Improving Access to High-Quality Mental Health Care for Veterans: Proceedings of a Workshop (2023)
Chapter: 7 Reflections and Future Considerations
Many speakers had reiterated that VA is not alone in facing the challenge of meeting a growing demand for mental health services with limited resources. Additionally, providers and community partners commonly face compounding difficulties, such as accurate identification of patients, workforce shortages, and geographic disparities. But at the same time, Kizer noted several success stories and potential models that can be operationalized to VA’s advantage. This chapter summarizes key themes from discussions and takeaways and suggestions from planning committee members for VA to advance its work.
PLANNING COMMITTEE REMARKS
Members of the planning committee summarized and reflected on the themes that emerged and some potential next steps VA can take to improve mental health access. Harris said training and community were referenced several times throughout discussions. But much of this work is happening in silos, she noted, which is a common problem that needs more attention. She suggested that VA should continue to work with CHWs and build that foundational support.
Viewing Veterans as Individuals
Silvia also reiterated the importance of community and using community resources, CHWs, pharmacists, and other groups—but realizing that veterans are not homogenous and come from a variety of different backgrounds. He suggested having a menu of options for resources to recognize this variability of individual needs. Some may need assistance with housing and others with substance use or depression. He also brought up the importance of efficiency. It may be possible to reexamine who is using which resources and develop a system to have people step down and open up the higher-acuity services for those who really need them.
Kizer shared a story from his time at a large state university system when many returning Operation Iraqi Freedom and Operation Enduring Freedom veterans were enrolling and using their education benefits. He asked the leadership at the time how many veterans were in the system (the second largest in the country), and they did not have that information. Although that issue has been corrected, he said, it is emblematic of what is seen in a variety of organizations: veterans are just not identified in the population being served.
Lewis discussed the wide diversity of identities among veterans and how they are a cross section of the general population spanning every demographic group. If we can understand how to best treat veterans, she continued, we can apply those lessons to all populations. We talk so much about collecting data,
she added, but how many data do we need to collect while people suffering from health disparities wait for us to figure out how to use them to deliver better care? She highlighted the need to pull all the information together and to analyze what is already being done and what can help clarify ways to move forward.
Potential Areas of Improvement for VA
Samorani highlighted three areas for VA to consider. The first is provider capacity, he said, but it is not limited to just hiring new people. For example, VA taking 6 months to extend a job offer and therefore losing qualified candidates is clearly a problem, and the process needs to be streamlined. Other ways to improve this capacity include developing partnerships; offering telehealth; leveraging AI tools, such as NLP; and generating notes automatically to save time. The second area is the type of care, he continued. He noted that most often services include therapy and medications, but many other interventions are available that show promise and require relatively fewer resources—such as mindfulness, yoga, and breathing exercises—although these are often difficult to reimburse outside of VA. The third area is outreach. As speakers pointed out, some veterans are not in the system because they have never gone to VA, but they may be the most isolated and have the most needs. He also reiterated the importance of partnerships with local organizations, including pharmacies, houses of worship, or community health centers.
Shore also shared three points in summarizing the workshop discussions. The first is that this is a complicated problem, and implementation is an ongoing process. Systems the size of VA can take a long time to change. Next, he built on Silvia’s suggestion of a menu of services, acknowledging that VA needs to balance system-level needs with local mental health access. He noted the careful line between standardizing care and allowing for adaptation and customization at the local level. The third and last point he split into two areas—short and long term. Some immediate ideas emerged from these discussions that VA could implement fairly rapidly, he explained. But, at the same time, a sea change is also occurring in response to the COVID-19 pandemic, paired with the increasing acceleration of technology. He suggested that VA examine its strategy over the next several years to reconfigure operations and workflow to support a larger foundation of mental health access.
Working Within the U.S. Government Context
Kizer asked for thoughts on the issue of timing, noting that changes and long-term planning for VA often rely on approvals and support from Congress. Harris suggested that looking at the current data and developing a long-term
plan must include a clear documentation of progress based on what has been learned. Silvia added that it is very complex, with millions of veterans already in the system and 200,000 leaving the service every year—and argued that this cannot be a 1-year-in-advance issue. Samorani agreed it is a long-term issue, but some points can be started on right now, within a year, such as creating new partnerships and encouraging other organizations to identify veterans in their system. Shore added that a strategy should be to have a long-term vision but include short-term deliverables for immediate discussion.
