Joint Hearing of the Committee on Homeland Security and Governmental Affairs of the U.S. Senate and the Committee on Veterans’ Affairs of the U.S. House of Representatives at 1:00 p.m. CDT.
Witness Testimony of The Honorable Eric K. Shinseki, Secretary, U.S. Department of Veterans Affairs*
Chairman Miller, Ranking Member Filner, and Members of the Committee, I appreciate the opportunity to address access to, and quality of, VA’s mental health care. I am accompanied today by Mary Schohn, Ph.D., Director, Office of Mental Health Operations, Antonette Zeiss, Ph.D., Chief Consultant, Office of Mental Health Services, and Annie Spiczak, Assistant Deputy Under Secretary for Health for Workforce Service, supporting all of VHA.
Over the past several years VA has been transforming its mental health delivery system in response to the growing demand for these services. Over the previous year, VA has learned a great deal about both the strengths of our mental health care system, as well as areas that need improvement. VA’s Office of Inspector General (OIG) recently completed a review of our mental health programs and offered four recommendations. The OIG cited a need for improvement in our wait time measurements, improvement in patient experience metrics, development of a staffing model, and provision of data to improve clinic management. VA is using the OIG results along with our internal reviews to implement important enhancements to VA mental health care. VA constantly strives to improve, and any data and assessments—positive or negative—will be used to help enhance services provided to our Veterans.
The OIG confirmed that Veterans seeking an initial mental health appointment did generally receive the required rapid triage evaluation in a timely manner. This is an important step to identify high risk patients who need immediate intervention. While a mental health evaluation within 14 days following the triage referral generally occurs, we agree with the OIG that not all Veterans were able to receive a full diagnostic and treatment evaluation required by VA policies, especially for some intensive services such as beginning a course of evidence-based psychotherapy. While the explanations for these findings are varied, none are satisfactory—VA must do more to deliver the mental health services that Veterans need in a time period that supports their care.
Based on these findings, we are enhancing staffing and recruitment efforts, updating scheduling practices, and strengthening performance measures to ensure accountability. By taking these steps, we are doing more than ever to deliver accessible, high quality mental health care to Veterans. My written statement describes how we have traditionally evaluated access to mental health care and how we propose to evaluate access in the future. It will then explain how we assess the quality of care delivered and potential new considerations on this topic. In light of these discussions, I will conclude with an explanation of VA’s recent enhancement of mental health staffing.
Access to Care
Ensuring access to appropriate care is essential to helping Veterans recover from the injuries or illnesses they incurred during their military service. Access can be realized in many ways: through face-to-face visits, telehealth, phone calls, online systems, mobile apps, and community partnerships. Over the last several years, VA has enhanced its capacity to deliver needed mental health services and to improve the system of care so that services can be more readily accessed by Veterans. VA believes that mental health care must constantly evolve and improve as new research knowledge becomes available. As more Veterans access our services, we recognize their unique needs and needs of their families—many of whom have been affected by multiple, lengthy deployments. In addition, proactive screening and an enhanced sensitivity to issues being raised by Veterans have identified areas for improvement.
In an effort to increase access to mental health care and reduce the stigma of seeking such care, VA has integrated mental health into primary care settings. Since the start of fiscal year (FY) 2008, VA has provided nearly two million Primary Care-Mental Health Integration (PC-MHI) clinical visits to more than 575,000 unique Veterans. Primary care physicians systematically screen Veterans for depression, post-traumatic stress disorder (PTSD), problem drinking, and military sexual trauma to identify those at risk for these conditions. Research on this integration shows that as a result, Veterans who would not otherwise be likely to accept referrals to separate specialty mental health care are now receiving mental health treatment. Among primary care patients with positive screens for depression, those who receive same-day PC-MHI services are more than twice as likely to receive depression treatment than those who did not. These are important advances, particularly given the rising numbers of Veterans seeking mental health care.
In August 2011, VA conducted an informal survey of line-level staff providers at several facilities and learned of concerns that Veterans’ ability to schedule timely appointments may not match data gathered by VA’s performance management system. These providers articulated constraints on their ability to best serve Veterans, including inadequate staffing, space shortages, limited hours of operation, and competing demands for other types of appointments, particularly for compensation and pension or disability evaluations. In response to this finding, VA took three major actions. First, VA developed a comprehensive action plan aimed at enhancing mental health care and addressing the concerns raised by its staff. Second, VA conducted external focus groups to better understand the issues raised by front-line providers. Third, VA is conducting a comprehensive first-hand assessment of the mental health program at every VA medical center. As of April 25, 2012, 63 of 140 (45 percent) site visits have been completed, and the remainder will be completed by the end of the fiscal year.
