VA Mental Health Provider Venting / Problem-solving / Peer Support Thread

[Sanman]

Speaking of performance evals, what is the actual utility of these?

As far as I can tell, it's tied to your performance bonus (if your facility does them) & EDRP is contingent on being satisfactory in all areas. I'm guessing it matters for promotions (since step increases are automatic)?

I don't have EDRP, would leave VA before taking a supervisory position and a couple hundred bucks after tax is definitely not enough to shape my behavior.

Is there anything else that I'm missing based on other people's experience?

I always skip doing things like filling in your own narrative each time these evals come up and always procrastinate things like TMS and OPPE because I haven't found much incentive to do otherwise lol.

Step increases are automatic as long as you receive all satisfactory scores. They can deny a step increase with an unsatisfactory eval. Other than that, you missed that you are working too hard.

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[cara susanna]

I got exceeds expectations even though I was slightly low for RVUs, so even that doesn't necessarily matter that much depending on your supervisor and what else you're doing.

 

[AcronymAllergy]

Our reviews factored into our annual bonus on the few years we received one. It wasn't a substantial difference from what I remember (e.g., maybe $500 vs. $1000). Probably more important for physicians, as I believe their bonuses are/were in the $10-20k range. And like you've said, I believe EDRP is contingent on at least being satisfactory.

As for BLS, as a few other folks have said, our facility pulled folks from patient care immediately upon expiration until it was completed.

 

[cara susanna]

Does anyone else think that chronic is one of the most unnecessary and useless specifiers for PTSD?

 

[WisNeuro]

Does anyone else think that chronic is one of the most unnecessary and useless specifiers for PTSD?

I thought they did away with that in 5? It was my understanding that the only specifiers now are the dissociative stuff and delayed onset.

 

[AcronymAllergy]

I thought they did away with that in 5? It was my understanding that the only specifiers now are the dissociative stuff and delayed onset.

That's my understanding as well. I still see it added pretty frequently, though. And some folks seem to be taking full advantage of ICD-11's inclusion of Complex PTSD as a diagnosis.

 

[cara susanna]

Ah, they DID get rid of it! Thank you. But unfortunately the VA insists on using ICD. So I guess I still have to deal with it, but now I will not feel guilty about using unspecified.

 

[Sanman]

Ah, they DID get rid of it! Thank you. But unfortunately the VA insists on using ICD. So I guess I still have to deal with it, but now I will not feel guilty about using unspecified.

Billing codes are all based on ICD not DSM whether in VA or outside, so until that catches up it will be in there.

 

[cara susanna]

Why do we keep using ICD? It's gonna be such a mess when ICD-11 hits and PTSD is drastically different.

 

[NeuroJaguar]

Why do we keep using ICD? It's gonna be such a mess when ICD-11 hits and PTSD is drastically different.

I believe it's a final rule through the US dept of health and human services dictating that all healthcare environments have have to use ICD-10 (I believe it's incorporated as part of HIPAA standards) ? Someone correct me if I'm wrong please

 

[Sanman]

Why do we keep using ICD? It's gonna be such a mess when ICD-11 hits and PTSD is drastically different.

ICD covers all medical dx (not just psychiatric) and is recognized by CMS and all the governing bodies as it is published by the World Health Organization as a standard with the U.S version getting input by CMS and AMA. DSM is managed by the American Psychiatric Association and is largely irrelevant except as a reference to practitioners like us.

 

[PsyDr]

I believe it's a final rule through the US dept of health and human services dictating that all healthcare environments have have to use ICD-10 (I believe it's incorporated as part of HIPAA standards) ? Someone correct me if I'm wrong please

You're correct. Except it's the ICD-10 CM.....

The USA uses a different version of the ICD than the rest of the world (i.e., the CM). The WHO owns the ICD, but they allow the AMA to publish a US specific version of the ICD. The publication of updates to the ICD-10 CM is a complicated thing, with lots of negotiations with the federal government.

It's also why the DSM is required to publish a cross walk between diagnostic codes.

 

[cara susanna]

That is SUCH a mess. If ICD is the standard, why don't they teach us that in school?

 

[Sanman]

That is SUCH a mess. If ICD is the standard, why don't they teach us that in school?

This is why I have taken the time to teach this stuff to interns and post-docs.

 

[AcronymAllergy]

ICD covers all medical dx (not just psychiatric) and is recognized by CMS and all the governing bodies as it is published by the World Health Organization as a standard with the U.S version getting input by CMS and AMA. DSM is managed by the American Psychiatric Association and is largely irreverent except as a reference to practitioners like us.

I wouldn't say it's largely irrelevant as a whole. Possibly as far as healthcare billing, sure. But DSM can be used in medicolegal/disability work.

