VA Mental Health Provider Venting / Problem-solving / Peer Support Thread
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Sanman
O.G.
The important lesson here is that President Commacho is not that bad after all.
I asked a few years back. I think the status sticks to them as long as they remain in the top [whatever]%age of 'high-risk' in relation to all other patients in that region/VISN/hospital(?) and I noted that some of the values are static (i.e., bipolar dx) and prone to error (i.e., bipolar dx). So, it's not even %age highest risk in relation to stable nomothetic norms---it's a rolling, mutating, top %risk 'scores' in that region/group. Think of it as 'risk-by-percentile-rank' rather than 'risk-by-exceeding-an-established-cutting-score.' So the 'norms' are updated/changed constantly since every member in the local sample's 'risk score' changes constantly.. I may be wrong, but that is my recollection. I remember commenting that it seemed kind of dumb to just set an arbitrary fixed percentage (5%?) of a subpopulation to always be labeled "high risk" no matter what the raw values (ostensibly) on their 'risk scores' actually were since someone could be 'bumped off' the list merely due to a couple other patients in their local pop becoming suddenly a bit 'sicker,' as it were (and, of course, vice versa). She just shrugged and continued to give me the same expressionless 'long live the Empir--I mean, Department of Veterans Affairs' empty gaze.
I think they used machine learning algorithms as part of some of the research and so it is not to be questioned because Brawndo is what plants crave.
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Do you always have to call them? Our ReachVet notification says that the veteran already knows about the program so nothing is needed if there isn't any clinically indicated reason to change the tx plan or reach out to them otherwise.
Sanman
O.G.
In this particular case, it is a patient I have contact with anyway. However, we are coming up on a year and I am still doing this monthly for what seems like no reason. I don't deal with a lot of reachvet folks as many of my higher risk folks end up at community hospitals. It just seems random as I have higher risk folks not flagged and this patient is stable and has been for months.
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AFGE just put out this press release (appears to directly affect VA psychologists):
www.afge.org
"The Take Care of America’s Veterans Act (H.R. 9237, S. 4744) is a massive, 554-page legislative package that consolidates more than 60 separate bills. While the bill package suggests it would improve veterans’ health care and benefits, it would in fact do the opposite.
The bill includes a provision that would convert VA psychologists, roughly 5,000 of whom are represented by AFGE, to the Title 38 personnel system, which would result in significant cuts to their current collective bargaining rights. The collective bargaining rights of Title 38 employees are limited by statute. In practice, this means that VA does not allow them to negotiate over routine workplace issues like scheduling or raise grievances over things like staffing shortages that undermine patient care or in situations where the VA fails to provide promotion and advancement opportunities that would attract health care workers to the VA. Title 38 employees also not allowed to utilize the negotiated grievance process to challenge management’s failure to pay them correctly or when the VA violates its own policies."
First I'm hearing of it. What are the pros/cons of Title 38 vs. 'Hybrid' Title 38 (isn't that what we are now?). Supposedly more flexibility for better pay after market surveys?
Bill Meant to Aid Veterans Instead Betrays our Military Heroes and Federal Caregivers
AFGE is urging members of Congress to reject legislation introduced last week that would undercut earned benefits for our nation’s military veterans, strip workplace rights and protections from thousands of psychologists at the Department of Veterans Affairs, and push more veterans outside the...
www.afge.org
"The Take Care of America’s Veterans Act (H.R. 9237, S. 4744) is a massive, 554-page legislative package that consolidates more than 60 separate bills. While the bill package suggests it would improve veterans’ health care and benefits, it would in fact do the opposite.
The bill includes a provision that would convert VA psychologists, roughly 5,000 of whom are represented by AFGE, to the Title 38 personnel system, which would result in significant cuts to their current collective bargaining rights. The collective bargaining rights of Title 38 employees are limited by statute. In practice, this means that VA does not allow them to negotiate over routine workplace issues like scheduling or raise grievances over things like staffing shortages that undermine patient care or in situations where the VA fails to provide promotion and advancement opportunities that would attract health care workers to the VA. Title 38 employees also not allowed to utilize the negotiated grievance process to challenge management’s failure to pay them correctly or when the VA violates its own policies."
