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

[cara susanna]

Yup, what a different world we'd all live in if the VA charged fees for late cx or no shows.

---

Members don't see this ad.

 

[Sanman]

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.

Well, the above data point certainly seems to agree with you. The other half of the question is whether those who tend to be non-compliant tend to gravitate toward VA care or if the policy breeds non-compliance.

 

[cara susanna]

That's a good point - we also may see the more severe patients, as presumably those who are functioning better have employment and private health insurance options.

 

[WisNeuro]

That's a good point - we also may see the more severe patients, as presumably those who are functioning better have employment and private health insurance options.

Maybe for younger, but I'd say my usual 60+ population is pretty similar in and out of the VA. I do take Medicare, FWIW.

 

[Sanman]

That's a good point - we also may see the more severe patients, as presumably those who are functioning better have employment and private health insurance options.

Based on my interaction with different eras, I find that those who served in WWII and Korea tended to be a larger cross-section of the public, Vietnam era folks tend to have the most complaints because they often did not choose to serve and feel they are owed something for being drafted, the peace time folks are fairly well adjusted. The 50 and below folks are either career military or came from a low SES background where the military was the only job option (or only one they could keep). A lot these folks never had the coping skills to handle life well before they developed mental illness, barely graduate high school or got a GED, and the VA is the only thing keeping them afloat in society. For a few of my younger folks, VA disability is the best paying gig they ever had.

 

[psycho1391]

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

Don't know about your VA, but engaging in measurement based care is an item on our performance eval.

 

[psycho1391]

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.

Here lately, I feel people in my clinic are more likely to show for in-person. I think its a motivation factor if they chose in-person. IDK though. My VVC clinic has a very high missed opportunity percentage compared to my in-person clinics.

 

[thebalmofhurtminds]

Not sure if this applies to any of your populations, but my no-show rate for telehealth on freeze/snow days is often more about kids being home.

 

[Sanman]

Not sure if this applies to any of your populations, but my no-show rate for telehealth on freeze/snow days is often more about kids being home.

Not a problem I generally have. Spouses being home is sometimes a problem. However, they usually just let me know in session and we don't discuss certain topics.

 

[cara susanna]

What is with this new Teams update or something that won't automatically change my emoticons into emojis? This may sound dumb but it's REALLY cramping my style

 

[Shiori]

What is with this new Teams update or something that won't automatically change my emoticons into emojis? This may sound dumb but it's REALLY cramping my style

Uh oh, I'm not having this issue.

They will probably revoke my GIF privileges at some point. I have a knack for finding the very unhinged ones.

 

[cara susanna]

Uh oh, I'm not having this issue.

They will probably revoke my GIF privileges at some point. I have a knack for finding the very unhinged ones.

The day we got GIFs on Teams, I was like "you guys are going to regret this."

So it's just me? Hrmm, maybe I'll try rebooting then.

 

[psy.d. 2021]

Anyone here navigate the edrp application process? Doing it now and the loan verification forms seem like they'll be a pain to get from Nelnet and Navient, two well known terribly run organizations. anyone have any tips for that?

 

[AcronymAllergy]

Anyone here navigate the edrp application process? Doing it now and the loan verification forms seem like they'll be a pain to get from Nelnet and Navient, two well known terribly run organizations. anyone have any tips for that?

I suspect the loan servicers should have a method of submitting documents for them to complete electronically or via fax.

 

[SikeThatsTheWrongNumber]

Anyone here navigate the edrp application process? Doing it now and the loan verification forms seem like they'll be a pain to get from Nelnet and Navient, two well known terribly run organizations. anyone have any tips for that?

it looks more painful than it is. Nelnet responded to my email request within one week. They sent me the completed forms in a nondescript envelope about one week after that.

i recommend that you withhold your SSN until the last step for security reasons.

 

[psy.d. 2021]

it looks more painful than it is. Nelnet responded to my email request within one week. They sent me the completed forms in a nondescript envelope about one week after that.

i recommend that you withhold your SSN until the last step for security reasons.

Do you happen to have a good email for Nelnet? Just want to make sure I'm not sending my request into a black hole

 

[aim-agm]

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

To add to this, PHQ9 doesn't even specifically query SI. It asks:
"Thoughts that you would be better off dead or of hurting yourself in some way"

This could include SI, thoughts of NSSIB, wish for death, ambivalence about life...or going to Church and hearing a sermon about how good Heaven is.

While I'm ragging on the PHQ9, I'll also add that despite some guidelines saying that scores of 5/27 or higher indicate depression, the minimum possible score to meet criteria for MDD is 15/27...but a score of 25/27 can be incompatible with MDD.

 

[JustNoticing]

Anyone here navigate the edrp application process? Doing it now and the loan verification forms seem like they'll be a pain to get from Nelnet and Navient, two well known terribly run organizations. anyone have any tips for that?

yeah, its not the most fun process, and there are too many forms and processes to go through, but companies like Nelnet are used to getting these forms, and downloading your payment history is surprisingly easy with them. My first year of EDRP went much smoother than I expected.

