAMC staff on the use of these  programs. We also collected information from the 10 VAMCs that referred  veterans to community provider pilot sites to assess the extent to which  VHA has referred veterans to these providers, and reviewed VHA’s pilot  program evaluation and related veteran satisfaction survey results.
We conducted this performance audit from September 2014 to October  2015 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: VHA provides a range of treatments and services to improve the mental  health of veterans, including teaching coping skills and offering tailored  programs to treat specific problems, such as depression, PTSD, and  substance abuse disorders, and to promote recovery. When needed  mental health care is not available through a local VHA provider, VHA has  avenues by which veterans may obtain care from non-VA providers in the  community.
subsections: section_title: Veterans’ Access to Mental Health Care
paragraphs: VHA policy states that veterans are entitled to timely access to mental  health care. There are a number of ways a veteran may seek access to  mental health care. (See fig. 1.) Upon initial referral or request for mental  health care, veterans new to mental health care (those not seen by a  mental health provider within the past 24 months through VHA) are to  receive initial assessments from either referring providers (such as  primary care physicians) or mental health providers; these assessments  identify those who need urgent or immediate access to mental health  care. Following the initial assessment, a veteran is to receive timely  access to a comprehensive mental health evaluation that includes a  diagnosis and a plan for treatment. The comprehensive evaluation— referred to as a full mental health evaluation—serves as a veteran’s main  entry point to mental health care.
Additionally, established veterans (those who already have received  mental health care within the past 24 months through VHA) are to receive  timely access to follow-up care. Follow-up care may be provided by a  single provider or, for those veterans who need a range of services, by  multiple providers. For example, a veteran may receive ongoing care from  both a psychiatrist and a psychologist to manage their symptoms.  Veterans with specific diagnoses, such as PTSD, are to be considered for  evidence-based therapies, such as cognitive processing therapy or  prolonged exposure therapy, as clinically appropriate. Furthermore,  veterans discharged from inpatient mental health stays are to receive  timely access to follow-up outpatient mental health care.
VHA’s scheduling policy establishes processes and procedures for  scheduling medical appointments, including mental health  appointments. This policy requires schedulers to obtain and correctly  record the preferred date—the date on which the veteran wants to be  seen—in VHA’s Veterans Health Information Systems and Technology  Architecture (VistA). VistA’s scheduling component was implemented in  1985 and VA is considering several options for updating or replacing this  scheduling component.
section_title: VHA Wait Time and Performance Data
paragraphs: In 1995, VHA established a policy of scheduling specialty care  appointments, including mental health appointments, within 30 days of  the date the veteran would like to be seen. In fiscal year 2011, based on  reported improved performance, VHA shortened its wait-time policy to 14  days for new veterans. In fiscal year 2015, VHA set a new policy for new  veterans in response to the Choice Act that veterans should be seen  within 30 days of the date the veteran wants to be seen. Currently, VHA  also has a policy of providing outpatient mental health care to a veteran  discharged from an inpatient mental health stay within 7 days and for  providing follow-up care to an established veteran within 30 days of the  clinically indicated date, commonly referred to as the return-to-clinic date.
To facilitate accountability for achieving its wait-time policies, VHA  includes wait-time and other performance data, such as the “missed  opportunity” rate—the percentage of scheduled appointments that were  not used because veterans did not show up for their appointments—in  several internal and external reports. VHA also makes publicly available  on its website its patient access reports (including monthly average wait  times for completed and pending mental health appointments for each  VAMC), and its Strategic Analytics for Improvement and Learning (SAIL)  reports, which assess VAMC performance across 25 quality measures,  including death and medical complication rates, customer satisfaction,  and access (based on wait-time data).
section_title: VHA Mental Health Providers
paragraphs: To meet the needs of veterans seeking mental health care, VHA has  sought to increase its mental health staff, including the number of  psychiatrists, psychologists, social workers, peer specialists and other  mental health professionals. In 2012, VHA began a two-part hiring  initiative: (1) VHA’s recruitment effort focused on hiring 1,600 new mental  health professionals, 300 new non-clinical support staff and filling existing  vacancies starting in June 2012; and (2) Executive Order 13265, issued  in August 2012, authorized the hiring of 800 peer specialist positions by  December 31, 2013, along with reiterating VHA’s goal of hiring 1,600 new  mental health professionals by June 30, 2013.
section_title: Non-VA Medical Care
paragraphs: Generally, eligible veterans may utilize the Non-VA Medical Care  Program when a VAMC is unable to provide certain specialty care  services, or when the veteran would have to travel long distances to  obtain care at a VAMC. Non-VA providers generally treat veterans in non- VA facilities, such as physicians’ offices or hospitals in the community,  and are commonly paid by VHA using a fee-for-service arrangement.
There are several ways veterans can obtain care from non-VA  providers. For example, the August 2012 Executive Order required VHA  to establish partnerships with community-based providers, such as  community mental health clinics (CMHCs), under a pilot program, to help  meet veterans’ mental health needs in a timely manner. The goal for the  pilot program was to decrease wait times and increase the geographic  reach of VHA mental health services. The Executive Order required VHA  to establish at least 15 pilot sites by February 27, 2013. In addition, in  2013, VA established the Patient Centered Community Care (PC3)  program to deliver care to veterans when local VAMCs and CBOCs  cannot provide the care due to demand exceeding capacity, geographic  inaccessibility, or other factors. More recently, the Choice Act  authorized non-VA care, including mental health care, for veterans with  certain access challenges. Under this authority, VHA created the  Veterans Choice Program (VCP) with the goal of meeting demand for  health care in the short term. Beginning in November 2014, for example,  certain veterans were able to receive non-VA care if the next available  medical appointment with a VA provider was more than 30 days from  their preferred date or if they lived more than 40 miles from the nearest  VA facility. Recently passed legislation requires VHA to submit a plan to  Congress by November 1, 2015 for consolidating its Non-VA Medical  Care programs under a single program.
section_title: Most Veterans in Our Review Received Care within 30 Days of Their Preferred Dates, but VHA’s Method of Calculating Wait Times Does Not Always Reflect Overall Wait Times
subsections: section_title: Most Veterans Received Full Mental Health Evaluations within 30 Days of Their Preferred Dates, though VHA’s Access Policies Conflict
paragraphs: Most veterans included in our review received full mental health  evaluations, which provide new veterans with an entry point to access  mental health care, in an average of 4 days of their preferred dates. At  the five VAMCs we visited, the average time in which a veteran received  this full evaluation ranged from 0 to 9 days from the preferred date. (See  table 1.)