Historically, VA has measured access to mental health services through several data streams. First, VA defined what services should be available in VA facilities in the 2008 VHA Handbook 1160.01 entitled Uniform Mental Health Services in VA Medical Centers and Clinics, and tracks the availability of these services throughout the system. Moreover, VA has added a five-part mental health measure in the performance contracts for VHA leadership, effective starting in October 2011. The new performance contract measure holds leadership accountable for:
- The percentage of new patients who have had a full assessment and begun treatment within 14 days of the first mental health appointment;
- The proportion of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans with newly diagnosed PTSD who receive at least eight sessions of psychotherapy within 14 weeks;
- Proactive follow-up within 7 days by a mental health professional for any patient who is discharged from an inpatient mental health unit at a VA facility;
- Proactive delivery of at least four mental health follow-up visits within 30 days for any patient flagged as a high suicide risk; and
- The percentage of current mental health patients who receive a new diagnosis of PTSD and are able to access care specifically for PTSD within 14 days of referral for PTSD services.
VA policies require that for established patients, subsequent mental health appointments be scheduled within 14 days of the date desired by the Veteran. This has been a complicated indicator, as the desired date can be influenced by several factors, including:
- The Veteran’s desire to delay or expedite treatment for personal reasons;
- The recommendation of the provider; and
- Variance in how schedulers process requests for appointments from Veterans.
VA understands virtually every health care system in the country faces similar challenges in scheduling appointments, but as a leader in the industry, and as the only health care system with the obligation and honor of treating America’s Veterans, we are committed to delivering the very best service possible. As a result, VA will modify the current appointment performance measurement system to include a combination of measures that better captures each Veteran’s unique needs throughout all phases of his or her treatment. Some Veterans may need to be seen more frequently than within 14 days (for example, if they need weekly sessions as part of a course of evidence-based psychotherapy), while others may not (for example, if they are doing well after intensive treatment and will benefit most from a well-designed maintenance plan with far less frequent meetings). VA will ensure this approach is structured around a thoughtful, individualized treatment plan developed for each Veteran to inform the timing of appointments.
VA has formed a work group to examine how best to measure Veterans’ wait time experiences and how to improve scheduling processes to define how our facilities should respond to Veterans’ needs. In the interim, the work group has recommended a return to the use of the “create date” metric (the metric used by the OIG during its review), which will minimize the complexity of the current scheduling process. The “create date” refers to the date on which a Veteran requested an appointment, and the wait time will be measured as the numbers of days between the create date and the visit with a mental health professional. The work group is currently developing an action plan to be reviewed by the Under Secretary for Health by June 1, 2012. Performance measurement and accountability will remain the cornerstones of our program to ensure that resources are being devoted where they need to go and being used to the benefit of Veterans. Our priority is leading the Nation in patient satisfaction regarding the quality and timeliness of their appointments.
Quality of Care
VA has made deployment of evidence-based therapies a critical element of its approach to mental health care. Mental health professionals across the system must provide the most effective treatments for PTSD and other mental health conditions. We have instituted national training programs to educate therapists in two particularly effective exposure-based psycho-therapies for PTSD: cognitive processing therapy and prolonged exposure therapy. The Institute of Medicine and the Clinical Practice Guidelines developed jointly by VA and the DoD have consistently concluded the efficacy of these treatment approaches.
Not everyone with PTSD who receives evidence-based treatment may have a favorable response. Although VA uses the most effective treatments available, some Veterans will need lifetime care for their mental health problems and may see slow initial improvement. Almost everyone can improve, but some wounds are deep and require a close, consistent relationship between VA and the Veteran to find the most effective individualized approaches over time. Veterans and their families should not expect “quick fixes,” but they should expect an ongoing commitment to intensive efforts at care for any problems.
A recent analysis of data shows that Veterans with the most severe PTSD are least likely to benefit from a standard course of treatment and to achieve remission. Other factors that predicted poor response were unemployment, co-morbid mood disorder, and lower education. In other words, those with the worst PTSD are least likely to achieve remission, as is true with any other medical problem.
Even when Veterans are able to begin and sustain participation in treatment, timing, parenting, social, and community factors all matter a great deal. Treatment, especially treatment of severe PTSD, may take a long time. Evidence also shows that whereas a positive response to treatment may reduce symptom severity and increase functional status among severely affected Veterans, the magnitude of improvement may not always be enough to achieve full clinical remission. This is no different than what is found with other severe and chronic medical disorders. Providing the best treatments with the strongest evidence base is crucial to care, but is only one piece of a broader, ongoing commitment to rehabilitative care and treatments for other co-occurring mental health problems or other psychosocial problems that may develop.
Based on ongoing surveys, we know that all VA facilities have staff trained at least in either prolonged exposure or cognitive processing therapy, and usually both. In addition, one of the preliminary results of our site visits found that many facilities have a strong practice of training more staff in these and other evidence-based therapies for a wide array of mental health problems.