First I'm hearing of it. What are the pros/cons of Title 38 vs. 'Hybrid' Title 38 (isn't that what we are now?). Supposedly more flexibility for better pay after market surveys?
They went over the pros/cons of Title 38 vs. Hybrid Title 38 at my old VA...I think back when there was a nationwide push to get psychologists moved to being full Title 38. I believe it allows for better/more flexible pay and other benefits (e.g., hiring incentives, leave, bonuses) but gives you less union protection. But if psychologists are members of the medical staff at their VA, that probably helps offset some of the loss of protections.AFGE just put out this press release (appears to directly affect VA psychologists):
Bill Meant to Aid Veterans Instead Betrays our Military Heroes and Federal Caregivers
AFGE is urging members of Congress to reject legislation introduced last week that would undercut earned benefits for our nation’s military veterans, strip workplace rights and protections from thousands of psychologists at the Department of Veterans Affairs, and push more veterans outside the...
"The Take Care of America’s Veterans Act (H.R. 9237, S. 4744) is a massive, 554-page legislative package that consolidates more than 60 separate bills. While the bill package suggests it would improve veterans’ health care and benefits, it would in fact do the opposite.
The bill includes a provision that would convert VA psychologists, roughly 5,000 of whom are represented by AFGE, to the Title 38 personnel system, which would result in significant cuts to their current collective bargaining rights. The collective bargaining rights of Title 38 employees are limited by statute. In practice, this means that VA does not allow them to negotiate over routine workplace issues like scheduling or raise grievances over things like staffing shortages that undermine patient care or in situations where the VA fails to provide promotion and advancement opportunities that would attract health care workers to the VA. Title 38 employees also not allowed to utilize the negotiated grievance process to challenge management’s failure to pay them correctly or when the VA violates its own policies."
First I'm hearing of it. What are the pros/cons of Title 38 vs. 'Hybrid' Title 38 (isn't that what we are now?). Supposedly more flexibility for better pay after market surveys?
There are VA hospitals where psychologists are NOT members of the medical staff? Hell, here even social workers are members of the 'medical staff' (officially).
Yep, I heard of at least a few. At my former facility, if I'm remembering correctly, SWs either weren't on the medical staff at all, or they were non-voting members.
As for Title 38 vs. not, I imagine there's probably a reason physicians and nurses aren't lining up en masse to push to change to hybrid or full Title 5 status.
Sanman
O.G.
There was a vote on this some years back that failed. It boiled down to market pay vs union protections I believe. Honestly, given the shenanigans of this admin, it may be a favor to us if they end up hitting the general schedule employees with pay cuts and other problems.
Psychologists were actually making a huge effort to become Title 38 (whatever physicians are) here a while back. I remember not wanting to because there was something related to productivity requirements, I don't remember what now.
Same, although our facility supported it for the most part. I honestly couldn't tell you the main downsides. Our lead psychologist gave a presentation on it, but I don't remember much.
I have some general questions I'd like some feedback on from psychologists at other VA's (especially in PCT's and BHIP) because 'if you've seen one VA, you've seen one VA.' I just need to know if what we're doing (major changes/ evolution in practice over the past few years) is also occurring at other sites.
About a year ago, admin essentially eliminated 90 min intakes in general mental health (still have 90 min in PCT). It was replaced by what they are calling a 'Psychotherapy Orientation' appointment. The outline/scope of this appointment (<60 min) is basically to get 'broad strokes' of what is bringing the client in for therapy, providing psychoeducation about therapy, administering PROM's, etc...NOT actual differential diagnostic work or full psychiatric / psychological interview in the classic sense. People have adjusted by giving up on doing any of their own differential diagnosis, case formulation, etc. and transferring these responsibilities to the dedicated PCT 'assessment/intake' psychologist (who does nothing but intakes one after another every single day) and/or the 'Assessment Psychologist' (a psychologist with an intern who does nothing but assessments including (increasingly) 'differential diagnosis' for all the psychologists who no longer diagnose their own patients they are treating).