I also think DSM's diagnostic criteria for PTSD are better overall than ICD's (and especially ICD-11's). ICD also has gems such as complex PTSD and postconcussional syndrome.

 

[cara susanna]

The VA is held to such high standards for timely consult management in-house but then with the community care dept it's like

 

[psycho1391]

The VA is held to such high standards for timely consult management in-house but then with the community care dept it's like

Right. Like most of the time at my VA, community care is done because of the wait time on house.
Kinda defeats the purpose for CC to take FIVE-EVER.

 

[cara susanna]

How this always goes:
1. I place community care consult, sched pt for 1 month f/u to ensure they don't get lost in the system
2. Month goes by without any action from cc
3. I see patient again, they opt to just see me for therapy in the future

 

[summerbabe]

How this always goes:
1. I place community care consult, sched pt for 1 month f/u to ensure they don't get lost in the system
2. Month goes by without any action from cc
3. I see patient again, they opt to just see me for therapy in the future

Sounds like a good SOP lol

 

[Sanman]

I wouldn't say it's largely irrelevant as a whole. Possibly as far as healthcare billing, sure. But DSM can be used in medicolegal/disability work.

I also think DSM's diagnostic criteria for PTSD are better overall than ICD's (and especially ICD-11's). ICD also has gems such as complex PTSD and postconcussional syndrome.

I would argue that most medicolegal/disability work is based on arguments between professional and a professional reference is useful in that instance. I don't know many instances in which the DSM is picked up or used by non-mental health professionals (except the lawyers/judges doing the medicolegal work). So, I do feel that it is largely irrelevant to non-professionals.

 

[Sanman]

How this always goes:
1. I place community care consult, sched pt for 1 month f/u to ensure they don't get lost in the system
2. Month goes by without any action from cc
3. I see patient again, they opt to just see me for therapy in the future

I am actually getting folks are unhappy with community care after getting it and bouncing back to us. Then again they are seeing the veteran only every 4-5 weeks. So, the doctor shopping continues...

 

[AcronymAllergy]

I am actually getting folks are unhappy with community care after getting it and bouncing back to us. Then again they are seeing the veteran only every 4-5 weeks. So, the doctor shopping continues...

Yep, that happened with us as well. Or I'd be booked out 6-8 months, would get them an appointment while also submitting the CC consult, and they'd still get in to see me before CC. I could count on one hand the number of CC neuropsych consults that actually went through successfully and before they got through my (admittedly long) waitlist.

 

[Grenth]

I know this is a complaint as old as the VA but can no one in leadership actually do math and figure out that it is not realistic to assign 4 new patients a week to people expected to do 25-28 hours a week of direct care total.

I realized after my 4 intakes, 2 groups I have 19 hours of follow-up on a week with no holidays etc. If I'm doing really strict EBPs (which I try to) can get someone churned out in 12-16 week if I offer weekly appointments which I usually can't. But it is also the policy at my VA that anyone who has accessed outpatient in the last 24 months is entitled to come right back for a follow-up without any triage elsewhere. So I typically have 1-5 patients coming out of the woodwork via PCMHI or direct message a week. It would take me less than 2 months to be completely out of follow-up slots it seems like.

They're pushing this Sprint access thing so hard and discussing moving to dedicated intake providers but I still don't see how it works to provide adequate follow-ups unless people need really brief episodes like for CBTi.

Is Sprint working well anywhere and what are you all doing?

 

[cara susanna]

I don't think Sprint will work well anywhere in MH, lol. Our supervisor is trying to use it as a way to push harder for active episodes of care and EBP access.

 

[Sanman]

I know this is a complaint as old as the VA but can no one in leadership actually do math and figure out that it is not realistic to assign 4 new patients a week to people expected to do 25-28 hours a week of direct care total.

I realized after my 4 intakes, 2 groups I have 19 hours of follow-up on a week with no holidays etc. If I'm doing really strict EBPs (which I try to) can get someone churned out in 12-16 week if I offer weekly appointments which I usually can't. But it is also the policy at my VA that anyone who has accessed outpatient in the last 24 months is entitled to come right back for a follow-up without any triage elsewhere. So I typically have 1-5 patients coming out of the woodwork via PCMHI or direct message a week. It would take me less than 2 months to be completely out of follow-up slots it seems like.

They're pushing this Sprint access thing so hard and discussing moving to dedicated intake providers but I still don't see how it works to provide adequate follow-ups unless people need really brief episodes like for CBTi.

Is Sprint working well anywhere and what are you all doing?

The only silly part about your statement is the suggestion that leadership actually looks at those numbers. The larger problem with mental health in general (as I have said before) is a lack of reimbursement and coding for decision making/management. As long as 45 min for CBTi or even supportive therapy is seen on a spreadsheet as the same as 45 min for a non-compliant, bipolar, complex PTSD, medically complex, etc. cases, the more people are incentivized to move to positions in lower acuity care areas. Sprint with only accelerate that trend.

