VA Mental Health: Action Needed to Improve Access Policies and Wait-Time Data
Published: 2015-10-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: This testimony summarizes the information contained in GAO's October 2015 report, entitled VA Mental Health: Clearer Guidance on Access Policies and Wait-Time Data Needed ( GAO-16-24 ).
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: Letter
paragraphs: I am pleased to be here to discuss our report that is being released today  on veterans’ access to VA mental health care, the latest review from our  extensive work in recent years on veteran’s access to care.
The Veterans Health Administration (VHA), within the Department of  Veterans Affairs (VA), has seen a 63 percent increase in the number of  veterans receiving mental health care between 2005 and 2013. 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 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 health care, including mental health care, and  VHA’s oversight of patient scheduling practices, particularly the reliability  of reported patient wait times and weaknesses in appointment scheduling  oversight. For example, 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 appointments for  mental health treatment. An August 2012 Executive Order directed VHA  to improve mental health care 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.
In this context, my testimony today summarizes the findings from our  report being released today on veterans’ access to mental health care  services, which addresses  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 of that  hiring on access to mental health care; and  4.  VHA’s community provider pilot program’s effects on veterans’ access  to mental health care.
To examine these issues we conducted site visits to five VA medical  centers (VAMC) and their affiliated community-based outpatient centers  (CBOC), which were selected for variation in mental health utilization,  geographic location, and participation in the community provider pilot  program, among other factors. For each of the five VAMCs we visited,  we reviewed a randomly selected sample of 20 outpatient medical  records to assess the timeliness in which veterans received mental health  appointments. 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. We also reviewed relevant VHA policies, federal  internal control standards, and other key documents, as well as  interviewed staff from VHA’s central office, the five selected VAMCs, and  the five corresponding Veterans Integrated Service Networks (VISN) that  oversee them, among others. We limited our scope to outpatient  specialty mental health care, which we refer to as mental health care,  because the majority of veterans with either a possible or a confirmed  mental illness, about 70 percent and 85 percent respectively, obtain  outpatient mental health care through VHA. Additional information on our  scope and methodology is available in our report. The work upon which  this statement is based was conducted in accordance with generally  accepted government auditing standards.
subsections: 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
paragraphs: The 100 veterans included in our review received a full mental health  evaluation in an average of 4 days of the date they preferred to be seen  (known as the preferred date). The full mental health evaluation is the  primary entry point to mental health care. 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.
However, we identified conflicting VHA policies regarding how long it  should take a new veteran to receive a full mental health evaluation: (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 polices, significant events or activities, such as ensuring  timely access to mental health care, to help ensure management  directives are carried out properly. 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 makes it difficult for them to ensure  timely access to care in light of increasing demand for mental health care.  As a result, we recommended VHA issue clarifying guidance on the  access standard for new veterans seeking mental health care. VA  concurred with this recommendation, stating that it is in the process of  revising the relevant policy in the Uniform Handbook to be consistent with  the 30-day wait time goal established in response to the Choice Act. VHA  stated that it is targeting issuance of the revised policy and clarifying  guidance for March 2016.
Further, although the average time between veterans’ preferred dates  and their full mental health evaluations in our review were generally within  several days, that time did not always reflect how long veterans may have  actually waited for mental health care. Because VHA uses a veteran’s  preferred date as the basis for its wait-time calculations, rather than the  date that the veteran initially requests or is referred for mental health  care, these calculations only reflect a portion of a veteran’s overall wait  time. While some of the delay in care may be attributed to a veteran not  wanting to start care immediately, we also found that some delays were  because a facility did not adequately handle a referral or request for  mental health care. In our review of 100 veteran records, we found that  significant delays can occur if the referral or request for an appointment is  not processed correctly or in a timely manner. For example, one veteran  in our review waited 174 days between the initial referral for mental health  care and the veteran’s preferred date due to a referral not being  appropriately managed. The veteran’s primary care provider was to have  placed a referral to psychology in March 2014, but our review of the  medical record found no evidence of the referral ever being placed.  Nonetheless, 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 appropriately requested). The veteran was then  able to schedule a full mental health evaluation approximately 1 week  later. On average, our review of 100 new veteran medical records found  that a veteran’s preferred date was 26 days after his or her initial request  or referral for mental health care, though this varied by VAMC. (See   fig. 1.)
In commenting on a draft of our report, VHA confirmed that they measure  wait times from preferred date to when the appointment occurs. However,  they disagreed with our calculations of the overall wait time for veterans  to receive full mental health evaluations, noting that these calculations do  not capture situations outside of their control, such as when a veteran  wants to delay treatment. 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.  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. Our current and previous work, along with the work  of VA OIG, highlights the limitations of VHA’s current scheduling  practices, including wait time calculations. In December 2012, we  recommended 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 has not yet implemented this recommendation, and we  continue to believe that implementation of this recommendation would  improve the reliability of wait time measures.
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, but the lack of clear policies  may contribute to unreliable wait-time data and precludes effective  oversight. Among other reasons contributing to the potential unreliability  of VHA wait-time data, we found VHA’s wait-time data may not be  comparable over time or between VAMCs.