There has been an organizational 'evolution' (de-evolution, actually) of clinical practice such that the 'treatment' psychologists expect all the differential diagnostic work, case formulation, treatment planning, etc. to be 'pre-completed' for them so they can just 'plug' the patient into a fixed protocol for either (a) depression, (b) anxiety, or (c) trauma. It is maddeningly simplistic and I believe unrealistic. You simply cannot just pre-extract the process/responsibility of ongoing assessment, case formulation, and differential diagnosis out of the treatment process and hand that responsibility off to someone else who only is going to be able to see the person for 1-3 sessions before sending them to treatment with someone else.
The other thing is that now nobody addresses 'the PTSD question' with their own clients (or anyone) anymore outside of PCT (PTSD specialty clinic) and PCT now has a 'full-time' intake/diagnosis psychologist who only does differential dx of PTSD and treatment planning (no therapy). So that SINGLE provider has the responsibility of 'answering the PTSD question' for all the PCT intakes. To make matters worse, the same provider has been assigned to do nothing but intakes for all the CBOCs (their BHIP services) in the region and on certain days that's all they do and all of the 'do they have PTSD or not' cases are getting specifically routed to that single provider.
This is a pretty good deal (never having to answer 'the PTSD question) for everyone but the one psychologist who has to do this for the entire facility and region.
Is anyone else going through this?
At your site, does your PCT require that people sending cases to them actually try to address the PTSD question themselves prior to sending a consult to PCT? Meaning, do your providers just fire off a consult to PCT if one of their patients starts claiming to 'have PTSD' and 'need a PTSD eval' or is that considered to be within the scope of practice/responsibility of your BHIP providers to be able to do with their own cases? Do your PCT's accept referrals straight from PCMHI of 'maybe they have PTSD' cases or are they encouraged to go through BHIP from PCMHI? Right now, almost all (95%) of cases presenting to PCMHI for the first time and without dx of PTSD (but wanting 'a PTSD eval') are being sent directly from PCMHI to PCT with a request to ('r/o PTSD'). Similarly, the few consults PCT gets from BHIP are on those cases that don't really appear to have PTSD (e.g., it has been ruled out by prior PCT consults/intakes and/or the person has seen 20 different providers over the past 10 years and NOBODY has diagnosed or suspected PTSD but because the veteran keeps insisting they have PTSD and insisting on yet another 'PTSD eval', BHIP providers just immediately enter a PCT consult to address that concern rather than doing any work themselves or holding any boundaries with the veteran around that). What is more frustrating, these cases almost never have a record of actually attending any psychotherapy (always no-shows/ dropouts) for MH conditions other than PTSD (MDD, SUDS) that they are actually diagnosed with and/or service connected for.
At your site, does BHIP insist everyone 'go through PCMHI first' yet simultaneously recommend PCMHI 'skip' BHIP and directly refer to PCT for any cases of 'possible PTSD' or 'evaluate for PTSD?'
At your site, do the rank-and-file BHIP psychology staff just get to never address 'the PTSD question' in their own caseloads?
About a year ago, admin essentially eliminated 90 min intakes in general mental health (still have 90 min in PCT). It was replaced by what they are calling a 'Psychotherapy Orientation' appointment. The outline/scope of this appointment (<60 min) is basically to get 'broad strokes' of what is bringing the client in for therapy, providing psychoeducation about therapy, administering PROM's, etc...NOT actual differential diagnostic work or full psychiatric / psychological interview in the classic sense. People have adjusted by giving up on doing any of their own differential diagnosis, case formulation, etc. and transferring these responsibilities to the dedicated PCT 'assessment/intake' psychologist (who does nothing but intakes one after another every single day) and/or the 'Assessment Psychologist' (a psychologist with an intern who does nothing but assessments including (increasingly) 'differential diagnosis' for all the psychologists who no longer diagnose their own patients they are treating).
