'Discharging' Veterans from MH Care in the VA System?

[Fan_of_Meehl]

So, we're getting pressure to 'improve access' in our clinics by putting increased pressure on veteran psychotherapy clients to engage more actively in self-change efforts in psychotherapy while we track outcomes via symptom self-report questionnaires. However, anyone who works in the VA system knows that there are folks in your caseload who actively or passively resist such engagement. So, in informal conversations (of course, nothing is written down) with supervisors/administrators, we are being urged to 'discharge' veterans from our clinics who show lack of progress over time and/or who are not sufficiently actively engaged with self--change efforts. Sounds good. Only problem is that we are told that even if they are 'discharged' from our clinic, they can--at any time--call the secretary and reschedule back into our clinic immediately and they'll show up on our clinic schedule to be seen for an appointment. Doesn't sound like they've been 'discharged' to me.

How do your facilities handle this issue?

Of course, two underlying never-spoken-about truths contribute strongly to the problem:

1) In the community, people can't just go to therapy indefinitely and have it be 'free' (insurance is going to run out or they are going to get tired of paying for it with no progress); at the VA, access to therapy is considered to be a 'right' (under #BeThere and 'suicide prevention is our top clinical priority') and veterans never have to pay for sessions, or for no-shows or last minute cancellations. This obviously contributes to the 'access' issues but no administrator will ever even acknowledge this aspect of the problem, let alone engage in a dialogue about possibly changing how we do things.

2) At the VA, it pays to be sick (but to have on record that you are trying to get better by attending mental health appointments). If a veteran indicates (by self-report) that their symptoms are decreasing, they face the real possibility of a substantial drop in monthly income...something that no one wants (or often is even prepared for) happening. Likewise, it is the rare service-connected veteran who is going to admit that they 'don't need' or 'aren't benefiting' from ongoing psychotherapy, again, for fear that this will jeapordize their benefits.

How do you all handle unilateral (i.e., therapist wants it, veteran objects) 'discharges' from your psychotherapy clinics?

Do you have 'mental health case managers' that you can discharge these patients to with the understanding that they'll at least be followed by someone in MH and checked in on for med refills, supportive therapy, suicide screenings, etc.? I've heard that other faciliteis have these MH case managers but we do not.

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[cara susanna]

First off, this is so validating. Thank you.

Second, we have the same issue in our clinic. We are being pressured about "panel management" and access. So we're caught in this confusing and ambiguous double snare where we fear having poor access but also fear discharging people unilaterally due to worries about "denying care." To this day I don't quite understand to what degree or what type of care we can place limits on, and I don't feel like management has ever properly explained it to me. Generally, we are told that we need to discharge patients if they don't have actual treatment goals. There is a focus on measurement-based care so we can point to symptom levels and say, hey, you're actually doing pretty well. In practice, that doesn't always happen and definitely not as easily as we're told it will. Some therapists in our clinic are extremely good about discharging patients who aren't willing to do actual work. I am not one of them, unfortunately. I am getting better at over time, simply because I have to (my f/u access is terrible). Whenever I meet with a new patient I explain the "session of care" idea. I also have "inherited' patients who expect therapy forever and ever. Some I'm able to discharge and some have stuck around. As you said, though, discharging a patient doesn't always mean anything. I've discharged people and they've gotten back on my schedule very easily.

Also, I feel like a lot of times the VA "trains" patients to do more supportive therapy because, due to insistence on initial access at the expense of engagement access, often I am only able to see people monthly. I try to assign homework etc but it's hard to ensure compliance when you aren't seeing them frequently enough. So they get used to that.

I do feel the VA needs to acknowledge that, at some point, you can't have it both ways. You can't have good access while also ensuing everyone who wants therapy gets it, even if they don't "need" it.

I had a supervisor tell me on internship (in the VA): "We [therapy] are like water. And if people have water, they will drink it."

