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. 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. 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). 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

Summary: 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. 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. 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.