There has been an organizational 'evolution' (de-evolution, actually) of clinical practice such that the 'treatment' psychologists expect all the differential diagnostic work, case formulation, treatment planning, etc. to be 'pre-completed' for them so they can just 'plug' the patient into a fixed protocol for either (a) depression, (b) anxiety, or (c) trauma. It is maddeningly simplistic and I believe unrealistic. You simply cannot just pre-extract the process/responsibility of ongoing assessment, case formulation, and differential diagnosis out of the treatment process and hand that responsibility off to someone else who only is going to be able to see the person for 1-3 sessions before sending them to treatment with someone else.
The other thing is that now nobody addresses 'the PTSD question' with their own clients (or anyone) anymore outside of PCT (PTSD specialty clinic) and PCT now has a 'full-time' intake/diagnosis psychologist who only does differential dx of PTSD and treatment planning (no therapy). So that SINGLE provider has the responsibility of 'answering the PTSD question' for all the PCT intakes. To make matters worse, the same provider has been assigned to do nothing but intakes for all the CBOCs (their BHIP services) in the region and on certain days that's all they do and all of the 'do they have PTSD or not' cases are getting specifically routed to that single provider.
This is a pretty good deal (never having to answer 'the PTSD question) for everyone but the one psychologist who has to do this for the entire facility and region.
Is anyone else going through this?
At your site, does your PCT require that people sending cases to them actually try to address the PTSD question themselves prior to sending a consult to PCT? Meaning, do your providers just fire off a consult to PCT if one of their patients starts claiming to 'have PTSD' and 'need a PTSD eval' or is that considered to be within the scope of practice/responsibility of your BHIP providers to be able to do with their own cases? Do your PCT's accept referrals straight from PCMHI of 'maybe they have PTSD' cases or are they encouraged to go through BHIP from PCMHI? Right now, almost all (95%) of cases presenting to PCMHI for the first time and without dx of PTSD (but wanting 'a PTSD eval') are being sent directly from PCMHI to PCT with a request to ('r/o PTSD'). Similarly, the few consults PCT gets from BHIP are on those cases that don't really appear to have PTSD (e.g., it has been ruled out by prior PCT consults/intakes and/or the person has seen 20 different providers over the past 10 years and NOBODY has diagnosed or suspected PTSD but because the veteran keeps insisting they have PTSD and insisting on yet another 'PTSD eval', BHIP providers just immediately enter a PCT consult to address that concern rather than doing any work themselves or holding any boundaries with the veteran around that). What is more frustrating, these cases almost never have a record of actually attending any psychotherapy (always no-shows/ dropouts) for MH conditions other than PTSD (MDD, SUDS) that they are actually diagnosed with and/or service connected for.
At your site, does BHIP insist everyone 'go through PCMHI first' yet simultaneously recommend PCMHI 'skip' BHIP and directly refer to PCT for any cases of 'possible PTSD' or 'evaluate for PTSD?'
At your site, do the rank-and-file BHIP psychology staff just get to never address 'the PTSD question' in their own caseloads?
We have centralized intakes, meaning that you see the patient for intake but may not get them for therapy, but every provider does them. Intakes include diagnostic and case formulations and treatment recommendations/brief planning. Our PCT providers do their own intake with the person assigned to them for an EBP (except for me, although I am technically a remote member of our PCT I operate in our local system where we do the centralized intake. So I just do an EBP pre-treatment session as the first appt)
PCMHI will see people for brief therapy but if they think they're more appropriate for OPMH, will refer them right away. They will not definitively diagnose PTSD.
My last PCT we did a brief group orientation then brought each patient back for an intake, where we would do a CAPS-5 and treatment planning.