 

[Grenth]

Yeah, the episodes of care seems like a good idea in theory but it also seems incompatible with the political incentive to have care accessible to whoever wants it whenever they want it and for however long.

If we define access as intakes it might work great but I am starting to realize (slow learner here) that a system that allows free care and ties illness to benefits is not going to motivate people to benefit from discrete efficient episodes of treatment unless they give us a functional mechanism for discharging/denying care which seems unlikely to happen.

I do think this is probably more of an issue for those of us in general mental health since specialty clinics have more mechanisms for discharge/shuffling people around.

 

[Sanman]

Yeah, the episodes of care seems like a good idea in theory but it also seems incompatible with the political incentive to have care accessible to whoever wants it whenever they want it and for however long.

If we define access as intakes it might work great but I am starting to realize (slow learner here) that a system that allows free care and ties illness to benefits is not going to motivate people to benefit from discrete efficient episodes of treatment unless they give us a functional mechanism for discharging/denying care which seems unlikely to happen.

I do think this is probably more of an issue for those of us in general mental health since specialty clinics have more mechanisms for discharge/shuffling people around.

Depends on how your local system is set up and how good you are at playing the system.

 

[Grenth]

My local system is set up to be chaotic and motivate all but the worst providers to leave it seems. I am very lousy at playing the system but I'm wising up since I don't want to leave if there's any hope things can improve. I'm learning tricks here and would appreciate any more people have to share.

 

[cara susanna]

Yeah, the episodes of care seems like a good idea in theory but it also seems incompatible with the political incentive to have care accessible to whoever wants it whenever they want it and for however long.

If we define access as intakes it might work great but I am starting to realize (slow learner here) that a system that allows free care and ties illness to benefits is not going to motivate people to benefit from discrete efficient episodes of treatment unless they give us a functional mechanism for discharging/denying care which seems unlikely to happen.

I do think this is probably more of an issue for those of us in general mental health since specialty clinics have more mechanisms for discharge/shuffling people around.

Yes, I think there are major systemic barriers. The active episodes of care model though just stipulates that you have periods where you check in on progress and determine if additional care is needed. It's not saying "at this date we're ending treatment and that's that." Granted, even with that we all know we have patients we are going to see for their rest of their/our lives.

I'm 50% general OPMH (and even my 50% PCT role is limited in terms of who I can discharge) so I feel your pain.

 

[summerbabe]

They're pushing this Sprint access thing so hard and discussing moving to dedicated intake providers but I still don't see how it works to provide adequate follow-ups unless people need really brief episodes like for CBTi.

Is Sprint working well anywhere and what are you all doing?

It doesn't and will not.

From my experience, whenever a new political priority arises, we will do whatever we can to satisfy that priority, even if it literally undoes everything the the last/previous political priority was trying to achieve.

From a purely political perspective, it's likely that the last set of admin/leaders who issued the previous guidance are no longer in govt service (or VA service or in another VA role with other demands) so their institutional knowledge & desires get wiped away and we focus on the new priorities.

Some individual sites are better at pushing back or using half measures to look like they are meeting these new goals (and usually have plans to tweak metrics in small but meaningful ways that help them stay under the radar) but most sites don't have that type of leadership stability. Or have leadership stability but everybody is just looking to get promoted and will do the politically expedient thing.

So we basically end up as the definition of throwing the baby out with the bath water. Rinse & repeat endlessly.

I try to do what I can to be subversive in small ways that promote good patient care (but generally stays under the radar) since that's about all I can control.

 

[cara susanna]

Yup, this is a congress thing and unfortunately the VA has to obey the whims of the government even if they are completely unreasonable or clinically not indicated.

 

[psy.d. 2021]

Us outpatient mental health therapists were just informed about this push for sprint recently in my clinic. It sounds punishing toward providers who need to take time off at worst, and an administrative mess when trying to figure out intake clinics when already short staffed at best. I wish our leadership would slow play this until national stopped caring. It really annoys me that the big wigs only seem to care about when someone is initially seen and don't care about whether vets have good access to ebps or even improve in tx

 

[cara susanna]

Us outpatient mental health therapists were just informed about this push for sprint recently in my clinic. It sounds punishing toward providers who need to take time off at worst, and an administrative mess when trying to figure out intake clinics when already short staffed at best. I wish our leadership would slow play this until national stopped caring. It really annoys me that the big wigs only seem to care about when someone is initially seen and don't care about whether vets have good access to ebps or even improve in tx

Upper leadership also has NO idea how mental health works and always treats it the same as primary care.