As more providers are trained in these approaches to care, facilities are shifting from their more traditional counseling approach to these newer treatments. We have not always communicated well enough to Veterans the nature or reason behind these changes. These new programs emphasize a recovery model, which is strengths-based, individualized, and Veteran-centered. A recovery-oriented model does not focus exclusively on symptom reduction, but has as its goal helping Veterans achieve personal life goals that will improve functioning while managing symptoms. These efforts have been recognized as successful in the academic literature and through a Government Performance and Results Act review conducted by RAND/Altarum, which concluded that VA mental health care was superior to other mental health care offered in the United States in almost every dimension evaluated.
Before the development of these evidence-based approaches, VA made every effort to offer clinical services for PTSD based on clinical experience and innovation. Some of these approaches have developed into the evidence-based approaches we have now, while others have not been shown to offer the help that was expected. Even those therapies that did not help in truly alleviating PTSD could come to feel like “lifelines” to those receiving them. For example, some sites hold group educational sessions to help Veterans understand PTSD symptoms and causes, and these sometimes developed into ongoing groups. While group therapy for PTSD can be effective and is cited in the VA/DoD Clinical Practice guidelines, group therapy is understood (and validated) as possible only in fairly small groups—usually fewer than 10 participants. Educational groups often have far more members, sometimes up to 50 or more; while this can be an effective way to conduct psycho-education, it cannot be considered “group therapy.”
Veterans who have used some of the PTSD services previously adopted by VA may not be familiar or comfortable with newer approaches, and we must continuously educate Veterans and others about what treatments are most likely to be effective and how Veterans can access them. Some of our own providers have not understood these changes. The National Center for PTSD has been providing guidance through the PTSD mentoring program to help facilities collaborate with providers and Veterans in the transition. We have developed educational processes to help clarify the need for and rationale behind efforts to change clinical practice patterns to ensure best possible care for VA.
VA’s realignment of VHA last year created an Office of Mental Health Operations with oversight of mental health programs across the country. This has aligned operational needs and connected resources across the agency with data collection efforts to bring the full picture of VA’s mental health system into focus. In fiscal year 2011, VA developed a comprehensive mental health information system that is available to all staff to support management decisions and quality improvement efforts. This year, a collaborative effort between VA Central Office and field staff is underway to review mental health operations throughout the system and to develop quality improvement plans to address opportunities for improvement through dissemination of strong practices across the country.
Enhancing Mental Health Staffing
Decisions concerning staffing and programs were determined historically at the facility level to allow flexibility based on local resources and needs. In the past year, as evidence accumulates, it has become clear that sites can benefit from more central guidance on best practices in determining needed mental health staff. While no industry standards for accurate mental health staffing ratios exist, VA developed and is piloting a national prototype staffing level model for general mental health outpatient care. This staffing level model uses a methodology that considered findings in academic literature, consultation with other health care systems, and utilization and staffing data. This staffing model will be further refined as VA monitors its effectiveness and incorporates team-based concepts. VA will build upon the successes of the primary care staffing model and apply these principles to mental health practices. The model is based on the following guiding principles:
- Delivering quality comprehensive mental health care;
- Coordinating mental health care across all MH disciplines and the integration with primary care;
- Ensuring effectiveness and efficiency of service delivery by having all staff working at their highest level possible;
- Promoting team staffing to support all providers to function at the highest level;
- Dedicating time for indirect patient care activities (for example, care planning and team coordination); and
- Supporting a team response to emergent and non-emergent patient and family needs (for example, unscheduled phone calls).
The model’s clinical staffing ratio is as follows:
Full Time Employee Equivalent for Mental Health Clinic Panel Size of 1,000
Total Mental Health Clinician
Administrative Clerical Support
Clinical Support Direct
Applying this model and these ratios, VA determined an additional 1,700 mental health staff members (including administrative and clerical staff) were needed to augment existing resources across the country. Clinical staff will represent all specialties, including psychologists, psychiatrists, social workers, mental health nurse, licensed professional counselors (LPC), licensed marriage and family therapists (MFT), and others. In addition, VHA projected an additional 100 compensation and pension examiners would be needed. Each Veterans Integrated Service Network (VISN) is receiving some additional support in either clinical or clerical staff or compensation and pension examiners. VA is also adding 100 staff to the Veterans Crisis Line to support projected increases in the use of this service. These enhancements in total will add more than 1,900 employees to VA’s existing mental health staff of more than 20,500. VA Central Office is providing technical assistance to VISNs to help them with implementation and is providing additional funding to aid recruitment and hiring. VA’s Office of Mental Health Operations will obtain monthly updates from facilities receiving funding to ensure implementation is timely and that resources are used appropriately.
