16

Findings, Conclusions, and Recommendations

The previous chapters of this report present the committee’s assessment of the accessibility, patient-centeredness, quality, and outcomes of the mental health care services provided by the Department of Veterans Affairs (VA) health care system, managed by the Veterans Health Administration (VHA), which is a sub-cabinet level agency within the VA, focusing especially on services for veterans of Operations Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND). The committee’s approach to gathering information to address its task was threefold: reviewing the literature on health services and other relevant topics, conducting site visits to VA facilities around the nation, and developing and fielding a survey of OEF/OIF/OND veterans. This chapter presents the committee’s key findings and its conclusions and recommendations.

KEY FINDINGS

The committee’s findings about the demographics of the OEF/OIF/OND population, its need for mental health services, and the accessibility and quality of the VA’s mental health services are presented in detail in Chapters 6 and 8–15. Key findings are summarized here.

A significant percentage of the OEF/OIF/OND veteran population is in need of mental health care. The committee’s survey found that

• Of an estimated 4.2 million OEF/OIF/OND veterans, 41 percent of veterans have a potential need for mental health services. Veterans were considered to have a mental health need if they had a positive result on at least one of five mental health screeners or had reported being told by a health professional they have a mental health condition. This finding is consistent with the results from another national survey of OEF/OIF/OND veterans (Elbogen et al., 2013). The mental health screeners used in these surveys are not diagnostic instruments and therefore a positive screen does not necessarily mean that a veteran has a mental health condition; rather,

• it indicates a need for further clinical assessment by a mental health professional to determine a diagnosis and whether there is a need for treatment.

• More than two-thirds (69 percent) of OEF/OIF/OND veterans who had a positive result on one or more mental health screeners in the survey reported having been told recently by a health professional that they have a least one mental health disorder.
• Nearly one-quarter (22 percent) of OEF/OIF/OND veterans perceive a need for care. This was measured by responses to a question about whether the veterans felt a need to see a professional because of mental health problems.
• More than half of veterans who have a mental health need do not perceive a need for mental health services, which suggests that some veterans do not seek care because they do not perceive that they personally have a need.
• Combat exposure and cumulative deployment time are among the strongest predictors associated with having a mental health need.

There is a substantial unmet need for mental health services in the OEF/OIF/OND population.

• Of those who have an assessed mental health need (as determined by a positive mental health screen or reported diagnosis), less than half (44 percent) of OEF/OIF/OND veterans have sought either VA or non-VA mental health care services. While all of the remaining estimated 900,000 veterans cannot definitively be categorized as having unmet needs, the survey results suggest that a substantial number do have unmet needs.
• Among the 22 percent of veterans reporting a perceived mental health need, 48 percent have sought either VA or non-VA mental health care services. Among those veterans with a perceived need who also had an assessed need, 55 percent sought such care.
• Therefore, depending on which measure of potential need is used (assessed need or assessed need in combination with perceived need), the proportions using VA or non-VA mental health care services varies from 44 to 55 percent, a range that suggests that a large number of veterans are not getting care and that the potential unmet may be substantial.
• These results are consistent with several studies of the VHA demonstrating that a large proportion of veterans do not receive any treatment following diagnosis of posttraumatic stress disorder (PTSD), alcohol or other substance use disorders (SUDs), or depression.
• Veterans who have a mental health need but do not have a disability rating are substantially less likely to be receiving mental health services than veterans who do have a disability rating.

A number of VA health system factors may facilitate or be barriers to veterans’ willingness to seek care.

• A lack of awareness about how to connect to the VA for mental health care is pervasive among OEF/OIF/OND veterans.
  • The committee’s survey found that among OEF/OIF/OND veterans who have a mental health need and who use mental health services about two-thirds use the VA. Among those who have a mental health need who have not sought VA mental health services, their main reasons are they do not know how to apply for VA mental health care benefits, they are unsure whether they are eligible, or they are unaware that the VA offers mental health care benefits.
  • The same reasons were frequently reported by veterans interviewed on the site visits. Veterans said that they were especially confounded by the VHA and the Veterans Benefits

• Administration (VBA) eligibility and the range of mental health care and other services offered by the VA.