 

[psycho1391]

That moment when you have a vvc appointment and you don't want to call a patient before the 15 minute no show mark, but in meetings it is emphasized that missed opportunities are a big concern. *SIGH*.

 

[cara susanna]

That moment when you have a vvc appointment and you don't want to call a patient before the 15 minute no show mark, but in meetings it is emphasized that missed opportunities are a big concern. *SIGH*.

How is that a missed opportunity?? It's the patient's responsibility to show up on time.

I usually call 5 min into VVC but there are patients I don't call anymore because I'm sick of chasing them.

 

[Sanman]

How is that a missed opportunity?? It's the patient's responsibility to show up on time.

I usually call 5 min into VVC but there are patients I don't call anymore because I'm sick of chasing them.

I will say this, I have had a few folks end up in the wrong VVC room by clicking on the wrong appt. So it never hurts to call and check that.

 

[psycho1391]

How is that a missed opportunity?? It's the patient's responsibility to show up on time.

I have no clue, but if an appt is cancelled DURING the scheduled time or no shown, the beancounters count that as a "missed opportunity" and it looks bad.

 

[Sanman]

I have no clue, but if an appt is cancelled DURING the scheduled time or no shown, the beancounters count that as a "missed opportunity" and it looks bad.

Looks bad for who? I certainly don't care.

 

[summerbabe]

I have no clue, but if an appt is cancelled DURING the scheduled time or no shown, the beancounters count that as a "missed opportunity" and it looks bad.

We are having this exact same discussion right now so national guideline on no-shows/cancels has changed at some point recently, including suggestions on what to do to increase productivity when this happens (like sending secure messages with workload credit to other patients - lol).

 

[psycho1391]

We are having this exact same discussion right now so national guideline on no-shows/cancels has changed at some point recently, including suggestions on what to do to increase productivity when this happens (like sending secure messages with workload credit to other patients - lol).

Man I'm at like 110% productivity. We are just going to catch up on things if someone no shows/cancels.

 

[psycho1391]

Have you all seen this article?

It is an opinion piece against gender identity in patient care within the VA.

 

[Shiori]

Have you all seen this article?

It is an opinion piece against gender identity in patient care within the VA.

Yeah, it's a weird article because a lot of their policy critiques are a function of CPRS limitations or just a (I'll be generous) misinterpretations of policy. Ex: we definitely still track biological sex in the chart and the clinical reminders default to biological sex. In additional to biological sex, self-identified sexual identity is also tracked. We use both. It would be more helpful if there were more clinical reminder options, but that's not a thing yet. I haven't worked with Cerner, so I can't speak about that.

I know every hospital makes due with the spaces they have, but the policy is very clear about expectations and workarounds. Many of the authors' other issues involve the theoretical situation of cis men pretending to be trans to have access to the women in WHC for...reasons? In the policy for WHC, it requires single occupancy bathrooms. We only see one patient at a time in exam rooms. What often ends up happening is that WHC will schedule trans patients for specific times to avoid anyone feeling uncomfortable, trans and cis folks alike. We're in a rural, red area. We have adapted.

It has been an ongoing discussion among cis and trans women about who feels comfortable where. Just for practical reasons, several trans patients have voiced a desire for a specialty clinic where there are providers with expertise in their care. They often have to make appointments with endo, and speech pathology, dematology, etc. instead of it all being in one dedicated space. Several of the bigger, local hospitals have that setup due to differences in care. Many trans women would likely still prefer to be seen in WHC, but I bet many others would prefer a more tailored option.

Clearly, I am passionate about this topic.

 

[summerbabe]

Have you all seen this article?

It is an opinion piece against gender identity in patient care within the VA.

Clickbait-ey headline? Check.

Boogeyman-style hypothetical scenarios presented as reality? Check.

Absence of nuanced discussion to push a political narrative that would be more fitting for one’s personal Twitter? Check

Yes, sounds like a typical The Hill op-ed.

To the actual discussion: balancing competing needs is very hard. Some facilities are probably doing a better job than others. Some rules/policies are probably generally more helpful while others pose more problems than solutions.

But presenting this as a zero sum scenario (which it is not nor should be) is wildly stupid IMO.

 

[JustNoticing]

Have you all seen this article?

It is an opinion piece against gender identity in patient care within the VA.

its TERFY bull****, embarrassing to have been written by licensed psychologists, and very clearly violates the APA code of ethics.

Unlike some, I do think there should be space for good faith discussions about trade-offs, inclusive gender care with traumatized populations and the like, but this op-ed is not that.

 

[WisNeuro]

its TERFY bull****, embarrassing to have been written by licensed psychologists, and very clearly violates the APA code of ethics.

Unlike some, I do think there should be space for good faith discussions about trade-offs, inclusive gender care with traumatized populations and the like, but this op-ed is not that.

Actual codes, or perhaps the aspirational guidelines in a certain light?

 

[JustNoticing]

Actual codes, or perhaps the aspirational guidelines in a certain light?

5.04 Media Presentations - particularly inaccurate statements about sex and gender/not based in evidence and out of line with the APA guidelines for practice with transgender individuals
And
3.03 Other Harassment
Psychologists do not knowingly engage in behavior that is harassing or demeaning to persons with whom they interact in their work based on factors such as those persons' age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status.