PCMHI will see people for brief therapy but if they think they're more appropriate for OPMH, will refer them right away. They will not definitively diagnose PTSD.
My last PCT we did a brief group orientation then brought each patient back for an intake, where we would do a CAPS-5 and treatment planning.
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This is pretty much how we do intakes. The provider doing the intake almost always takes the veteran unless there is a reason not to like fit or competence. We have a "session 0" to get the patient oriented and to figure out if they're in the right place. Then up to 4 sessions to nail down a case conceptualization and treatment plan. No one is checking that aggressively though.
Whenever there is a case where diagnostic clarity is needed, we do the psychodiagnostic assessments here in BHIP typically. We don't have a lot of people specifically seeking out PTSD diagnoses though. A big portion of consults are ADHD and Autism diagnosis requests.
PCMHI does the more health-based assessments as part of the consult process for the requested service like bariatric surgery, spinal cord stim, etc. I do know that PCMHI is supposed to send them to us in BHIP before they go to any of the specialty clinics.
Due to staffing shortages, PCMHI might start doing more psychodiagnostic testing soon, but just to help out (and help with their burnout).
We're supposed to have a formalized PCT, but don't anymore due to staffing issues. Almost everyone here has good training in PTSD treatment, so it hasn't been an issue so far. There are two nearby VAs who have PCTs, so we can always send them there if they have a strong preference for that. 🫠
This is not how we do it. Ours is similar to the above comments. They took our 90 minute intake away in the past and just for good measure they added a follow-up slot with the 60 minutes they got from taking away 30 minutes from the two intakes. But we're all expected to complete the intake, diagnosis, and if there's time do some treatment planning. Usually I can get the intake done but I need a second appointment to plan treatment. When it was 90 I could do it all in one go for simpler cases. When there's more of a question on differential dx it can take multiple appointments, but we're taking that on, not farming it out.
This is good to hear (and what I thought). I don't believe it's fair or sustainable to just have one provider do all PTSD evals/ intakes.
I think if it’s just working in general, more than you would think? But specific numbers, I’m not sure. VA disability exams are increasingly done by contractors and they’re not good and it’s not difficult to get 💯. If you don’t you can appeal or try again until you’re satisfied. Getting to 💯 is a second job for some after the military. Disability % does not equal “disabled” in the VA C&P medical-legal context. You’ll see some veterans with three pensions. Joined at 18, retired at 38, (pension), got as 💯 disability (second one), then worked another 20 years at the VA or BOP.
VA disability compensation enrollment has grown so so dramatically, outpacing changes in the veteran demographics. Compensation-seeking veterans tend to report more distress than non-compensation-seeking veterans, despite no differences in PTSD diagnostic rates, and are much more likely to overreport or exaggerate symptoms on MMPI validity scales, etc. here are esom relevant citations I’ve used before In different papers.
Bass, C., & Halligan, P. (2014). Factitious disorders and malingering: Challenges for clinical assessment and management. The Lancet, 383(9926), 1422–1432.
Freeman, T., Powell, M., & Kimbrell, T. (2008). Measuring symptom exaggeration in veterans with chronic posttraumatic stress disorder. Psychiatry Research, 158(3), 374–380.
Young, J. C., Roper, B. L., & Arentsen, T. J. (2016). Validity testing and neuropsychology practice in the VA healthcare system: Results from recent practitioner survey. The Clinical Neuropsychologist, 30(4), 497–514.
Frueh, B. C., Elhai, J. D., Gold, P. B., Monnier, J., Magruder, K. M., Keane, T. M., & Arana, G. W. (2003). Disability compensation seeking among veterans evaluated for posttraumatic stress disorder. Psychiatric Services, 54(1), 84–91.
Marx, B. P., Engel-Rebitzer, E., Bovin, M. J., Parker-Guilbert, K. S., Moshier, S., Barber, J., & Keane, T. M. (2017). The influence of veteran race and psychometric testing on Veterans Affairs posttraumatic stress disorder (PTSD) disability exam outcomes. Psychological Assessment, 29(6), 710–719.