• The process of accessing VA mental health services has been burdensome and unsatisfying for many OEF/OIF/OND veterans. Reports of barriers to access from the committee’s survey and site visits include
  • The majority (54 percent) of OEF/OIF/OND veterans surveyed who use the VA and have a mental health need reported that the process of getting mental health care was burdensome.
  • Appointment scheduling continues to be a problem for a large percentage of veterans: Among VA users who have a mental health need, only about half (49 percent) reported that it was easy to get an appointment, and about one-third (34 percent) reported that they were dissatisfied with the time between their requests and the appointments. Nearly 40 percent of OEF/OIF/OND veterans who do not plan to use VA mental health care services in the future indicated that it was because the wait time for appointments at the VA is too long.
  • One in five OEF/OIF/OND veterans who are not at all likely to use VA mental health services in the future agreed with the statement “VA doctors/staff did not provide good quality treatment.”
  • Changes that OEF/OIF/OND veterans would like to see at the VA include making the process for scheduling appointment easier, better quality services and customer service, and more available services or facilities.
  • Site visit interviews illustrated many examples of the difficulties that veterans encounter when enrolling or interacting with the VA system; among the frequently reported themes were problems getting appointments, difficulties with interpersonal interactions with the administrative staff, and overall customer service.
• From a systems perspective, the VA can facilitate access by ensuring VA leadership and management acumen are focused on aligning resources to veteran needs. Chronic workforce problems exist that have a significant impact on the care veterans receive. Complex eligibility criteria and confusing procedures to transition between the Department of Defense (DoD) and the VA are examples of policy-related barriers veterans encounter when seeking VA health care.

Many veterans’ personal factors may facilitate or be barriers to veterans’ willingness to seek care.

• OEF/OIF/OND veterans who have a mental health need and who have significant others who support their seeking treatment are much more likely to use VA health care services than veterans without such support.
• Transportation and convenience may pose challenges for many OEF/OIF/OND veterans. A lower percentage of non-VA users who have mental health need live within 30 miles of a VA facility compared with VA users who have mental health need (45 percent versus 73 percent). A lower percentage of non-VA users who have mental health need live within a 45 minute drive from a VA facility compared with VA users who have mental health need (44 percent versus 76 percent). A lower percentage of non-VA users who have mental health need reported that it is very easy, somewhat easy, or neither easy nor hard to get to the nearest VA facility that offers mental health services compared with VA users who have mental health need (49 versus 75 percent).
• Other transportation challenges described by the veterans who were interviewed include having to rely on public transportation or rides from organizations such as the Disabled

• American Veterans and travel limitations associated with having a mental health condition or chronic pain.

• Regarding the mode of receiving care, 45 percent of OEF/OIF/OND veterans surveyed responded that they would likely use the Internet and 44 percent would likely use the phone to receive mental health care. Younger veterans tended to be more open to obtaining mental health care using the Internet.
• Approximately one-third of OEF/OIF/OND veterans who have a mental health need said that they have concerns about the following employment issues: spending time off from work, harm to their careers, denial of security clearance, and receiving less confidence and respect from co-workers and supervisors.
• OEF/OIF/OND veterans who have a mental health need also reported fears that discrimination could affect their ability to own guns, lead to a loss of contact with or custody of their children, or lead to a loss of medical or disability benefits.

A majority of OEF/OIF/OND veterans who use the VA report positive aspects of and experiences with VA mental health services.

• The committee’s survey found that approximately two-thirds or more of OEF/OIF/OND veterans who have a mental health need and use VA services endorsed the following reasons to use the VA: prescription benefits, entitlement to services, a lower cost of services, the convenience of the VA location, liking the VA doctors or already using the VA for years, and the VA was the only available source of mental health care.
• A majority of VA users who have mental health need are positive about the VA’s delivery of services, including the availability of needed services, the privacy and confidentiality of medical records, the ease of using VA mental health care, the mental health care staff’s skill and expertise, and the staff’s courtesy and respect toward patients.
• Those interviewees on the site visits who were satisfied with their care often pointed to ways their values and preferences had been accommodated by their individual providers. These veterans reported that they felt that their provider respected their preferences for treatment, honored their experiences as former members of the military, understood what they (the veterans) felt was important, and cared about them.

Many OEF/OIF/OND veterans receive high-quality mental health care from the VA; however, the VA’s ability to deliver high-quality mental health care consistently to all veterans across facilities and subpopulations is an ongoing challenge.

• The VA uses state-of-the art and scientifically validated practices to address and treat mental health conditions that are common in veterans. It has a robust process for disseminating evidence-based practices (EBPs) throughout the VA’s health care system and for training its providers to use them.
• While studies comparing the quality of mental health care received by veteran versus civilian populations are scarce, there are data showing that the VA performs favorably on key measures of mental health care quality when compared to private health plans.
• Problems with manpower and physical infrastructure affect both access to care and the quality of the patient experience. The VA is experiencing significant shortages of mental health care providers despite efforts such as training programs for health professionals and using a wider variety of types of mental health professionals and paraprofessionals. Burnout and job-related stress

• among VA mental health providers may contribute to high turnover. The physical infrastructure issues include a lack of office and exam room space, insufficient parking at VA medical centers (VAMCs), and aging buildings, but changes are hampered by fiscal and regulatory processes.