Edit: I should add that we have a no show/late cancellation policy that allows us to cancel all future appointments until the patient has demonstrated they can engage in therapy (e.g., attending a group).

 

[Sanman]

I have to say that I feel bad for some of the mental health clinic, CBOC, and other areas that have uncapped access. I used to handle large patient loads at my previous job, but didn't have silly VA requirements to contend with regularly. I am currently capped by the HBPC team limits, so safe from unfettered access. That said, I still encounter some access issues largely due to the HBPC team accepting inappropriate patients, IMO.

I think some questions need to be answered here:

1. What services are you offering? The VA has done a terrible job at defining what mental health is treating and rolling out a standardized level of care. There is a lot of talk about EBPs, but their training programs are slow and you can have a job for years before they actually train you to do what VA central office would like. That said, if you limit what you are treating that helps to sort the wheat from the chaff. Don't want to participate in X,Y.or Z treatment? Call back when you want it, that is all we offer. Currently, HBPC is pushing a 6 session short-term problem-solving protocol for mental health. I am using this as an opportunity to prune my caseload of new useless patients.

This is the problem with a lot the general mental health that the VA has. Used well, it can address issues that are not covered by a specific protocol. Managed poorly at a departmental level, it becomes a garbage dump for everyone when there is no one else that wants them, but they need to go somewhere. This has been managed poorly at my VA for a long time.

2. What is their access to other providers? The veterans on meds are a godsend. Let them go to psychiatry every few months and let me know if things get worse. Those not going to psychiatry (or VA psychiatry) always present an access problem. The VA seems to feel that someone in mental health needs to babysit anyone that ever had a diagnosis related to depression, suicidality, PTSD, etc. This then leads to the question of how often do you really need to see these people and for what reason. Since there is no mental health case manager for my patients, I am it. To stop the bleeding, I try and educate my veterans and slowly setting a frame for them. Don't have an acute problem you need to work on? See you in 3 or 6 months and for a case management visit. If you need to address something, I will address it with short-term time limited therapy. The slow fade/taper seems to work with many existing patients. Don't work harder than them.

This is what I am trying to move toward anyway. I still have a subset of pain in the ass patients that will call the white house hotline if you try and change the status quo on them. Those seems to be something I am stuck with for now. However, if I kept letting that happen, I would keep seeing the same 8-10 folks for the rest of my career.

 

[cara susanna]

I have to say that I feel bad for some of the mental health clinic, CBOC, and other areas that have uncapped access. I used to handle large patient loads at my previous job, but didn't have silly VA requirements to contend with regularly. I am currently capped by the HBPC team limits, so safe from unfettered access. That said, I still encounter some access issues largely due to the HBPC team accepting inappropriate patients, IMO.

I think some questions need to be answered here:

1. What services are you offering? The VA has done a terrible job at defining what mental health is treating and rolling out a standardized level of care. There is a lot of talk about EBPs, but their training programs are slow and you can have a job for years before they actually train you to do what VA central office would like. That said, if you limit what you are treating that helps to sort the wheat from the chaff. Don't want to participate in X,Y.or Z treatment? Call back when you want it, that is all we offer. Currently, HBPC is pushing a 6 session short-term problem-solving protocol for mental health. I am using this as an opportunity to prune my caseload of new useless patients.

If you use that approach, it can be argued that you're "denying care." The patient may go above your head, or even your middle management's head, and in the end get what they want. Some clinics are so terrified of that, they'll give the patient what they want from the getgo.

This is the problem with a lot the general mental health that the VA has. Used well, it can address issues that are not covered by a specific protocol. Managed poorly at a departmental level, it becomes a garbage dump for everyone when there is no one else that wants them, but they need to go somewhere. This has been managed poorly at my VA for a long time.