VHA has two policies that conflict in their definitions of timely access to a  full mental health evaluation for a veteran new to VHA mental health care:  (1) a 14-day policy established by VHA’s Uniform Handbook for Mental  Health Services, and (2) a 30-day policy set by VHA in response to the  Choice Act. To date, VHA has not provided guidance on which policy  should be followed, which is inconsistent with federal internal control  standards that call for management to clearly document, through  management directives or administrative policies, significant events or  activities, such as ensuring timely access to mental health care, to help  ensure management directives are carried out properly. VHA officials  told us they are aware of the discrepancy and that there is an internal  group working to revise the access policies for mental health care, as well  as the Uniform Handbook, to ensure consistency, but the officials could  not provide a timeline for completion. When we assessed the veteran  records included in our sample against these two policies, we found that,  across all five VAMCs, 86 of the 100 veterans included in our review  received a full mental health evaluation within 30 days of the preferred  date and 81 veterans received this evaluation within 14 days. As a result  of the conflicting policies, a number of VHA officials, including VISN and  VAMC officials, told us they do not know which policy they are currently  expected to meet, which may make it difficult for them to ensure timely  access in light of increasing demand for mental health care. By not  clarifying which access policy currently applies to mental health care,  VHA is limited in its ability to effectively manage timely access to mental  health care.
section_title: VHA’s Method of Calculating Wait Times Does Not Always Reflect Veterans’ Overall Wait Times for Appointments and Services
paragraphs: Although the averages for the time between veterans’ preferred dates and  their full mental health evaluations were generally within several days,  they may not reflect overall wait times. We found that because VHA uses  veterans’ preferred appointment date—not the date veterans initially  request or are referred for mental health care—as the basis for its wait- time calculations, these calculations may only reflect a portion of  veterans’ overall wait time. This occurs because veterans generally are  not asked for their preferred dates until some period of time after they  request or are referred for mental health care. (See fig. 2.)
On average, our review of 100 new veteran records found that a veteran’s  preferred date was 26 days after their initial request or referral for mental  health care, though this varied by VAMC. (See table 2.)
Delays between initial request or referral date and a veteran’s preferred  date may be due to a veteran not wanting to start treatment immediately.  However, based on our review of records, we also found that some  patients were delayed in receiving care because a facility did not  adequately handle a referral to mental health care.
For example, one veteran received a referral to psychology in  November 2013 when the referring provider noted that the veteran  should be evaluated for PTSD. However, no contact was made with  the veteran until the veteran called back in July 2014 and asked for an  evaluation. As a result, the veteran’s preferred date was 279 days  after the initial referral.
Another referral led to a veteran waiting 174 days between their initial  referral for mental health care and their preferred date. The veteran’s  primary care provider was supposed to have placed a referral to  psychology in March 2014, but we could not find evidence of the  referral ever being placed. Despite not placing a proper referral, the  veteran’s primary care provider alerted a VHA psychologist who  reached out to the patient in March 2014, by phone, but did not leave  a message. No VAMC mental health provider reached out again until  September 2014, after the veteran’s primary care provider made a  referral (this time documented correctly). The veteran was then able  to schedule a full mental health evaluation approximately 1 week later.
One veteran called the suicide prevention hotline in August 2014  expressing suicidal thoughts and then hung up. The hotline staff  contacted the VAMC and the local authorities who found the veteran  intoxicated and took him to a local jail to stabilize. The VAMC  contacted the veteran a couple days later to discuss mental health  treatment (which the veteran declined at the time) but did not follow  up again with the veteran until February 2015, when the veteran  contacted a VHA social worker to say he was suffering from severe  depression and continued to have suicidal thoughts. As a result, the  veteran’s preferred date was 181 days after the initial contact for  mental health care.
Veterans who receive a full mental health evaluation may experience  additional delays in receiving treatment. Our review found that veterans  do not always begin treatment specific to their mental health condition  (such as a prescription for medication or a course of psychotherapy) at  the appointment in which they receive their first full mental health  evaluation. We found this for 50 of the 100 new veterans whose records  we reviewed.
One veteran called into a VAMC expressing suicidal thoughts and  was seen the same day for a full mental health evaluation, but no  appointment for treatment was made at that time as the veteran was  starting a new job. The veteran did not receive treatment for more  than 7 months and the mental health providers at the facility did not  document any attempts to contact the veteran during that time.
Two veterans with PTSD, both initially referred in March 2014,  received their full mental health evaluations in April 2014, within 30  days of their initial requests or referrals. However, neither received  treatment until August 2014, nearly 4 months after their full mental  health evaluations.
Another veteran was initially referred to mental health care in  September 2014 after a screening for veterans returning from the  recent conflicts in Iraq and Afghanistan. While the veteran was seen  for a full mental health evaluation within 30 days and subsequently  seen in a PTSD orientation group, the veteran did not receive  treatment until December 2014, nearly 80 days from the time of the  full mental health evaluation. The veteran’s file provided no indication  of the reason for the treatment delay.
Based on our records review, we found that whether veterans received  treatment for their mental health conditions during their full evaluation  appointments was generally dependent on the type of mental health  professional who conducted the evaluation. Generally speaking, veterans  who were evaluated by a psychiatrist received some type of mental health  treatment during their full evaluation appointments, while veterans who  were evaluated by a psychologist or substance abuse professional often  did not receive treatment specific to their mental health condition at their  full evaluation appointments. We found that the timeliness in which  veterans received this first treatment varied by VAMC included in our  review. (See table 3.)
The differences between the date of the initial request or referral to care  and the preferred date are consistent with previous findings by the VA  OIG, which found in 2012 that VHA’s starting point for its wait-time  calculation was not a meaningful measurement of a veteran’s waiting time  to receive an evaluation. VHA officials agreed that the current  calculation does not capture the time between when a veteran is referred  to or requests mental health care and when the veteran is contacted to  schedule a mental health appointment or to when a particular course of  treatment starts, but also said there is currently no consensus on the  appropriate standard or measure for when the calculation should begin or  end.
section_title: VHA Is Generally Meeting Access Policies for Other Types of Mental Health Appointments
paragraphs: VHA’s Uniform Handbook also defines policies for timely access to other  types of mental health appointments, such as follow-up appointments and  outpatient appointments following discharge from an inpatient mental  health stay. In particular, established veterans should receive follow-up appointments within 30  days of their return-to-clinic dates;  veterans recently discharged from inpatient mental health stays  should receive outpatient appointments (either by phone or in-person)  within 7 days of discharge; and  veterans with PTSD should receive evidence-based therapies for  PTSD.