• While the evidence-based mental health services are available to veterans and are mostly concordant with clinical standards and policy mandates, the committee’s research and the literature demonstrate that there are significant gaps in the delivery of that care:
  • Many veterans are not getting care as set forth in clinical standards for dosage, frequency, and follow-up. For example, prolonged exposure therapy and cognitive processing therapy require specified treatment intervals. Based on site visits and the research literature, system issues, such as lag times between appointments that interfere with treatment fidelity, and patient factors, such as patient preferences for the treatment type and engagement and retention in treatment, influence the delivery of EBPs.
  • The VA has made patient-centered care a priority with programs such as Whole Health, patient-aligned care teams, and integrated health care. Some of the veterans and staff who were interviewed reported negative experiences and did not seem to view the VA as patient centered, but their negative comments largely reflected workforce issues (short staffing, employee turnover, and professional burnout), difficult interpersonal interactions with support staff, and issues related to a lack of providers with experience in military culture.
• Compared to veterans from other eras, the OEF/OIF/OND veteran population is younger, has a larger number of women, and is more racially and ethnically diverse. Demographic characteristics are changing, and so is the spectrum of mental needs. Select population groups, including women, racial and ethnic minorities, and homeless veterans, face unique barriers to access to mental health care compared with male, white, and housed veterans. These groups also have differences in diagnosis patterns and disparities in treatment.

The VA dedicates resources to and has a history of implementing innovative practices in the areas of patient care, health information technology, and quality monitoring.

• The VA has implemented innovative and evidence-based models of collaborative and integrated care to improve the delivery of mental health treatment including primary care–mental health integration, the Behavioral Health Interdisciplinary Program, and a continuum of care based on a stepped-care model approach.
• The VA has long-standing experience and expertise with electronic health records (EHRs), telehealth, virtual care technologies, and tele-mental health research and app development.
• The VA has many data systems tracking patient care; however, it has not yet systematically collected and reported standardized patient-reported outcome measures. The VA has a stated goal of completing by 2018 development and release of a comprehensive tracking system that will allow providers to track the flow of their patients through mental health care and monitor their outcomes with standardized patient-reported outcome measures. The committee is not aware of how the VA will maximize the use of clinical outcome data that are collected to enable aggregate program-level outcome evaluation.
• The VA is using some community-based mental health resources to serve veterans—for example, through the Veterans Choice Program and partnerships with organizations specializing in veterans’ services—to help alleviate the VA’s workforce and infrastructure problems. However, the VA does not collect adequate information about the approaches it uses to ensure care coordination of and quality monitoring for services the VA offers through contracts with community providers.

CONCLUSIONS AND RECOMMENDATIONS

As the nation’s largest provider of mental health care services, the VA health care system has tremendous mental health care expertise, many and diverse care delivery assets, and substantial training and research capabilities. It has a unique and unparalleled opportunity to address the mental health care needs of veterans in a truly integrated and strategic manner. Furthermore, the VA is positioned to inform and influence how mental health care services are provided more broadly in the United States.

After reviewing extensive evidence, which was presented in earlier chapters of this report, the committee concludes that the VA provides mental health care that is generally of comparable or superior quality to mental health care that is provided in the private and non-VA public sectors and that it has multiple centers of excellence in various aspects of mental health care. However, the accessibility and quality of mental health care services across the system varies by facility. For example, the committee found variability in staffing levels, types of providers, infrastructure resources, and veterans’ access, and in the types and consistency of treatments provided. It should be noted that problems with accessibility and quality of mental health care are not unique to the VA; similar problems also have been reported in the private and non-VA public sectors. Although many OEF/OIF/OND veterans are satisfied with the VA’s mental health care, the committee believes that there are multiple opportunities for improving VA mental health care, especially with regard to increasing or facilitating access to care, providing care that centered on the patient’s needs and expectations (that is, patient-centered care), and ensuring the consistency and predictability of readily accessible high-quality care being provided across the entire system. To become a high-reliability provider of mental health care services (described in Chapter 7), the VA needs to align its resources with the need for services and consistently and predictably provide readily accessible, high-quality mental health care at every facility for every veteran on every occasion.

Recommendation 16-1. The VA should set a goal of becoming a high-reliability provider of high-quality mental health care services throughout the VA health care system within 3 to 5 years. The VA should develop a comprehensive system-wide strategic plan for providing readily accessible, high-quality, integrated mental health care services to improve the overall health and well-being of veterans. This plan should have a 3- to 5-year horizon and its implementation should be regularly monitored, reviewed, and updated, as needed, during that time.