2. What is their access to other providers? The veterans on meds are a godsend. Let them go to psychiatry every few months and let me know if things get worse. Those not going to psychiatry (or VA psychiatry) always present an access problem. The VA seems to feel that someone in mental health needs to babysit anyone that ever had a diagnosis related to depression, suicidality, PTSD, etc. This then leads to the question of how often do you really need to see these people and for what reason. Since there is no mental health case manager for my patients, I am it. To stop the bleeding, I try and educate my veterans and slowly setting a frame for them. Don't have an acute problem you need to work on? See you in 3 or 6 months and for a case management visit. If you need to address something, I will address it with short-term time limited therapy. The slow fade/taper seems to work with many existing patients. Don't work harder than them.

Our psychiatrists (much of this is to their credit) strongly push therapy and will refer for it even if the patient isn't motivated.

 

[Sanman]

If you use that approach, it can be argued that you're "denying care." The patient may go above your head, or even your middle management's head, and in the end get what they want. Some clinics are so terrified of that, they'll give the patient what they want from the getgo.

Only if you give them no options. Community care or a 3 to 6 month follow-up with you is not is not denying care, it is rationing care. Your defense is the EBP model that the VA is pushing. Not saying it always works. If they go above my head whatever, I'll take them if I have to. If it becomes a pattern I am not happy about....that is why it is important to have paid off my loans and my car, have a small mortgage payment, and a healthy F U fund.

Our psychiatrists (much of this is to their credit) strongly push therapy and will refer for it even if the patient isn't motivated.

Not much credit if there if the referral is not properly assessed. Anyone can do paperwork. You can still answer a consult and assess them based on your own skills. If the patient is not agreeable to a treatment plan or not doing the work... document, document document! I just defended myself against a white house complaint I knew was coming my way. Not much for them to say when you the veteran refuses reasonable referrals (inpatient PTSD and substance abuse treatment) and missed multiple appointments that are in the chart, and presented safety issues.

Don't get me wrong, it is an uphill battle. However, you have to start somewhere. It does help that I used to manage multiple clinicians and a few thousand patients previously. If I can't sort it out, I am happy to leave the problem at the feet of my boss because there is generally no good answer. This is why you don't go into VA middle management, lol.

 

[erg923]

This is borne of a system that, fundamentally, gives free mental healthcare for life to someone solely because of their former occupation, and a public that both does and does not support it at the same time.

Of course, such an idea is cost prohibitive (no other developed countries do it this way). Of course such a thing will lead to various iatrogenic and unforeseen consequences, both clinical and financial. But no one want to talk about these realities because the population is "veterans."

 

[WisNeuro]

This is borne because of a system that, fundamentally, gives free mental healthcare for life to someone solely because of their former occupation, and a public that both does and does not support it at the same time.

Of course, such an idea is cost prohibitive (no other developed countries do it this way). Of course such a thing will lead to various iatrogenic and unforeseen consequences, both clinical and financial. But no one want to talk about these realities because the population is "veterans."

Free mental healthcare for life is not the issue that makes this cost prohibitive. The fact that people are incentivized to utilize vast amounts of various services to "prove" their well compensated "disability" is the problem. There are, of course, many of those that need the services, but most of our superusers were people with obvious signs of malingering. Of course, there is no way anyone in Congress will touch rooting out malingerers with a 1000 foot pole as it is political suicide that will be spun into "hating our troops" by the usual suspects.

 

[erg923]

Free mental healthcare for life is not the issue that makes this cost prohibitive. The fact that people are incentivized to utilize vast amounts of various services to "prove" their well compensated "disability" is the problem. There are, of course, many of those that need the services, but most of our superusers were people with obvious signs of malingering. Of course, there is no way anyone in Congress will touch rooting out malingerers with a 1000 foot pole as it is political suicide that will be spun into "hating our troops" by the usual suspects.

Unlimited mental health treatment/sessions for life is cost-prohibitive. This is not a judgment, its just fact. No one does it this way...anywhere else in the world.

We can argue about why this happens all we want, but the fact is that it does, and I don't think its good "policy" to approach healthcare delivery from such a broad angle as "I was once in the military." That's not what the Veterans Administration was designed to do, and now we (and veterans) are paying the consequences. We did this back in the 60s too. We shouldn't have to keep repeating it.