Our review found that veterans generally received follow-up appointments  and post-discharge appointments in accordance with the Uniform  Handbook. Specifically, 126 of the 134 veterans’ appointment records  that we reviewed and included a return-to-clinic date documented by the  provider received follow-up appointments within 30 days of that return-to- clinic date. In addition, our review of 20 veterans discharged from  inpatient mental health units at the four VAMCs we visited that provided  inpatient mental health care found that these veterans received an  outpatient follow-up within 2 days of discharge, on average, and all but  one received this follow-up within 7 days of discharge. However, our  review found that not all veterans received evidence-based PTSD  therapy. Out of the 51 veterans with a diagnosis of PTSD whose records  we reviewed, 7 entered into PTSD evidence-based treatment and 44 did  not. Mental health providers we interviewed said veterans with PTSD do  not always receive these treatments because providers a) do not feel the  veteran is appropriate for this intensive treatment, b) have limited  availability in their schedule for this level of intensive treatment and, as a  result, only select the candidates mostly likely to succeed, or c) the  veteran declines.
section_title: VHA Monitors Access to Mental Health Care, but Current Policies Cannot Ensure Reliable Data, Which Precludes Effective Oversight
paragraphs: VHA monitors access to mental health care through on-site reviews of  clinic operations and sharing data, internally and externally, on mental  health access, but the lack of clear policies for reliable data on veteran  wait times and missed opportunities precludes effective oversight.  Among other things, VHA’s on-site reviews are to determine compliance with the policies for mental health care, as  defined in the Uniform Handbook;  reduce variability in access and quality of mental health care  nationwide; and  identify best practices and areas for growth at each VAMC.
We reviewed the findings of the most recent VHA on-site review for each  of the five VAMCs we visited. VHA’s recommendations included having  one VAMC clarify local policies for referring veterans to mental health and  establishing clear criteria on when veterans who have completed  treatment should be discharged to primary care or other providers for  ongoing monitoring and maintenance. VHA also recommended that  another VAMC revise local policies for addressing veteran “no shows”— when a veteran did not attend their appointment and did not cancel in  advance—to be consistent with VHA requirements. Following the visits,  VHA requires VAMCs to submit corrective action plans that detail how the  recommendations will be implemented. For example, one VAMC’s action  plan stated that it revised the local no-show policy and trained relevant  staff.
VHA officials said they also share data on mental health access, such as  appointment wait times and VAMCs’ missed opportunities rate, with VISN  and VAMC staff through internal VHA websites and with the public  through its SAIL and patient access reports. However, our previous work,  as well as that of the VA OIG, has shown that VHA wait-time data is  unreliable and prone to errors and interpretation. Among other things,  we found in December 2012 that VAMCs were not implementing VHA’s  scheduling policies in a consistent manner, which led to unreliable wait- time data. While VHA has taken steps to increase training in proper  scheduling practices, we found three additional reasons contributing to  the unreliability of VHA’s mental health care wait-time data, which is  inconsistent with federal internal control standards that state management  should use and communicate, both internally and externally, quality  information to achieve its objectives. These include: (1) the wait-time  data-entry process has the potential for errors, (2) data may not be  comparable over time, and (3) data may not be comparable across  VAMCs. In addition, we found that one VAMC was using a document  outside of VHA’s scheduling system to track veterans referred for a  certain type of mental health clinic.
The wait-time data entry process has the potential for errors. Wait- time data relies on information entered at the time an appointment is  scheduled, a process which we found has the potential for errors,  including scheduler errors (e.g., entering an incorrect preferred date) that  are compounded by high turnover in these positions, limitations with the  scheduling system (e.g., the ability to view only appointments that follow a  veteran’s entered preferred date, not those that fall on the day(s) leading  up to that date), and variation in how the preferred date is determined  (e.g., providers basing their preferred return-to-clinic date on appointment  availability instead of on the veteran’s preferred date). For example, we  found one case where VHA’s system-generated wait-time data was  calculated incorrectly, based on our review of the records. We identified  that the scheduler did not properly search for the next available  appointment and, as a result, the VistA scheduling system incorrectly  used the date the appointment was created (as opposed to the veteran’s  preferred date) to calculate the VHA wait time. VAMC officials said this is  an easy mistake to make because of the limitations of VHA’s scheduling  system.
Officials from all of the VAMCs we visited told us that there is the potential  for scheduling errors. As result, they may not always be able to rely on  VHA’s aggregated wait-time data. Instead, some officials said they need  to view individual-level information to monitor timely access, which can be  time consuming and burdensome. Specifically, officials from one VAMC  said that each day they review all scheduled appointments to identify and  correct scheduling errors that may affect the accuracy of their data. We  found in December 2012, that VHA’s scheduling policy was unclear and  subject to interpretation and this led to difficulty achieving consistent and  correct application of the policy by schedulers. As a result, we  recommended that VHA update its scheduling policy or identify wait-time  measures that are not subject to interpretation or prone to scheduling  error. Until VHA clarifies its scheduling policy so that it is not as subject  to interpretation or error, or develops new wait time measures, as we  recommended, it is likely to continue to have data errors and may be  missing an opportunity to improve the reliability, and thus usefulness, of  its data.
Data may not be comparable over time. VHA has changed the  definitions used to calculate various mental health wait-time measures;  thus, these measures may not be comparable over time. For example,  VHA officials said that in fiscal year 2014 the definition of a ‘new mental  health patient’ changed from an individual who had not been seen within  a specific mental health clinic, such as the general mental health clinic or  PTSD clinic, to an individual who had not been seen in any mental health  clinic. According to VHA officials, this change was made because some  veterans were being incorrectly flagged as new in the scheduling system  if their appointments with their regular providers were scheduled in a  different clinic (e.g., general mental health versus PTSD) than normal. A  number of VHA officials, including VAMC and VISN officials, told us they  were not sure which definitions were in effect at the time of our interviews  or gave conflicting answers about which definitions were currently being  used, which is contrary to federal internal controls standards that call for  management to communicate relevant and reliable information in a timely  manner. VHA has not clearly communicated the definitions used or  changes to the definitions, which limits the reliability and usefulness of the  wait-time data and VHA’s ability to use these measures to determine  progress in meeting stated objectives for veterans’ wait times. Until VHA  clarifies how different access measures are defined and calculated, and  communicates any changes over time, local and VISN officials are likely  to face difficulties accurately assessing wait times, and identifying needed  improvements.