The VHA needs to undertake a concerted, system-wide effort to organize and align its care delivery assets and processes of care toward this end, while concomitantly working with the VBA and other elements of the VA to achieve this goal. In some cases, this effort will mean marshalling additional or revamped care delivery and infrastructure assets, especially with regard to workforce and facility needs. To support these efforts, the VA should develop a comprehensive strategic plan or roadmap for reaching this objective. The strategic plan should address at least the following areas:

1. Ways to enhance and facilitate timely access to patient-centered care and remove barriers to access. Broad input from patients using mental health care, as well as from staff, about service satisfaction and the barriers to providing patient-centered care should be solicited. Evaluate service-improvement programs such as MyVA as well as the many mental health service programs that the VA offers to learn whether these programs are achieving stated goals. Facilities should be identified that have high service satisfaction, service effectiveness, increased access, and efficiency with the objective of calling out practices that might be adopted by other facilities.
2. Workforce issues, including the recruitment, hiring, and retention of diverse staff; ensuring that VA health professionals are working at the top of their skills and expertise; and using health professional training programs to address staffing needs.

3. The integration of the services of non-VA mental health care providers (for example, providers participating in VA community care programs such as the Veterans Choice Program) into the VA health care system. Independent evaluation of the utilization and quality of mental health services specifically provided by community-care programs.
4. Facility and other infrastructure needs, including facility physical plant issues that present barriers to access (for example, a lack of parking) or to the efficient and effective delivery of patient-centered care (for example, insufficient space for clinical evaluations and treatment).
5. The integration of mental health care with both primary and non–mental health specialty care.
6. The use of virtual care technologies, including telehealth and Internet-based technologies, to enhance access to and the delivery of mental health care.
7. Performance management to advance the quality of mental health care.
8. Incorporation of continuous quality improvement into all aspects of mental health care delivery.
9. The deployment and use of EBPs.
   1. Address barriers to providers’ use of recommended guidelines.
   2. Review existing priority areas in clinical guidance and policy directives to confirm the evidentiary base underlying the practices recommended for these priorities and to identify clinical practices requiring reassessment, inclusion, or removal.
   3. Increase use of EBPs through efficient and scalable clinical training procedures.
10. The system-wide review, modification, and standardization of policies and processes of care that facilitate and support access and the provision of high-quality mental health care.
11. Ways to foster and nurture innovation in methods and processes of mental health care.
12. Identifying and addressing research gaps and priorities.

The development of this strategic plan should be informed by the numerous studies and evaluations that have been conducted of VA health care in recent years. The VA should examine those reports to determine the reasons why some recommendations contained in them were judged to be appropriate but were not implemented. As appropriate, those recommendations, along with the recommendations contained in this report, should be collated and incorporated into or otherwise addressed in the mental health care strategic plan (see Recommendation 16-1). The committee understands that an analogous process was used to create the Mental Health Strategic Plan of 2004 (VHA Mental Health Strategic Plan Workgroup/Mental Health Strategic Health Care Group, 2004), which appeared to be effective in addressing a number of long-standing, chronic problems with provision of VA mental health care.

Below the committee makes additional recommendations that expand on some of the strategic plan areas listed above in Recommendation 16-1.

Access to Mental Health Care

In earlier chapters of this report and as summarized above in the section on key findings, the committee identified a number of ways OEF/OIF/OND veterans were having problems accessing mental health care from the VA. On the basis of those findings, the committee believes that the VA needs to do more to bring veterans who have unmet mental health care needs into the VA health care system. The lack of awareness about how to connect to the VA for mental health care demonstrates the need for awareness campaigns and effective dissemination of the mental health care opportunities, eligibility criteria, and services to help veterans understand how and where to access mental health care. The VA’s recent initiative to offer emergency mental health care to veterans with other-than-honorable discharge status is an important step in improving access for veterans who may be in need of immediate help. It may be particularly challenging to support veterans who are not ready to seek mental health services but who may want to obtain services

at a later time. The VA should consider strategies for following up with veterans at regular intervals (for example, every 3 to 6 months for 2 to 3 years) following discharge from the military.

Recommendation 16-2. Via policy changes and other approaches, the VA should eliminate barriers to accessing mental health care experienced by OEF/OIF/OND veterans. The VA should adopt additional strategies to engage veterans, expand outreach efforts beyond the initial post-deployment period, and improve its transitional services as well as VHA and VBA processes with the goal of enhancing and facilitating access to mental health care.