Data may not be comparable over time. VHA has changed the  definitions used to calculate various mental health wait-time  measures, and a number of VHA officials we interviewed, including  VAMC and VISN officials, told us they were not sure which definitions  for new mental health patients were in effect for calculating wait-time  measures or gave conflicting answers about which definitions were  being used. VHA has not clearly communicated the definitions used or  changes made to these definitions used in its wait-time calculations,  which is contrary to federal internal controls standards that call for  management to communicate reliable and relevant information in a  timely manner. This limits the reliability and usefulness of these data  in determining progress in meeting stated objectives for veterans’  timely access to mental health care. As a result, we recommended  that VHA 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. VHA  concurred with our recommendation and stated that it plans to publicly  provide an updated data definition document in October 2015 and will  issue an information letter in November 2015 that contains sources  where both internal and external stakeholders can locate the  definitions used to calculate wait times, including how a new patient is  defined.
Data may not be comparable between VAMCs. When VAMCs use  open-access appointments, data may not be comparable across  VAMCs. Open-access appointments are typically blocks of time for  veterans to see providers without a scheduled appointment. In these  cases, because appointments are not scheduled until veterans come  to the medical center, the preferred and appointment dates are the  same and wait times are calculated as 0 days, regardless of when  veterans initially requested or were referred for mental health care.  We found inconsistencies in the implementation of these  appointments, including one VAMC that was referring veterans to  these open-access appointments after an initial evaluation by phone  rather than rather than being given specific appointments. Those  veterans who were referred to the open-access appointments were  tracked using a manually maintained list outside of VHA’s scheduling  system. We found that follow-up with these veterans was inconsistent,  and nearly half never showed up to the open-access appointments.  VHA does not have guidance that clarifies how to manage and track  open-access appointments, which 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 that 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. 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  posing serious risks to veterans needing mental health care.
As a result, we recommended VHA issue clarifying guidance on how  open-access appointments are to be managed. VHA concurred with our  recommendation, stating that it conducted training during the summer of  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. VHA further stated its  plans to aggressively monitor appointment management and identify  areas of local inconsistency in scheduling procedures. However, VHA’s  description of same-day appointments does not capture the  circumstances we observed during our review, in which veterans who  would normally be given an appointment were instead referred to an  open-access clinic. We reviewed the training that VHA said was provided  to schedulers, but it did not address the circumstances we described.  Given differences between types of same-day 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 to ensure veterans are getting  their needs served and to improve data comparability across VAMCs.
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
paragraphs: VHA hired about 5,300 new clinical and non-clinical mental health staff  between June 2012 and December 2013 for both its inpatient and  outpatient programs, meeting the goals of its hiring initiative. Officials at  the five VAMCs we visited reported local improvements in access to  mental health care due to the additional hiring. For example, officials at  one VAMC reported being able to offer more evidence-based therapies.  Officials at this VAMC, as well as officials from another VAMC and two  CBOCs, cited the ability to provide mental health care at new locations  where they were previously unable to do so.
Although VHA considered their hiring initiative a success because it met  its goals, the five VAMCs we visited still had mental health staff vacancy  rates ranging from 9 to 28 percent, and 4 of the 5 VMACs were unable to  meet overall demand for mental health services. Officials at the five  VAMCs reported a number of challenges in hiring and placing mental  health providers, including pay disparity with the private sector;  competition among VAMCs filling positions at the same time;  lengthy VHA hiring process;  lack of space for newly hired mental health staff;  lack of support staff to assist providers; and nationwide shortage of mental health professionals.
Despite VHA’s hiring initiative, additional staff likely will be needed to  meet VHA’s growing 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.
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, and using internships and  academic affiliations to find potential recruits. 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. Officials at the five VAMCs we visited also described  strategies they used to manage demand for mental health care in light of  staffing challenges, including (1) increasing the use of telehealth and  group therapy (rather than individual therapy); (2) addressing space and  staffing constraints by sharing offices or altering provider schedules; and  (3) referring veterans to other VA locations when a preferred CBOC was  not available.
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
paragraphs: In 2013, 10 VAMCs across VHA participated in a pilot that 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. Veterans received  approximately 2,400 mental health appointments through the CMHCs,  which accounted for approximately 2 percent of the total mental health  care provided across the 10 participating VAMCs. Nearly half of the care  provided through the pilot program was through partnerships with the  Atlanta VAMC. 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. According to VHA’s survey of veterans who received  care through the CMHCs during the pilot, veterans were generally  satisfied with the care they received.
VHA and CMHC officials in our review described a number of successes  and challenges related to the pilot program. Successes included  improved capacity and communication. For example, officials at one  VAMC said they would not have been able to maintain mental health care  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. VAMC and CMHC officials also said that  having a VAMC liaison on site or a dedicated point of contact improved  communication, which helped facilitate veterans’ access to care.
Challenges with the community provider pilot included a number of  administrative issues, including challenges with the timely receipt of  medical documentation and payment for services, as well as technical  challenges, particularly related to the transfer of medical files and the use  of telemental health technology. Other challenges included confusion  among some VAMC officials about the different non-VA programs  available to veterans and concerns about the appropriateness of care,  including whether there were a sufficient number of community providers  with the necessary training and experience to provide culturally  competent and high-quality care to veterans.
Chairman Isakson, Ranking Member Blumenthal, and Members of the  Committee, this concludes my prepared statement. I would be pleased to  answer any questions that you may have at this time.
section_title: GAO Contact and Staff Acknowledgments
paragraphs: If you or your staff members have any questions concerning this  testimony, please contact Debra A. Draper at (202) 512-7114 or  draperd@gao.gov. Contact points for our Offices of Congressional  Relations and Public Affairs may be found on the last page of this  statement. Other individuals who made key contributions to this testimony  include Lori Achman, Assistant Director; Jennie F. Apter; Jacquelyn  Hamilton; Eagan Kemp; Vikki L. Porter; and Malissa G. Winograd.
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