Data may not be comparable between VAMCs. In particular, data may  not be comparable when VAMCs use open-access appointments (i.e.  blocks of time where veterans may see providers without a scheduled  appointment). Specifically, two VAMCs we visited often referred veterans  to open-access appointments. In these cases, because appointments  were not scheduled until veterans came to the VAMC to be seen, the  preferred and appointment dates were the same and wait times were  calculated as 0 days, regardless of when veterans requested or were  referred for mental health care. Additionally in these cases, because  appointments were not scheduled prior to veterans showing up for care,  the VAMC’s missed-opportunity rate may have been lower and may not  be comparable to that of other VAMCs that did not use open-access  appointments.
We found that one of the VAMCs we visited had a list of veterans referred  to open-access appointments rather than being given specific  appointments. This list was maintained outside of VHA’s scheduling  system in a spreadsheet that was not systematically updated. Officials  stated the spreadsheet was not used for clinical decision-making.  However, the manual maintenance of the list raises concerns about the  potential to lose track of veterans who may have needed mental health  services more urgently. This VAMC’s own documentation stated that  there is no system in place to alert providers if a patient did not arrive for  an open-access appointment, limiting officials’ ability to follow up at least  three times in accordance with VHA’s policy to contact veterans at least  three times if they miss an appointment without canceling, referred to as  their no-show policy. To mitigate the risk of lack of follow up for these  veterans, VAMC officials told us that prior to being placed on this open- access appointment list, veterans receive a telephone screening by a  mental health nurse who determines their risk level, but also to give  veterans themselves an opportunity to determine if and when they should  be seen.
Of the 644 veterans who were placed on the referral list for open-access  appointments at this VAMC in fiscal year 2014 and through February  2015, close to half (278) were reported as not having shown, and were  generally either mailed a letter reminding them about the open-access  clinic or had no action recorded. We randomly selected 15 of these  veterans’ medical records for review, and found inconsistencies with the  VAMC’s application of VHA’s no-show policy for veterans that did not  attend an appointment. Just over half, 8 veterans, did not receive mental  health care through the open access clinic or through an individual  appointment. Of these 8 veterans, only 1 was contacted three or more  times to remind them of the need to be seen—in accordance with VHA’s  no-show policy. The other 7 veterans were not adequately contacted and  received phone calls, one letter, or no reminders. One of the veterans that  did not receive any type of reminder was brought to the emergency  department 1 month later by local police stating that he felt suicidal. The  veteran was then admitted for inpatient mental health care. Another  veteran was referred to an open-access appointment in January 2015,  but did not attend an open access appointment and was not in contact  with VHA again until the veteran called in May 2015.
VHA does not have guidance that clarifies how open-access  appointments should be used, how such appointments should be  scheduled, or how veterans referred for these types of appointments  should be tracked. This is inconsistent with federal internal controls that  call for management to clearly document policies for significant activities  to help ensure management’s directives are carried out properly. As a  result, officials at the VAMCs who used open-access appointments said  they were unclear about how they could be used, how they should be  entered into VHA’s scheduling system, and whether local tracking  mechanisms were compliant with VHA scheduling policies. Officials from  one of these VAMCs also said that while they referred some veterans to  open-access appointments, they also began giving these veterans  scheduled appointments after VHA officials told them that not providing  scheduled appointments may not comply with VHA’s scheduling policy.  In addition, VHA officials said they were not aware of uniform guidance  about open-access appointments, and that this lack of guidance could  explain why different VAMCs use different approaches. Without guidance  on how appointment scheduling for open-access clinics is to be managed,  VAMCs can continue to implement these appointments inconsistently,  and place veterans on lists outside of VHA’s scheduling system,  potentially leading to serious negative health outcomes for veterans that  need mental health care.
section_title: VHA’s Hiring Initiative Met Goals, but VAMCs Reported Continued Challenges in Hiring Mental Health Staff and Meeting the Growing Demand for Mental Health Care
subsections: section_title: VHA’s Hiring Initiative Met Its Goals, but VAMCs Reported Continued Challenges Hiring and Placing Mental Health Providers
paragraphs: VHA increased mental health staff at its facilities nationwide through a  two-part hiring initiative: (1) VHA’s recruitment effort focused on hiring  1,600 new mental health professionals, 300 new non-clinical support staff  (such as scheduling clerks), and filling existing vacancies starting in June  2012; and (2) Executive Order 13265, issued in August 2012, which  authorized the hiring of 800 peer specialist positions by December 31,  2013, along with reiterating VHA’s goal of hiring 1,600 new mental health  professionals by June 30, 2013. As a result of this initiative, which  included both inpatient and outpatient mental health positions, VHA hired  about 5,300 new clinical and non-clinical mental health staff. In  particular, VHA hired:
1,667 new mental health staff (as of June 30, 2013);
304 non-clinical support staff (as of June 30, 2013);
2,357 staff to fill existing mental health vacancies and any vacancies  that opened during the initiative (as of June 30, 2013); and
932 peer specialists (as of December 31, 2013).
VHA hired various types of mental health staff to fill positions under the  agency’s hiring initiative. (See table 4.) Many hires were for social  workers and psychologists, positions that officials at VAMCs we visited  reported hiring as part of the hiring initiative.
Officials at the five VAMCs we visited reported local improvements in  access to mental health services due to the additional hiring. For  example, officials at one VAMC reported being able to offer more  evidence-based therapies as a result of the additional hiring. Officials at  this VAMC, as well as officials at a second VAMC and two CBOCs,  reported being able to provide mental health care at new locations where  they were unable to do so prior to the hiring initiative. For example, prior  to the hiring initiative, officials at one VAMC said one of their CBOCs had  no capacity to provide mental health therapy services. As a result of the  hiring, VAMC officials were able to add a psychologist at that CBOC who  now provides mental health therapy and testing services for veterans who  visit that location.