Specific actions to be undertaken include

1. The VA, along with DoD, should re-examine the processes for transitioning services from DoD to VA with the objective of enhancing the coordination and integration of services (including the determination of benefits and disability ratings and the transfer of health care records) and with the continuation of health care services. Possible improvements could include setting up initial VA health appointments as part of the Transition Assistance Program and providing liaisons who can be contacted to assist throughout the transition process and for a period of time afterwards.
2. The VA should examine the VHA and VBA interfaces with the goal of creating standard protocols (for example, for VBA compensation exams) to facilitate veteran access to services for physical and mental health conditions. The VA should view VBA compensation and pension examinations as an opportunity to engage veterans in ongoing care.
3. The VA should use assertive outreach to bring veterans who have mental health care needs into the system. The U.S. Department of Housing and Urban Development–VA Supportive Housing program to address veteran homelessness is an example of how assertive outreach already has been effective for the VA.
4. The VA should assess the availability and effectiveness of its peer specialist program and other support programs (for example, patient care navigators) at its facilities and develop appropriate implementation strategies if the assessment determines that these resources should be augmented.

Site visits also revealed that case managers and formal and informal system navigators are effective at helping veterans navigate both the VA bureaucracy and VA facilities. The various veteran service organizations have often played a critically important role in this regard, especially with regard to assisting veterans with VBA disability evaluations. However, navigational resources are limited and not available in all VAMCs.

As discussed in Chapter 2, mental health care services in the private sector are not adequate to meet the current demand for such services in many communities across the United States. There are, however, communities where resources are sufficient to do more and where these resources could be used to meet veterans’ needs. Several of these resources are described in Chapter 9. These resources generally provide ancillary and complementary services to support mental health treatment obtained from VA providers and from community care providers such as Veterans Choice Program providers.

Recommendation 16-3. The VA should examine how its facilities interface with community resources and compile an inventory of VA–community collaborations with the objective of identifying exemplary or model collaborations and best practices for forging community partnerships.

Equitable Care

Demographic data show that the OEF/OIF/OND veteran population is more racially and ethnically diverse and has more women than other veteran cohorts. As detailed in Chapter 13, the literature reveals differences in mental health diagnosis and treatment patterns across races and ethnicities among veterans receiving care at the VA. The reasons are not clear, but some researchers posit that the difference in diagnosis patterns may be related to provider characteristics, doctor–patient communication, patient participation, or the lack of cultural sensitivity in diagnostic criteria for mental health conditions. The rates of using mental health care services also differ across different demographic groups.

A published study reported that women veterans who served in OEF/OIF have a higher need for mental health care compared to women veterans from previous conflicts. The committee’s survey found that women veterans are significantly more likely to believe that they are not entitled or eligible for VA mental health services compared with men veterans who served in OEF/OIF/OND. The committee heard from women veterans during the site visits that staff at VA health facilities sometimes assumes that they are wives accompanying their husbands and not themselves veterans. They also are at times uncomfortable in VA clinic waiting rooms because they get unwanted sexual attention which can be particularly unsettling for women veterans who have experienced military sexual trauma. Although the research is still emerging, it seems that lesbian, gay, and bisexual veterans may use mental health services at a lower rate than veterans who are not lesbian, gay, or bisexual (see Chapter 13). Transgendered veterans may be more likely to have a mental health diagnosis than non-transgendered veterans. Research on homeless veterans shows that they are more likely to defer or delay mental health care than housed veterans even though they have a greater need for services. While interventions to reduce mental health stigma are emerging, stigma remains a barrier to seeking mental health care among veterans (as is the case broadly in the United States). Symptom severity may predict higher perceived stigma.

Recommendation 16-4. The VA should take steps to ensure that its diverse patient population receives readily accessible, high-quality, integrated mental health care services. Areas to focus on are service delivery, workforce issues, and resource allocation (including the logistics of care delivery and the structure of clinical space).

Specific actions should include

1. Ensuring that clinical environments are supportive of quality care for racial and ethnic minorities by ensuring that the racial and ethnic diversity among clinical and administrative staff reflects the diversity of the patient population, identifying and addressing discrimination, and monitoring and addressing health care disparities.
2. Ensuring that clinical environments are supportive of quality care for women veterans, efforts that should include the provision of gender-appropriate providers and intolerance of harassment of women veterans by either staff or fellow patients.
3. Assessing the needs of lesbian, gay, bisexual, and transgender veterans and providing an appropriately welcoming and supportive environment.
4. Assessing the needs and barriers to care for rural-dwelling veterans and ensuring that the demand for care in rural locations is met.
5. Identifying the homeless veterans who are being served and adjusting clinical services to provide them quality care and facilitate domiciliary services when appropriate.
6. Ensuring that both VA and community care providers understand military culture.