Trivedi, A. N., Jiang, L., Miller, D. R., Lee, A. F., Niu, Q., Mor, V., & Kuo, B. J. (2022). Association of disability compensation with mortality and hospitalizations among Vietnam-era veterans with diabetes. JAMA Internal Medicine, 182(1), 46–54.
Duggan, M., Rosenheck, R., & Singleton, P. (2010). Federal policy and the rise in disability enrollment: Evidence for the Veterans Affairs' disability compensation program. Journal of Law and Economics, 53(2), 379–398.
Clarke, P. M., Gregory, R., & Salomon, J. A. (2015). Long-term disability associated with war-related experience among Vietnam veterans: Retrospective cohort study. Medical Care, 53(5), 401–408.
I only do assessments at my VA and you’re 100% right on providers not doing their own diagnostic work. Honestly, a lot of the diagnostic work they think is necessary really isn’t to just identify thoughts feelings and behaviors They can target with specific interventions but they sure do want it. Some of the differential work I do is so basic, but I’m the only provider that has time to do it. I try to send some back and say just take a therapy session to do some structured interviewing and give an IDAS 2 or something…
getting as many days off as physicians and RNs get is the biggest pro. potentially flexibility on pay, but we have that now anyway as long as the SSRs don't expire. it comes at the expense of loss of some worker protections and longer probationary periods.AFGE just put out this press release (appears to directly affect VA psychologists):
Bill Meant to Aid Veterans Instead Betrays our Military Heroes and Federal Caregivers
AFGE is urging members of Congress to reject legislation introduced last week that would undercut earned benefits for our nation’s military veterans, strip workplace rights and protections from thousands of psychologists at the Department of Veterans Affairs, and push more veterans outside the...
"The Take Care of America’s Veterans Act (H.R. 9237, S. 4744) is a massive, 554-page legislative package that consolidates more than 60 separate bills. While the bill package suggests it would improve veterans’ health care and benefits, it would in fact do the opposite.
The bill includes a provision that would convert VA psychologists, roughly 5,000 of whom are represented by AFGE, to the Title 38 personnel system, which would result in significant cuts to their current collective bargaining rights. The collective bargaining rights of Title 38 employees are limited by statute. In practice, this means that VA does not allow them to negotiate over routine workplace issues like scheduling or raise grievances over things like staffing shortages that undermine patient care or in situations where the VA fails to provide promotion and advancement opportunities that would attract health care workers to the VA. Title 38 employees also not allowed to utilize the negotiated grievance process to challenge management’s failure to pay them correctly or when the VA violates its own policies."
First I'm hearing of it. What are the pros/cons of Title 38 vs. 'Hybrid' Title 38 (isn't that what we are now?). Supposedly more flexibility for better pay after market surveys?
AVAPL has historically been in favor of title 38, while AFGE has not been. AVAPL/APA got the language in the bill the last time, and then AFGE successfully lobbied to have it removed.
Yeah, the SSRs definitely changed the math a bit on hybrid vs. full title 38. T38 would still add some (permanent) flexibility there, and hiring becomes less cumbersome most likely. I think it can result in better bonuses as well. The downside of the additional leave (30 days/year and max balance of 120 days, at least when I was there) is that it has to be used in full-day increments. Or maybe half-day; I vaguely recall physicians being able to use half-days at my facility after I'd been there a few years.
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Sanman
O.G.
The days become a bit of a moot point when coverage starts to thin out. I am already struggling to take all the days I have.
My VA is one without an SSR for psychologists so I guess I should be pulling for this since I don't get the SSR anyway
Sanman
O.G.
If you don't have an SSR that means:
1. You are already at or above market rate
2. Your service chief sucks and did not apply in 2021
3. You were not working for VA at that point.
Will the market rate apply to those already employed at VA or only future employees? Will it matter if your service chief does not advocate for higher paying positions?