Further, officials at four of the five VAMCs we visited cited the benefits of  having the additional peer specialist hires to assist mental health  professionals in performing a variety of therapeutic and supportive tasks  with fellow veterans. Peer specialists at the facilities we visited said they  educate veterans on available mental health services, provide peer  counseling, engage veterans who are resistant to discussing mental  health issues, model effective coping techniques, and co-facilitate therapy  groups. While VAMC officials cited the benefits of the peer specialists,  they also said they initially did not receive clear guidance from VHA on  their intended role and thus were unsure how to incorporate the position  into the provision of mental health care. Consequently, officials said it  took more time to take full advantage of these newly hired positions.
Although VHA considered their hiring initiative a success, officials at the  five VAMCs we visited reported a number of challenges in hiring and  placing mental health providers, including
Pay disparity with the private sector. Officials at all the VAMCs we  visited said that VHA salaries for mental health professionals were not  competitive with private sector salaries. For example, officials at one  VAMC said they experienced difficulties in recruiting mental health  staff, such as psychiatrists, and lost prospective hires to the private  sector.
Competition among VAMCs. Officials at three of the five VAMCs we  visited also stated that, because every VAMC across the country was  trying to fill mental health staff positions at the same time during the  hiring initiative, competition among the different VAMCs was high. For  example, officials at one VAMC said they made offers to candidates  who then used those offers as leverage to secure higher offers at  other VAMCs.
Lengthy hiring process. Even when candidates were available to fill  positions, officials at four of the five VAMCs we visited stated that  VHA’s lengthy hiring process—which could take anywhere from 3  months to more than 1 year—was a challenge, possibly resulting in  losing candidates who took positions elsewhere during that time.  Officials at one VAMC attributed the delays to a lack of human  resources staff to complete the administrative side of the hiring  process. Despite the VAMC’s staff growing significantly as a result of  VHA’s hiring initiatives, officials said the VAMC did not hire any  additional human resources staff, which increased the workload of  existing staff and contributed to hiring delays.
Lack of space. Once the hiring process was completed, officials at  four of the five VAMCs and all five CBOCs we visited reported  difficulties getting mental health hires in place to provide care due to a  lack of sufficient space. All of the VAMCs we visited had either  recently completed or were in the process of undergoing expansions  of mental health space in their VAMC or CBOC buildings. Officials at  one of the CBOCs we visited said that although they moved into their  current facility in July 2014, by April 2015, they were already  struggling with space constraints.
Lack of support staff. Four VAMCs we visited reported that a lack of  non-clinical support staff resulted in providers taking on some of the  administrative burden, which reduced their clinical availability. For  example, officials at one VAMC said that while the recent hiring  initiatives added staff to improve access, without a corresponding  initiative for hiring support staff, providers are now also scheduling  patient appointments, addressing office equipment issues, and  handling phone calls about administrative issues, in addition to their  clinical duties.
Nationwide shortage of mental health professionals. Officials at  three VAMCs we visited reported that the nationwide shortage in  mental health professionals also presented a hiring challenge.  According to the Department of Health & Human Services’ (HHS)  Substance Abuse and Mental Health Services Administration, the  nation faces a current shortage in the mental health and addiction  services workforce, and that shortage is expected to continue. As of  July 2015, there were about 4,000 areas designated as having a  shortage of mental health professionals, which HHS’s Health  Resources and Services Administration projected would require  almost 2,700 additional mental health providers to fill the need in  these underserved areas.
Additional staff likely will be needed to meet VHA’s continuing demand for  mental health care. In an April 2015 report, VHA projected a roughly 12  percent increase in mental health staff would be needed to maintain the  current veteran staffing ratios for fiscal years 2014-2017. As of March  2015, VHA’s mental health staff vacancy rate (14 percent) was similar to  that of VHA’s overall staff vacancy rate (16 percent), even though the  vacancy rates were calculated differently. Mental health staff vacancy  rates varied widely among VAMCs we visited, from 9 to 28 percent.  Four of the five VAMCs we visited had mental health staff vacancy rates  that were higher than the national average. (See table 5.)
To address some of the mental health hiring challenges, VAMCs reported  using various recruitment and retention tools, including hiring and  retention bonuses, student debt repayment, hiring telehealth providers at  VHA facilities outside of the region (e.g., a provider located in another  state), and using internships and academic affiliations to find potential  recruits. For example, officials at one VAMC reported using relocation  and recruitment bonuses up to 15 percent of the base salary (usually  around $5,000) to recruit mental health clinicians. In November 2014,  VHA raised the annual salary ranges for all physicians system-wide,  including psychiatrists, to enhance the agency’s recruiting, development,  and retention abilities when compared with the private sector.
section_title: VHA’s Hiring Initiative Coincided with an Increased Demand for Mental Health Care That VAMCs Reported Being Unable to Meet
paragraphs: Officials at four of the five VAMCs we visited stated that they were still  unable to meet overall demand for mental health care despite VHA’s  hiring initiative. In addition, an official from a VHA office tracking mental  health staffing and access data had not observed any systemic reduction  in wait times or staff-to-patient ratios nationally, in part because of  simultaneous increased demand for mental health care. Nationally, VHA  outpatient mental health staffing totals increased from 11,138 full-time  equivalents in fiscal year 2010 to 13,795 in fiscal year 2014, a 24 percent  increase. Over the same time period, the number of veterans receiving  outpatient mental health care increased from 1,259,300 to 1,533,600, a  22 percent increase. The 22 percent increase in veterans receiving  outpatient mental health care has outpaced general growth in the number  of veterans using VHA services overall. During the same time period,  from fiscal year 2010 through fiscal year 2014, the total number of  veterans who used any VHA services increased 9 percent, from  5,441,059 to 5,955,725. VHA attributed the increased demand for  mental health care to the influx of veterans returning from the recent  conflicts in Iraq and Afghanistan, increased proactive screening efforts,  and VHA’s increased capacity to provide mental health care.
Officials at the five VAMCs we visited described strategies they used to  manage demand for mental health care in light of staffing challenges:
Changing the type of mental health care offered. To maintain  access given the increased demand, VAMC officials told us they  increased the use of telehealth, group therapy (rather than individual  therapy), and lengthened the time between therapy appointments.  Officials at three of the five VAMCS we visited stated they have  increased the use of telehealth to meet the increased demand for  mental health services that exceeds their capacity, particularly in rural  areas where it is more difficult to hire staff. For example, officials at  one VAMC stated that a psychiatrist position has remained open for 2  years at a rural CBOC that has experienced significant increased  demand for mental health care. Because of the difficulty in getting that  position filled, VAMC officials hired a psychiatrist located in another  state to provide mental health care via telehealth to veterans visiting  that CBOC. Further, officials at four VAMCs we visited said they refer  veterans to group therapy due to shortages in the availability of  individual therapy appointments. Finally, officials at three VAMCs and  two CBOCs we visited reported shortening appointments or spacing  out follow-up individual therapy appointments at longer intervals than  what providers preferred. For example, officials at one VAMC we  visited said that when they are short staffed, they use shorter  appointment times than they would prefer (e.g., 30 minutes) or extend  the time between follow-up appointments, which means they did not  see patients as often as the providers would prefer.