Human Resources and Capital Assets

As detailed in Chapter 8, the committee found that some VA facilities are understaffed and have inadequate clinical and office space to support the efficient delivery of care or patient-centered care. As a result of these infrastructure problems, VA mental health providers sometimes cannot meet the demand for mental health care services and providers “burn out,” which can interfere with the quality of the relationship between the veteran and provider. Primary care–mental health integration is one strategy that the VA has employed to realign its human resources to reduce service fragmentation and improve patient care. While the VA needs to ensure that its existing mental health care resources are allocated in a manner that optimizes the likelihood that they are effectively and efficiently used, it was clear to the committee that additional staff and clinical space are needed at some facilities. The committee recognizes that increasing the VA’s mental health workforce is particularly challenging, given the nationwide shortage of mental health care providers, and consequently it believes that the VA should explore ways it can use its educational and training infrastructure to address its workforce needs. Space shortages appear to be more of a concern at VAMCs and VA community-based outpatient centers (CBOCs) than at Vet Centers.

The lack of adequate space and workforce appears to be a prominent reason that staff at some VA facilities sometimes cannot provide EBPs. The use of therapy groups, which is a legitimate and often clinically indicated treatment approach, appears in some cases to have been used as a method of managing the overwhelming service demand.

Veterans sometimes experience a lack of continuity in their mental health care because of the turnover of providers and, especially, providers in training. (Many VA facilities are affiliated with academic medical centers, and, as is customary in academic training programs, trainees gain experience by treating veterans but must discontinue the therapeutic relationship when they rotate to a different clinical service or complete training.) The committee believes that the training of mental health care providers at VA facilities is highly desirable, but it also believes that the VA should make an effort to better bridge the transition from one trainee therapist to another. Some possible ways to accomplish this include limiting the number of times that the same veteran transitions to new trainees, better preparing veterans for the transition of caregivers by better coordination to minimize gaps in care, more strategic case assignment (for example, because EBPs are time limited, they may therefore be well suited for trainees), and improving efforts to assess whether a treatment can be completed or transitioned to a different level of care within the time frame of a trainee’s experience. The VA should raise provider awareness of the issue of continuity of care from the veteran’s perspective.

The VA has a variety of incentive programs to help bolster recruiting and retention. As described in Chapter 8, Title 38 U.S.C. positions, for example, can be filled by appointing a former or current VA trainee without formally posting the position and going through the full recruitment process. At present, the only types of mental health care providers included under Title 38 are physicians, psychologists, nurses, and physician assistants. Reclassifying all types of mental health care workers, including substance use counselors, under Title 38 might help in addressing some of the mental health care workforce problems.

As noted in Chapter 8, the committee heard repeatedly during its site visits that the VA’s human resources management process is cumbersome and onerous. There was broad support for improving the human resource management process, specifically with regard to the recruitment, onboarding, and retention of both care provider and support staff. Prominent among some of the suggestions for improving human resources related to mental health services were initiating the recruitment of staff as soon as a potential vacancy is identified or otherwise as early as possible in order to minimize the length of vacancies and also streamlining the hiring and onboarding processes. The recruitment of staff may benefit from improving working conditions, including having adequate clinical and office space to support efficient and effective patient-centered care; offering incentive awards; better supporting clinicians so that they

can focus more on clinical work and spend less time on administrative and clerical tasks; and creating work environments and processes that allow the staff to work to the fullest extent allowed by their licenses. In some cases, staff members will also need to be better trained in issues that are specific to caring for veterans, including OEF/OIF/OND veterans. Among other things, this training would include issues such as military culture and military sexual trauma.

During the site visits, many veterans reported that they highly valued the care that they received at Vet Centers and that they preferred to go to Vet Centers for their mental health care instead of VAMCs or CBOCs. Some of the reasons that veterans offered for preferring using the Vet Centers were the availability of marital and family therapies, a less formal atmosphere, seemingly enhanced confidentiality, shorter wait times, more flexible hours of operation, and the Vet Center’s emphasis on counseling services rather than the use of medications. Peer support is typically readily available as well. The VA should explore how the Vet Center program could be enhanced or, alternatively, how the characteristics of the Vet Centers that appeal to veterans could be replicated at CBOCs and VAMCs.

Recommendation 16-5. The VA should evaluate whether all types of mental health care workers could be brought under Title 38 U.S.C. and if this might alleviate some workforce shortages. If the assessment indicates that this reclassification would have a salutary effect, then the VA should pursue the necessary solutions.