We are testing this model through a pilot program in VISNs 1, 4, and 22, and we anticipate national implementation of this new model by the end of this fiscal year. While the model may be refined as a result of the pilot testing, it provides a clear basis for assessing staffing for mental health services, and shows that currently there are shortfalls at some sites nationally that VA is addressing. We will use this staffing level model, with refinements made over time, to guide staffing decisions in the future. This will be combined with a review of revised clinical outcome measures, to be developed in consultation with other subject matter experts from VHA and the OIG, to evaluate whether enhanced staffing results in enhanced performance on more valid measures. We will reassess levels of care needs and specialty services based on these multiple data sources.
Despite the national challenges with recruitment of mental health care professionals, VA continues to make significant improvements in its recruitment and retention efforts. Specialty mental health care occupations, such as psychologists, psychiatrists, and others, are difficult to fill and will require a very aggressive recruitment and marketing effort. VA has developed a strategy for this effort focusing on the following key factors:
- Implementing a highly visible, multi-faceted and sustained marketing and outreach campaign targeted to mental health care providers;
- Engaging VHA’s National Health Care Recruiters for the most difficult to recruit positions;
- Recruiting from an active pipeline of qualified candidates to leverage against vacancies; and
- Ensuring complete involvement and support from VA leadership.
VA anticipates the majority of hires for this effort will be selected within approximately 6 months, with the most “hard-to-fill” positions filled by the end of the second quarter of FY 2013. A VHA task force is targeting the recruitment and staffing requirements to bring these new employees into VA as effectively and efficiently as possible to meet our goals leveraging all available tools to bring needed providers on board.
Implementation of the model will also support linking patients to their Patient Aligned Care Team (PACT) for care management (including medication maintenance and monitoring), enhance care transitions, expand peer-led services and community engagement for supportive care, and increase access to evidence-based individual and group psychotherapies, family and marital psychotherapies, and psycho-pharmacological treatments. The model will guide optimal team composition and provider-to-patient ratios assessed based on facility complexity levels and patient care needs.
VA Central Office began collecting monthly vacancy data in January 2012 to assess the impact of vacancies on operations and to develop recommendations for further improvement. In addition, VA is ensuring that accurate projections for future needs for mental health services are generated. Finally, VA is planning proactively for the expected needs of Veterans who will separate soon from the Department of Defense (DoD) as they return from Afghanistan. We track this population to estimate the number of such Veterans, how many are anticipated to seek VA care, and how many who seek care are anticipated to need mental health evaluation and treatment services. These processes will continue, with special attention to whether patterns established up to this point may change with the expected increase in separations from active duty military.
As part of VA’s efforts to implement section 304 of Public Law 111-163 (Caregivers and Veterans Omnibus Health Services Act of 2010), VA is increasing the number of peer specialists working in our medical centers to support Veterans seeking mental health care. These additional staff will increase access by allowing more providers to schedule more appointments with Veterans. Simultaneously, VA is providing additional resources to expand peer support services across the Nation to support full-time, paid peer support technicians. While providing evidence-based psychotherapies is critical, VA understands Veterans benefit from supportive services other Veterans can provide.
Finally, VA’s efforts to nurture and sustain our academic affiliations provide opportunities across the country for residents in different disciplines, including psychiatry and psychology, to continue their education while helping our Veterans. VA currently supports more than 2,500 training positions in mental health occupations (including psychiatry, psychology, social work, and clinical pastoral education residency positions).
By adding staff, offering better guidance on appointment scheduling processes, and enhancing our emphasis on patient and provider experiences through specific performance measures, we are confident we are building a more accessible system that will be responsive to the needs of our Veterans while being responsible with the resources appropriated by Congress. OEF/OIF/OND Veterans have faced more and longer deployments than previous generations of Servicemembers, and their families have shared these challenges. Many of these Veterans also have survived battlefield injuries that previously would have been fatal. Other challenges are presented by Vietnam era Veterans who seek mental health care at far higher levels than prior generations of older adults. In part, that is because we did not have the effective treatments for them when they returned from service more than 40 years ago. We know that the therapies discussed previously are effective for this population, and we welcome their search for mental health care. As VA reaches out to serve all generations, and as our intensive, effective outreach programs bring in greater numbers of Veterans to VA’s health care system, we must constantly find ways to keep pace with the need for expanded capacity for mental health services and for those services to be based on the best possible known treatments.
Mr. Chairman, we know our work to improve the delivery of mental health care to Veterans will never be done. We appreciate your support and encouragement in identifying and resolving challenges as we find new ways to care for Veterans. This concludes my prepared statement. My colleagues and I are prepared to respond to any questions you may have.