Countering space and staffing constraints. VAMC officials  reported using several strategies to address space shortages such as  office sharing, increased teleworking or altering provider schedules,  and converting closets into small offices. Officials at one VAMC told  us they had designated one provider just for new patient intake  appointments. This provider’s schedule was made up of 90 minute  time slots devoted to assessing the acuity of new patients and  referring them to the appropriate source of care. Officials at another  VAMC we visited told us they made use of limited office space for  individual therapy appointments by having their providers record  patient notes in common areas.
Referring veterans to other VA locations when a preferred CBOC  is not available. Officials at two VAMCs we visited said that when  veterans are unable to receive timely care at their preferred CBOC  location, they refer that veteran to the VAMC or another CBOC for  care until space becomes available at their preferred location. These  two VAMCs had a total of 175 veterans on their transfer lists at the  time of our visits. We reviewed 30 of these 175 veterans’ records and  found 26 veterans were waiting for care at a preferred location and 4  veterans were placed on this list in error. Of the 26 veterans that were  waiting for care at a preferred CBOC, 17 were receiving care at other  VAMCs or CBOCs until capacity became available at their preferred  CBOC and 9 were not. Of the 9 veterans not receiving care at another  location, 7 veterans’ records clearly documented that they refused  care at an alternative location and 2 veterans’ records did not clearly  document if they refused alternate care. According to officials at one  CBOC, VAMC social workers followed up every month with veterans  who opted not to receive care at the VAMC and instead wait for an  opening at the preferred CBOC to assess their current mental health  status.
section_title: VHA’s Community Provider Pilot Program Expanded Access to Mental Health Care for a Limited Number of Veterans; VAMCs Reported Successes and Challenges
subsections: section_title: VHA’s Community Provider Pilot Program Provided Mental Health Care for a Limited Number of Veterans
paragraphs: In 2013, 10 VAMCs across VHA established partnerships with 23  community mental health clinics (CMHCs), as required by an August  2012 Executive Order in an effort to help VHA meet veterans’ mental  health needs; these CMHCs provided mental health care to a limited  number of veterans. The over 2,400 mental health appointments that  veterans received through the CMHCs accounted for approximately 2  percent of the total mental health care provided across the 10 VAMCs.  The most common service veterans received was individual therapy or  counseling, but other commonly provided services included group  therapy, medication management, and treatment for substance abuse  (including intensive outpatient treatment and 28-day residential  programs).
Veterans were generally satisfied with the care they received from the  CMHCs in the pilot, according to VHA’s survey. Veterans who were  referred between January 2013 and December 2013 were surveyed  retrospectively and 61 percent were completely or somewhat satisfied  with the care they received and 19 percent were completely or somewhat  dissatisfied.
Most of the 10 VAMCs established partnerships with one or two CMHCs,  although one of the participating VAMCs, Atlanta, established seven  partnerships. As such, nearly half of the care provided through the pilot  program was through partnerships with the Atlanta VAMC. The Atlanta  CMHCs provided 1,150 appointments to veterans, while the partnerships  with other VAMCs generally provided far fewer appointments. For  example, the Indianapolis and Mountain Home VAMCs’ partnerships  provided the next highest number of appointments, with 664 and 170  appointments respectively, while certain CMHCs that partnered with the  Sioux Falls VAMC provided fewer than 10 appointments. (See table 6 for  additional information on the community provider pilot sites.)
The most common partnership between VAMCs and CMHCs was for the  CMHC to provide care on a fee basis. This type of arrangement was used  for 12 CMHCs. Payments under fee-basis care are made to non-VA  health care providers on an individual veteran basis. The seven CMHCs  that partnered with the Atlanta VAMC provided care through locally  negotiated contracts, which established the specific services to be  provided to veterans. Finally, four CMHCs established partnerships  through which VHA mental health providers, located elsewhere, provided  telemental health care to veterans at designated CMHCs that were closer  to veterans’ homes than either the nearest VAMC or CBOC.
While the pilot program has ended, some VAMCs continued their  partnerships with affiliated CMHCs. When the pilot ended, the funding  for the partnerships ended as well. VAMCs that continued their  partnerships had to identify new funding sources, and in general, staff  reported that they funded the ongoing partnerships through their normal  funding mechanisms. For example, officials from the Atlanta VAMC said  that they used money from their discretionary budget to fund the care  provided by the CMHCs after the pilot ended. VAMC officials who ended  their relationship with CMHCs generally reported that they did so due to a  perceived lack of veterans’ interest.
section_title: Officials Identified Successes and Challenges of the Community Provider Pilot Program
paragraphs: VHA and CMHC officials described a number of successes and  challenges related to the pilot program. Improved capacity and  communication were among the community provider pilot successes:  Improved capacity. Officials at one VAMC said they would not be  able to maintain mental health access at current levels without the  capacity provided by the pilot sites. Additionally, officials at three  VAMCs said their partnerships allowed them to expand access by  providing additional and more convenient care to veterans living in  rural areas. Specifically, officials from one of these VAMCs said that,  prior to their telemental health partnership with a CMHC, some  veterans traveled 2 or more hours to receive care, but using the  CMHC drastically reduced veterans’ travel times and the VAMC’s  travel reimbursement costs. Similarly, many veterans reported that  they were able to receive care at CMHCs that were much closer than  the nearest VAMC or CBOC, according to a VHA survey. VHA’s  survey also found that approximately 80 percent of veterans reported  travel times of more than 30 minutes to the nearest VAMC, while  approximately 50 percent reported that traveling to the nearest CMHC  took less than 30 minutes.