 

[WisNeuro]

5.04 Media Presentations - particularly inaccurate statements about sex and gender/not based in evidence and out of line with the APA guidelines for practice with transgender individuals
And
3.03 Other Harassment
Psychologists do not knowingly engage in behavior that is harassing or demeaning to persons with whom they interact in their work based on factors such as those persons' age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status.

While I don't agree with the authors, I think one would have a hard time making a case that these are "clear" and unambiguous violations of the code, particularly given the amorphous character of the underlying literature. I'm all for hitting people on clear violations, but I think this is far from it. If anything, APA taking a stance would just make them look even more baldly politically partisan.

 

[Shiori]

I'm more curious if VA will do anything. There was a statement on Friday, but I didn't have the energy to read it.

 

[JustNoticing]

I'm more curious if VA will do anything. There was a statement on Friday, but I didn't have the energy to read it.

I didn't see that statement, would you be willing to share it?

 

[Shiori]

It might be on the LGBTQ national side of things. I'm not sure if VA proper has said anything.

 

[WisNeuro]

I'm more curious if VA will do anything. There was a statement on Friday, but I didn't have the energy to read it.

The content of any message will depend on how much VA upper brass want to fight multiple lawsuits.

 

[Shiori]

There are lawsuits coming from a variety of angles. They're going to try to piss off the fewest number of people as possible and keep their head down.

 

[psycho1391]

It might be on the LGBTQ national side of things. I'm not sure if VA proper has said anything.

Yeah I'm not finding anything yet. Two of my colleagues contacted national. I'll update you all if I find anything.

 

[cara susanna]

Ohh, it's The Hill. Say no more.

If they really care about rape victims and women exclusive spaces, there are far bigger fish to fry in terms of trying to pressure the VA politically.

 

[Shiori]

The policies for VA are pretty basic. Use the veteran's preferred name and pronouns. It's is practically an act of congress to get someone fired for anything, so people break this policy all the time. Accidentally and intentionally. The solution is usually a training by me for the clinic. For me, it's always been at the clinics request because they don't want to be rude to the patients. Also, half the printed materials have the wrong name and gender on them in the best of circumstances. They can get things changed in their chart, but it's a massive pain. CPRS will still show that they are trans.

They have access to all medical treatments up until surgery and then again related to any complications from surgery. I help the medical providers navigate reconciling their accrediting body's medical standards, VA standards, and WPATH standards for care. If someone is uncomfortable due to a whole host of reasons from lack of training to religion, we have alternatives. Honestly, all of the pushback I get from clinics is lack of training.

People can use the bathroom of their choice. The VA is trying to move to more single stall options because of the high rate of MST for everyone, regardless of gender. Single stall restrooms are required in the Women's Health Clinic.

If they're receiving care in a particular clinic, they can be in the waiting room. If someone has an issue, we take the uncomfortable person back early or find some other accommodation.

That's pretty much it.

 

[Shiori]

Yeah I'm not finding anything yet. Two of my colleagues contacted national. I'll update you all if I find anything.

Sorry, it's in the Teams chat for VCCs.

 

[cara susanna]

TFTW when you realize you've memorized certain items on the Columbia.

 

[AcronymAllergy]

TFTW when you realize you've memorized certain items on the Columbia.

I had the first 2 items memorized so I could just include them in my normal interview when asking about any recent SI/HI. Definitely saved some time and aggravation.

 

[cara susanna]

I had the first 2 items memorized so I could just include them in my normal interview when asking about any recent SI/HI. Definitely saved some time and aggravation.

I usually administer it through MHA and waiting for that to open takes SO LONG. It's way easier when you can just recite the first two items and the last one (last if they don't need the additional questions)

 

[Sanman]

I usually administer it through MHA and waiting for that to open takes SO LONG. It's way easier when you can just recite the first two items and the last one (last if they don't need the additional questions)

I have a printed copy that is my go to for this reason.

 

[AcronymAllergy]

I have a printed copy that is my go to for this reason.

Yeah, I also had some printed copies available in my testing office that came in handy, especially if either of the first two questions was positive. Otherwise, I'd ask the questions I had memorized during the course of my interview, and would then pull up the note for it afterward while completing my regular appointment note.

Also yes, CPRS knows all, and invariably takes longer to load when you need to get something done quickly.

 

[Shiori]

I wish other types of providers would stop recommending psychological approaches to my clients. I'm not defensive about feedback, but come to me first.

 

[Sanman]

I wish other types of providers would stop recommending psychological approaches to my clients. I'm not defensive about feedback, but come to me first.

I wish other types of providers would stop promising I will do things that are not recommended psychological interventions.

 

[Shiori]

I thought it was a psychological approach. I looked up the acronym to verify. They want me to tap meridian points on my Veteran to induce a calmer state.

 

[Sanman]

I thought it was a psychological approach. I looked up the acronym to verify. They want me to tap meridian points on my Veteran to induce a calmer state.

Sounds like emotional freedom techniques.... maybe send them back for some eye of the newt potion to go with it.