I know I am in the minority with this opinion, but I have come to believe that a segregated healthcare system such as the VA is not good for veterans or for society in general in the long-term.

 

[WisNeuro]

Unlimited mental health treatment/sessions for life is cost-prohibitive. This is not a judgment, its just fact. No one does it this way...anywhere else in the world.

This is not a fact, do you have non-VA data that backs this assertion up? I'd actually argue that adequately treating MH conditions would lead to huge improvements in outcomes of comorbid physical health problems, or even the onset of conditions (e.g., diabetes). We have mounds of data showing the downstream savings when we engage in certain preventative efforts, it's not a stretch to think that available MH treatment would act as a force multiplier for these savings with what we know about the interplay of un(der)treated MH conditions with medical conditions.

 

[erg923]

This is not a fact, do you have non-VA data that backs this assertion up? I'd actually argue that adequately treating MH conditions would lead to huge improvements in outcomes of comorbid physical health problems, or even the onset of conditions (e.g., diabetes). We have mounds of data showing the downstream savings when we engage in certain preventative efforts, it's not a stretch to think that available MH treatment would act as a force multiplier for these savings with what we know about the interplay of un(der)treated MH conditions with medical conditions.

Do you have data that "unlimited' does? You are well trained....I know you know "more/longer" doesn't necessarily equate to better outcomes. Its just the kitchen sink approach, right? Does't work.

I would be more open to the VAs approach if they attempted to do any semblance of utilization management/oversight for mental health services. But I don't think they do?

 

[WisNeuro]

Do you have data that "unlimited' does? You are well trained....I know you know more/longer doesn't equate to better outcomes. Its just the kitchen sink approach, right? Does't work.

I would be more open to the VAs approach if they attempted to do any semblance of utilization management/oversight for mental health services. But I don't think they do?

No, but we have more data that the preventative approach works, as opposed to the opposite. Also, I was not the one asserting something as "fact." It's not the kitchen sink approach, we actually do have good data that shows that this works. For example, adequately managing MH symptoms leads to better diabetes compliance. This isn't magic, it's not theoretical, it actually does work. The VA is not a good example of this due to the SC issue. You're extrapolating the VA approach to what would happen if everyone had access to MH care, it's apples and oranges.

 

[erg923]

No, but we have more data that the preventative approach works, as opposed to the opposite. Also, I was not the one asserting something as "fact." It's not the kitchen sink approach, we actually do have good data that shows that this works. For example, adequately managing MH symptoms leads to better diabetes compliance. This isn't magic, it's not theoretical, it actually does work. The VA is not a good example of this due to the SC issue. You're extrapolating the VA approach to what would happen if everyone had access to MH care, it's apples and oranges.

I think we may be looking/talking at 2 different things? I am not debating anything you have said regarding the intersection MH and physical health-well-being. Preventive healthcare (or mental healthcare) is one thing. But my insurance plan does not provide unlimited sessions related to these without cost because of my former occupation. That's were the it gets hairy for me. I have a fundamental disagreement with occupational status alone availing people to unlimited medical and MH treatment compared to others. I know many may disagree with me here. But it happens to be my most recent "epiphany" in my human journey.

 

[WisNeuro]

I think we may be looking/talking at 2 different things? I am not debating anything you have said regarding the intersection MH and physical health-well-being. Preventive healthcare (or mental healthcare) is one thing. But my insurance plan does not provide unlimited sessions related to these without cost because of my former occupation. That's were the it gets hairy for me. I have a fundamental disagreement with occupational status alone availing people to unlimited medical and MH treatment compared to others. I know many many may disagree with me here. But it happens to be my most recent "epiphany" in my human journey.

I also don't think that only providing care based in occupation is a good thing. But you also argued that ubiquitous MH treatment was not viable from a cost perspective, which would not seem to be the case looking at some data.