 

[AbnormalPsych]

I worked at a place where upper leadership thought that depending on the disorder, you just pull the corresponding tx manual off your bookshelf and read it together with the patient in session and do worksheets together for few visits, then they are cured. And you put the manual back on the shelf, and on to the next.

.... tell me you've never seen a patient, without telling me you've never seen a patient. MBAs, man.

 

[thebalmofhurtminds]

Reading this thread to remind myself why I shouldn't go over to our local VA, despite them getting a nearly 15k raise recently...

 

[WisNeuro]

This thread summarized should be what the VA slogan should be for recruiting providers.

"The VA, we're not for everybody."

 

[AcronymAllergy]

VA can definitely be a good gig, especially with the pay bumps and if you're the type of person who's not easily aggravated by administrative hassles, can let bureaucratic frustrations roll off your back, and land at a good VA with supportive mid- and upper-level management. I think mid-career folks are the ones who have the hardest time there. There's big appeal for returning for 5 years before retiring to be able to take your health insurance with you.

 

[cara susanna]

Not me racing to cancel the BHL Touch administration for my patient who late cancelled, otherwise they'll report their chronic SI on the PHQ-9 and I'll have to try to reach them via phone

 

[Shiori]

Most of my patients have decided it's too cold for therapy. I have seen two people today and one person for half a session yesterday.

 

[Sanman]

Most of my patients have decided it's too cold for therapy. I have seen two people today and one person for half a session yesterday.

Is this telehealth or in-person? In-person will take a huge hit on these days but telehealth would surprise me. Just grab some hot cocoa and come get therapized.

 

[summerbabe]

Most of my patients have decided it's too cold for therapy. I have seen two people today and one person for half a session yesterday.

My local hard freeze warnings didn't include but also didn't exclude emotions, ya know?

Not me racing to cancel the BHL Touch administration for my patient who late cancelled, otherwise they'll report their chronic SI on the PHQ-9 and I'll have to try to reach them via phone

I'm very pro measurement based care in principle but too often anti measurement based care in practice for reasons exactly like this.

 

[Sanman]

VA can definitely be a good gig, especially with the pay bumps and if you're the type of person who's not easily aggravated by administrative hassles, can let bureaucratic frustrations roll off your back, and land at a good VA with supportive mid- and upper-level management. I think mid-career folks are the ones who have the hardest time there. There's big appeal for returning for 5 years before retiring to be able to take your health insurance with you.

Though there are many complaints, I think VA falls pretty high on the salaried employee scale as far as desirability. Certainly better than those large, take 50% of your money group practices. Now a good group or solo PP is a different animal altogether. However, I personally think that is more of an option when you don't need the job/money and can afford to take risks.

 

[WisNeuro]

My local hard freeze warnings didn't include but also didn't exclude emotions, ya know?

I'm very pro measurement based care in principle but too often anti measurement based care in practice for reasons exactly like this.

Measurement can be good, but not when it's just measurement for measurement's sake, or to check a box for someone in regional office, such is the case in the VA. I'm a big proponent that we should be doing a lot more to track healthcare outcomes to help with policy and regulation, but as measurement is generally done currently, that is not really possible in a meaningful way.

 

[cara susanna]

Most of my patients have decided it's too cold for therapy. I have seen two people today and one person for half a session yesterday.

I had 1 out of 4 patients show today, and I'm all telehealth at the moment.

 

[Sanman]

I had 1 out of 4 patients show today, and I'm all telehealth at the moment.

So much for telehealth improving attendance.

 

[Shiori]

Yeah, I have an almost even split of telehealth and face to face. I haven't noticed much difference in their no-show and cancellation rates.

 

[WisNeuro]

Given that the no-show rates for VA patients is already an outlier, it'd be hard to notice differences in no-show rates to begin with.

 

[Shiori]

Don't forget about the VA's exhaustive system of metrics. I can look at just about any breakdown little my heart desires.

 

[Sanman]

Given that the no-show rates for VA patients is already an outlier, it'd be hard to notice differences in no-show rates to begin with.

Even with VA no show rates, you would think the attendance rate would be better when the bar is set as pickup your phone and click a button. You don't even need to get out of bed to do that. Let alone put on clothes.

 

[WisNeuro]

Even with VA no show rates, you would think the attendance rate would be better when the bar is set as pickup your phone and click a button. You don't even need to get out of bed to do that. Let alone put on clothes.

I honestly don't think it's ease of attendance for the most part. I really do think it boils down to zero accountability on the patient's part. They can generally no-show as much as they want with minimal backlash. The total number of no shows in my clinical practice over the past 3 years in my private practice is less than what I would generally get in a few weeks at the VA. And, of those no-shows, one was hospitalized the night before, and one literally died, so in essence I've only had one actual no show in 3 years.