Recommendation 16-6. The VA should conduct a broad examination of its various types of facilities to assess how it could realign its human resources and capital assets to better meet the demand for mental health care services. Adequate clinical and office space and staffing are necessary to reduce wait times, lessen administrative and clerical burden on clinicians, improve the fidelity of treatment, and increase adherence to clinical practice guidelines.

Health Technology

In its review of the literature and its analyses of its survey and site visit information, as detailed in Chapters 6 and 14, the committee found that the VA is using health technology, including telemedicine (the use of electronic information and communication technologies to provide health care) and mHealth (mobile health apps), to increase access to mental health care and to treat and help manage a variety of mental health conditions, including PTSD, depression, and SUDs. While telemedicine infrastructure has been widely rolled out, its actual use across the VA is highly variable and seems to be dependent on local champions and use cases, rather than on directed strategic approaches. The VA has been steadily increasing funding for telemedicine and has expanded telemedicine services throughout its health system. Nearly all of the published literature supports the use of telemedicine as a way of effectively delivering various health care services and, especially, mental health care. However, the literature regarding the use of telemedicine to deliver evidence-based treatments, specifically prolonged exposure and cognitive processing therapies, is sparse. Literature regarding the effectiveness of mHealth technologies also is sparse, but emerging. Furthermore, the use of virtual care technologies for mental health care is not yet fully integrated as a part of standard clinical care at the VA. Several barriers to access to care, such as the long distances to VA clinics and VA workforce shortages, could be addressed by using tele-mental health for clinical services.

While the growth of tele-mental health indicates the VA’s commitment to using technology to improve access to mental health care, research gaps in the field remain, as do implementation and attitudinal barriers in the VA. Long-term outcome studies are needed on the use of tele-mental health for conditions other than PTSD or depression. Further research also is needed on the use of tele-mental health

for evidence-based therapies—for example, therapies delivered in the home or in mobile settings—and for technologies other than videoconferencing, such as mHealth smartphone applications. In another use of health technology, research is needed to better understand how to optimize VA health information systems for comprehensive surveillance of suicide attempts among VA health care service users. To further maximize the benefits of health technology, the VA needs greater buy-in and commitment from national and local VA leaders, providers, and veterans in order to enable telehealth modalities to be a standard part of routine care, when appropriate. Coordinated training efforts at the provider and leadership level could improve buy-in and successful adoption.

Recommendation 16-7. The VA should leverage its existing health technology infrastructure and internationally recognized expertise in telehealth and virtual care to substantially expand the scale and quality of its tele-mental health and technology-supported mental health services for clinical, research, and educational purposes.

The VA is already a widely recognized leader in the research and development of, as well as the implementation and use of, electronic health records, telemedicine, and clinical information technologies such as mHealth to be used at the provider–veteran interface, but the potential value of this infrastructure and personnel capacity and strength is not currently being fully realized. The VA needs to move from this position of strength and set quantitative targets for the use of virtual care technologies (for example, to have 30 percent of all mental health consultations being performed online within 3 years), similar to what was done with regard to increasing ambulatory surgery in the VA in the late 1990s. It should do this by

1. Collaborating with partners, such as DoD and academic medical centers, to increase and support strategic research into the best use of these information technologies to support the mission of the VA and the care of veterans nationally, with a focus on methods used in dissemination and implementation research.
2. Substantially increasing and scaling the use of clinical information technologies for direct mental health care (for example, video, telephony, e-consults, messaging, apps, virtual reality, and gamification), and integrating them as a routine choice as part of stepped care for veterans across the full range of VA mental health and primary care programs.
3. Training leadership at all levels throughout the VA on how to promote and incentivize the increasing use of health information technologies in every VA area and on how to capture and copy examples of excellent implementation and innovation found in other VA regions.
4. Increasingly employing qualified providers as a virtual network of experts to work across the country, rather than primarily in a single region, and substantially increasing the use of such providers for meeting both training and service needs and capacities created by workforce shortages in some VA regions.
5. Making work conditions more flexible for many clinicians to enable them to increasingly work in a hybrid manner—both in person and online—and to work both within their own work regions and within other VA regions so that mental health care becomes available in a virtual manner, anytime, anywhere, especially direct to veterans in their homes. For workload and cost accounting purposes, providers will need to receive “credit” for work provided outside their own regions or networks.
6. Ensuring that the current VA EHR system is interoperable with DoD’s EHR and other commercially available EHRs to allow the passage of patient information (both physical health and mental health information) seamlessly and rapidly, thereby making sure that complete information is available to providers when and where it is needed.