Improved communication. Both VAMC and CMHC officials said that  having a VAMC liaison on site or a dedicated point of contact  improved communication. Specifically, one VAMC used previously  established relationships with CMHCs to identify pilot sites, and used  the pilot program to embed liaisons, who are VAMC employees, which  helped facilitate communication between the VAMC and CMHCs.  Embedded liaisons, who were registered nurses, were responsible for  veteran outreach, the resolution of complaints, and ensuring veterans  were receiving care comparable to that provided by the VAMC.  Officials at two other VAMCs improved communication by identifying  key points of contact. These points of contact worked to improve  communications by centralizing information sharing within the VAMCs  and CMHCs and addressing veterans’ or other concerns, such as  billing confusion.
Challenges with the community provider pilot included a number of  administrative issues, as well as concerns about the appropriateness of  care:  Medical documentation and billing. Officials at two VAMCs noted  difficulty receiving timely medical documentation and CMHC officials  we spoke with also described difficulty receiving timely payments from  VAMCs. VAMC officials reported that delays in receiving medical  documentation could limit the ability of VHA to provide quality care if a  veteran returned to the VAMC for care prior to the VAMC receiving  their medical documentation. CMHC officials reported waiting, at  times for months, for payments or resubmitting paperwork multiple  times because the VAMC appeared to have misplaced it. VHA  recommends including incentives for timely documentation in their  contracts with CMHCs as a best practice, but some VAMC officials  noted that they had little leverage when trying to create or use such  incentives. For example, officials at one facility said they had very little  leverage in obtaining documentation because they could not withhold  billing while waiting for documentation.
Technical challenges. Both VAMC and CMHC officials in our review  also reported experiencing technical challenges, particularly related to  the transfer of medical files and the use of telemental health  technology. Two VAMCs reported depending on secure fax to  exchange information because the VAMCs and the CMHCs used  different computer systems. VHA officials said they plan to provide an  internal report to VAMCs recommending, among other things, that  VAMCs and CMHCs establish standards and plans for sharing  information to reduce the impact on care and workload while ensuring  confidentiality.
Confusion among available non-VA programs. Some VAMC  officials expressed confusion about the different non-VA medical  programs, including the CMHC partnerships, available to veterans.  Some of the VAMCs in the pilot program extended their partnerships  with the CMHCs after the pilot program’s end. A VHA document and  VHA officials indicated that PC3 and VCP are now the primary  programs for obtaining non-VA care of all kinds, including mental  health care, although VAMC officials reported it is not always clear  which option should be used. Veterans at a facility that continues to  fund ongoing partnerships with CMHCs after the pilot program ended  would have at least three options for non-VA care (with PC3 and VCP  being the primary options). VAMC officials also reported that some  providers and patients were unaware of the CMHCs as a treatment  option for mental health care and that there is also confusion among  patients regarding which services VHA will pay for at non-VA facilities.  VHA officials said that veterans generally work with providers to  identify the most appropriate non-VA option for mental health care.  VHA central office officials said they leave non-VA care decisions up  to the individual VAMCs and generally do not review their non-VA  care coordination decisions. Previous reports from us and others have  highlighted inefficiencies in non-VA care delivery.
Concern about appropriateness of care. VAMC and VISN officials  also expressed concern about the appropriateness and effectiveness  of referring to community providers for mental health care, and had  concerns about the ability of community providers to provide culturally  competent and high-quality care to veterans. VAMC and CMHC  officials noted the importance of having providers provide culturally  competent mental health care for veterans, and some VAMCs were  reported to have provided such training to community providers.  Some VHA officials expressed concern about whether sufficient  providers in certain areas have the necessary training and experience  to treat certain types of veterans and one VAMC established  guidelines regarding which veterans were eligible to be referred for  non-VA care and which were not. VAMC officials said that some  veterans preferred receiving care through VHA rather than through a  CMHC. Together these factors may have contributed to veterans  generally choosing to remain within the VHA system for mental health  care. Finally, veterans referred to a CMHC did not always receive  care, for a variety of reasons, including that some veterans did not  want to receive mental health care once they were referred or  veterans did not show up for scheduled appointments.
section_title: Conclusions
paragraphs: Our review found that veterans at the selected sites were generally  receiving mental health care within 30 days of their preferred dates. A  veteran’s preferred date is the basis for how VHA calculates wait times,  although this approach may not accurately reflect veterans’ overall wait  times. In particular, the way in which VHA calculates the key wait-time  measure for new veterans generally does not account for the full amount  of time it takes veterans to receive their full mental health evaluations,  which we found ranged from 0 days to more than 200 days from their  initial requests or referrals. VHA officials told us they are aware that the  wait-time calculation does not include some portions of a veteran’s wait,  but said there is not currently consensus on what standard should be  used to begin or end this calculation.
In addition, we found that VHA management of mental health care, as  demonstrated through the use of clear policies and accurate  measurement of performance, could be improved in three areas. First, the  existence of two conflicting access policies (14 days versus 30 days) for a  full mental health evaluation, the primary entry point for mental health  care, creates confusion among VAMC officials and providers about which  policy they are expected to meet. By issuing clarifying guidance, VHA  would eliminate confusion and improve VAMC officials’ ability to make  decisions to prioritize and improve access. Second, VHA lacks guidance  on open-access appointments, which has caused confusion about these  appointments at the local level and may have contributed to some  VAMCs not complying with VHA’s scheduling policies. The lack of  guidance on open-access appointments also could lead to inconsistent  application of VHA’s access policies, hinder VHA’s ability to assure all  veterans are getting their needs served, and may skew the performance  measurements of VAMCs that use them—specifically wait-time data and  no-show rates—which would result in data that is not comparable across  VAMCs. Third, a key way in which VHA measures access to mental  health care is through the use of wait-time data. However, our interviews  with local and VISN officials confirmed confusion about what definitions  are in effect when calculating wait-time measures. The lack of guidance  on the calculation of these measures limits their reliability and usefulness.  Until VHA clarifies how different access measures are defined and  calculated and communicates any changes over time, local and VISN  officials are likely to face difficulties accurately assessing wait times and  identifying needed improvements.