Lewis explained that one of the examples demonstrating how difficult things can be is the PACT Act,1 which aims to bring numerous benefits to veterans that would otherwise be a struggle for some. The PACT Act reaches back to the Vietnam era and exposures there, she noted, and extends to the Global War on Terror era of conflicts, each with its own “Agent Orange.” Before it, the burden of proof regarding toxic exposures while serving was always on the veteran to demonstrate the link between cause and health effect. The PACT Act eliminated a lot of that stress, she said, leading to a wave of screening to identify individuals who have health issues or may develop them 5, 10, or more years from now. However, even getting the PACT Act passed was a delicate dance that took a lot of advocacy and back and forth across Congress.
FUTURE CONSIDERATIONS FOR VA
Matthew Miller, national director of suicide prevention at the VA Office of Mental Health and Suicide Prevention, shared his reflections on what is going well at VA, what the demands and needs are, and what lessons he took away from the workshop discussions. He thought VA has been very successful with crisis care through the world’s largest and most efficient crisis call center, the Veterans Crisis Line, which has 1,700 individuals dedicated to answering phone, text, or chat within an average of 9 seconds at a rate of 2,500 calls and 500 texts and chats per day. VA’s commitment to providing same-day access in mental health and primary care has led to interesting discussions about how to engage open access, he noted. VA has not solved all the challenges, but it is working on developing models within primary care and specialty settings to do this better. He also mentioned integrated care within primary care, noting that a significant part of the strategic plan in suicide prevention is embedding mental health expertise in pain clinics and within oncology clinics because they often see a high-risk population.
In terms of demand, Miller also referenced the PACT Act and how that will lead to increased eligibility. Similarly, the COMPACT Act Section 201
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1 For more on the PACT Act, see https://www.va.gov/resources/the-pact-act-and-your-va-benefits/ (accessed June 22, 2023).
authorizes full coverage of emergency care regardless of location for all veterans determined to be in acute suicidal crisis, which also includes 90-day followup care.2 This will significantly open the door to new patients, he added. The Hannon Act Section 201 also has a stipulation that any veteran receiving services through a grantee is now eligible for VA mental health services.3 He then asked about where we go from here. A comprehensive view of access and of the population is clearly needed. Regarding access, Miller emphasized the importance of approaching it in a tripartite manner to prevent a myopic view, where people become so fixated on one aspect that others are left behind. Second, he said, we need to review it across a continuum of care. Third, the mindset should be about an episode of care, meaning the goal should be to facilitate access not just for one or two visits but across an entire episode, guided by the literature. Last, he said access needs to occur in the context of the quadruple aim (improving quality, reducing cost, improving patient experience, and improving workforce well-being). Regarding a more comprehensive view of the population, Miller highlighted three variables—capacity, demand, and population need. Need and demand sound similar but are not synonymous. The takeaway is that access should be addressed from a perspective of demand and capacity matching.
Miller highlighted three categories of lessons that emerged from the workshop discussions: (1) structural (i.e., different systems, clinics, flows, and components such as navigators), (2) procedural (i.e., ideas related to assessment and a recovery-oriented focus), and (3) methodological (i.e., recommendations related to AI, ML, immersive technology, community care, or virtual care). This process will be a journey requiring key questions on what access means, how it is defined, how it can be measured, and what the standard is for achieving it. Unless these questions are addressed together, unrealistic expectations will likely be formed, he noted, and unsustainable systems will be built. In the end, this can lead to negative downstream consequences, where those who seek care at systems that do not adequately meet their needs will lose trust and may not seek help again or reengage in the future. As we continue to build trust with veterans, he concluded, it is important that we do so together, so veterans receive the care they need and deserve.
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2 For more on the COMPACT Act, Section 201, see https://cammack.house.gov/sites/evo-subsites/cammack.house.gov/files/evo-media-document/compact-section-201-direct-care-faqs.pdf (accessed June 1, 2023).
3 For more on the Hannon Act, see https://www.congress.gov/116/plaws/publ171/PLAW-116publ171.pdf (accessed June 1, 2023).
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