Quality Management

The VA has a long history of taking important steps to improve the care and services it provides to veterans. The VA has many key initiatives aimed at measuring system performance to improve mental health care access and quality. Recent efforts include the expansion of quality management data systems (such as Strategic Analytics for Improvement and Learning and the Mental Health Management System) with more measures of mental health care, the use of performance data to encourage greater engagement by VA management in mental health programming and improvement, the conduct of research (through Quality Enhancement Research Initiative resources, for example) to identify best practices for improved access and quality, and the creation of the Diffusion of Excellence Initiative which seeks to facilitate the routine use of effective practices across the health system. In addition, the VA’s programs to train clinicians on evidence-based mental health treatments and to promote the use of those treatments by clinicians are other ways the VA has increased its capacity to provide evidence-based care.

The VA uses a number of quality management strategies, programs, and systems, but questions remain about how well these efforts are driving the system to be more patient centered and value driven while also improving access to care and quality of care. Problems with provision of services suggest that the VA does not appear to be adequately generating and using data to improve its mental health care system. More attention is needed to identify the sources of variation across VISNs and VAMCs and on using performance data about the various access and quality domains to establish targeted quality improvement efforts.

Given the large numbers of veterans who do not seek mental health care (see Chapter 6) and the significant percentages of veterans who are not receiving mental health treatments that meet recommended dosages, frequency, or follow-up (see Chapter 11), particular attention should be placed on measuring and monitoring the delivery of evidence-based care, patient engagement in care, and continuity of care. These areas of performance measurement should address veterans who receive care within the VA health system and veterans who receive care through VA community care programs, such as the Veterans Choice Program.

As discussed in Chapter 15, the VA needs better and a broader array of quality measures to improve the interface between general medicine and mental health. Few indicators have been implemented at the VA or nationally that specifically assess the quality of mental and general health care integration. For example, there is a need for standardized measures assessing the ability of patients in primary care settings to access effective mental health care as well as to assess the ability of individuals treated in mental health care settings to access needed preventive services and primary care. The quality reported by subgroups (for example, the type of mental health condition and the specific demographics) can support targeted interventions.

None of the VA’s data systems for quality management described in Chapter 15 collect and use patient outcome data, which is a significant barrier to quality improvement. Understanding, demonstrating, and continually increasing the quality of VA mental health care depends on standardized outcome measures. Patient outcome data are the necessary standard against which to judge effectiveness of the VA facilities’ quality improvement efforts. Another priority area is methods for measuring and improving the delivery of psychosocial interventions. The preponderance of mental health measures focus on medication management for the treatment of mental health conditions. However, cognitive behavioral therapy is the first-line EBP for depressive and anxiety disorders (see Chapter 4). The committee found that the VA has started collecting data on the delivery of evidence-based psychotherapy using electronic clinical progress templates incorporated into veterans’ health records. Quality measures in this area can have an important role to play in supporting patient-centered treatment.

Finally, to become a high-reliability mental health care system, the VA has to develop a more robust quality management infrastructure that will support the continuous evaluation of access, quality of care, and outcomes, among other things. This requires a much more broadly based portfolio of performance

measures than exists today. And while the development and use of mental health performance measures has gained momentum in recent years, and while the VA has been an active participant in this arena, the committee believes the VA should take a lead role nationally in measuring the quality of mental health care. The VA health care system can serve as a testing ground for measurement innovation that can benefit both veterans and the U.S. population broadly. And because a growing number of veterans are receiving care in the non-VA public and private health care sectors, the VA has a vested interest in establishing standardized performance measures that can be used to assess and improve the quality of care.

Recommendation 16-8. The VA should take a lead role nationally in advancing quality management in mental health care. Toward this end, the VA should take steps to accelerate the development and use of standardized performance measures to assess and improve care for mental health conditions in veterans. It should engage with performance measure development organizations to develop a robust portfolio of mental health care performance measures. As part of its comprehensive mental health care strategic plan, the VA should articulate how performance measures will be rolled out and implemented, maintained, and used for quality improvement and research purposes, and otherwise managed.

The committee found that quality performance data are routinely reported internally and publicly to support and incentivize ongoing quality improvement and to facilitate transparency. The VA also is demonstrating efforts to use and improve upon resources, such as the new Diffusion of Excellence Initiative, for disseminating best practices. Yet the persistent variation in the quality of care and the low rates of delivering ongoing treatment throughout the VA health care system indicate a need for the VA to continue efforts to improve clinical quality processes and to continue to transform itself into a learning organization marked by a culture of continuous improvement.

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