Finally, our interviews with mental health appointment schedulers and  review of medical records confirmed our previous findings about how the  wait-time measures are subject to error. As a result, we are reiterating our  previous recommendation that VHA take actions to improve the reliability  of wait-time measures by clarifying the scheduling policy or identifying  clearer wait-time measures that are not subject to interpretation or prone  to scheduler error.
section_title: Recommendations for Executive Action
paragraphs: To enhance VHA’s oversight of veteran mental health care and, in  particular, improve and ensure the accuracy, reliability, and usefulness of  its mental health data, we recommend that the Secretary of Veterans  Affairs direct the Under Secretary for Health to take the following three  actions:  Issue clarifying guidance on which of its access policies (e.g., 14 day  or 30 day) should be used for scheduling new veterans’ full mental  health evaluations.  Issue guidance on how appointment scheduling for open-access  appointments are required to be managed.  Issue guidance about the definitions used to calculate wait times,  such as how a new patient is defined, and communicate any changes  in wait-time data definitions within and outside VHA.
section_title: Agency Comments and Our Evaluation
paragraphs: VHA provided written comments on a draft of this report, which we have  reprinted in appendix I. In its comments, VHA concurred with our three  recommendations and described the agency’s plans to implement each,  but disagreed with certain findings.
In its comments, VHA stated that with regard to our first recommendation,  the agency is in the process of revising the relevant access policy in the  Uniform Handbook for scheduling full mental health evaluations to be  consistent with the 30-day wait time goal the agency established in  response to the Choice Act. VHA stated that it has already changed its  data metrics and processes for measuring wait time to align with the 30- day goal, is in the process of revising the policy, and has plans to issue  clarifying guidance about the policy revisions, metrics, and expectations  for scheduling mental health evaluations. VHA plans to publicize this  information through national calls and set a target completion date of  March 2016.
With regard to our second recommendation, VHA stated that it conducted  training in summer 2015 for schedulers based on existing VHA policy that  included instructions on how to schedule same-day appointments, which  VHA considers to include open-access appointments. However, VHA’s  description of same-day appointments for individuals who need an initial  mental health evaluation, which is to occur within 24 hours of a request or  referral for mental health services, does not accurately represent what we  observed at two VAMCs during our review. At one of these VAMCs,  veterans that expressed a desire or were referred for mental health  services received their initial mental health evaluation over the phone,  and then, rather than being given a scheduled appointment for the full  mental health evaluation, were referred to the open-access clinic to  subsequently seek care. We found that close to half of the veterans at  this VAMC who were referred to the open-access clinic never showed up  at the clinic and follow-up was often inadequate. At the second VAMC, we  found that veterans were referred to the open-access clinic, but also were  given scheduled appointments for a future date. We have reviewed the  training provided to schedulers, as provided by VHA, and it was unclear  whether the type of same-day, walk-in appointments addressed by the  training would apply to what we observed in the field. Moreover, given  potential differences between certain types of walk-in appointments (e.g.,  walk-in clinics where no prior evaluation may be required and open- access clinics that include an evaluation prior to referral), issuing specific  guidance for open-access appointments would help ensure veterans are  getting their needs served and that data are comparable when VAMCs  use different approaches.
With regard to our third recommendation, VHA provided an overview of  the different places that data pertaining to wait times are released. VHA  stated that it plans to provide an updated data definition document in  October 2015 for the SAIL data and will issue an information letter in  November 2015 that contains sources where the general public and VHA  employees can find the definitions used to calculate wait times, including  how a new patient is defined.
More generally, VHA stated that the draft report does not capture the  many ways in which VHA ensures veterans receive the care they need  when they want it. In particular, VHA commented that our approach did  not highlight an initial assessment which veterans are to receive within 24  hours of initial contact. Although this assessment is discussed in the  report, we did not use this measure because, according to VHA officials  with whom we spoke, this information is not tracked consistently in VHA’s  medical record system. We clarified this point in the final report.  We  believe the report captures various ways VHA provides mental health  care, including care provided in outpatient and inpatient settings.
In addition, VHA commented that the use of the preferred date provides  meaningful data on wait times because it differentiates between the ideal  date a veteran wants to be seen and those dates that are either before or  after the veteran’s preferred date. VHA commented further that they  disagreed with our calculations of the overall time it takes for veterans to  receive full mental health evaluations, because it would not capture  situations outside of their control such as when a veteran wants to delay  treatment.  The preferred date is intended to take into account  veterans’  preferences. However, our calculations illustrate that the use of the  preferred date does not always reflect how long veterans are waiting for  care or the variation that exists not only between, but within, VAMCs. The  report recognizes that many factors could impact a veteran’s wait time,  including the veteran's preference. Further, we do not recommend a  specific method for calculating wait times. Rather, our calculations  included the time that a veteran waited after initially requesting or being  referred for care, but before an appointment is scheduled, at which time  the preferred date is set. During the period of time prior to establishing the  preferred date, we found instances of veterans’ requests or referrals for  care being mismanaged or lost in the system, leading to delays in  veterans’ access to mental health care. Given the potential vulnerability of  veterans seeking mental health care, we believe this time is an important  part of the veteran’s overall experience that provides meaningful  information for VHA. Our current and previous work, along with the work  of VA OIG, highlights the limitations of VHA’s current scheduling  practices, leading us to reiterate our previous recommendation that VHA  take actions to improve the reliability of wait-time measures by clarifying  the scheduling policy or identifying clearer wait-time measures that are  not subject to interpretation or prone to scheduler error.
VHA also commented that the full mental health evaluation should be  considered the start of a veteran’s treatment, and that therefore there is  no delay in care between this evaluation and the delivery of specific  interventions. However, during the course of our work, we found a lack of  consensus among VHA officials on the appropriate standard or measure  for calculating the beginning of treatment. Further, given the wide  variation we found across VAMCs in the average number of days  between a veteran receiving a full evaluation and their first treatment, as  discussed in the report, we believe this presents an important opportunity  for VHA to improve veterans’ experiences in accessing mental health  care.
Finally, VHA commented that our review did not extend to a clinical  medical record review to assess quality of care. A full clinical medical  record review was beyond the scope of our work. Our objectives in  reviewing a selection of veterans’ files were to examine veterans’ access  to and VHA’s oversight of timely mental health care. Our review allowed  us to address both objectives and provide recommendations for  improving veterans’ access to mental health care.
We are sending copies of this report to the appropriate congressional  committees, the Secretary of Veterans Affairs, and other interested  parties. In addition, the report will be available at no charge on the GAO  Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or at draperd@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix II.
section_title: Appendix I: Comments from the Department of Veterans Affairs
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Lori Achman, Assistant Director;  Jennie F. Apter; Robin Burke; Jyoti Gupta; Jacquelyn Hamilton; Sarah  Harvey; Eagan Kemp; David Lichtenfeld; Vikki L. Porter; Brienne Tierney;  and Malissa G. Winograd made key contributions to this report.