Not VA specific, but... is it really okay for SLPs to give RBANS?
I gave up on that fight last decade bc their cosplaying is gonna happen whether I object or not. Every once in a while I’ll get to shred an SLP doing something stupid like that in a legal case. The naming 7/10 for a 70% is the kind of trash analysis I’d find.
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Administer? Technically, yes. Pearson labels it as B Level test, which allows an SLP to administer the test (I also have similar feelings to you about this...).
Interpret and render a diagnosis? The answer to this is significantly more nuanced. SLPs can interpret RBANS results within their scope of practice, specifically as they relate to cognitive-communication function. They cannot officially offer a neuropsychological diagnosis based on findings.
Probably better than them giving subtests of the WJ out of context like they commonly do. Unfortunately, they often have zero idea of how to interpret this correctly and never use the validity indicators. And, have zero skepticism when a 30 yo with uncomplicated mild TBI performs far below ALF dementia patients, but can somehow still drive, dress, and bathe themselves properly. But, these also provide me great opportunities in legal cases to shred the false narrative, so, I'm all for it.
They fairly commonly conclude deficits secondary to TBI using the RBANS alone.
Unfortunately, I can't think of a single time I saw an SLP administer an RBANS and I actually agreed with their interpretation of it.
And yes, at least in my experience, it was more likely than not that when I saw an SLP had given the RBANS, there was an accompanying diagnosis of dementia due to (usually mild) TBI.
Although to be fair, there's a "neuropsychologist" in my catchment area who does the same thing.
Reminds me of when I saw an SLP interpret a raw score of 7/10 on Picture Naming in a 40 year old as, "70% correct, which is normal"
I would say that SLPs/OTs interpreting naming percentage correct seems to be the rule as opposed to the exception, unfortunately. Ignorance and practicing outside of scope runs rampant there.
I see this pretty regularly.
Yeah, that is why they use ICD "R" codes. It's never the F code/diagnosis of "ADHD". It's always the R code/symptom complaint of "attention and concentration deficit".
Thank you for addressing this point.
Was this diagnosis rendered by the SLP or the treatment team (physician, I am assuming...)?
It was usually mentioned in the note by the SLP. I don't recall if they actually added it to the patient's chart, although at VA, chart diagnoses (i.e., the "problem list") are their own special world.
The VA Problem List is one of the most hilarious things I've seen, if it weren't so sad. How many times I've seen "dementia" and then sourced it back to a PACT appointment
My lord
You just blew my mind with this.
There is a separate "problem's list" from diagnoses? Like, what's the point? Especially, if scope of practice is not a major factor in adding something to it. Can housekeeping come in and add "messy bed" or "stroke" to the problem list, if they felt so inclined?
-Signed, just a humble psychologist who works at an AMC, not a VA
Yup, anyone can add to the problems list. It's basically the same as "diagnosis" but doesn't always (read: often does not) match up with actual diagnoses. That's why when we code our encounters, it is recommended to select the diagnosis from a list of those used in previous encounters, as opposed to the problems list.
Sanman
O.G.
If you are going to ask questions like that, best not to work for the federal government.
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Yeah, as was said, almost anyone can add items to the problem list, although technically CPRS (not sure about the new systems) does have different permission sets. So purely administrative staff may not be able to add to the problem list, for example, and I don't think everyone has access to mental health notes.
That said, the problem list is also notorious for containing diagnoses from years/decades ago that may no longer be applicable. Clinicians also often add problems that are really more of a rule-out than diagnosis, or relate to what the person was referred for rather than what they actually have. The issue is that those older/inaccurate/not applicable diagnoses often never end up getting changed. I used to try to at least adjust diagnoses of MCI to dementia or vice versa whenever applicable, and adjust other MH diagnoses as I was able, but beyond that, there wasn't much I could do.
This is one reason why if research has been conducted on a VA sample and is scraping the problem list for diagnoses (rather than doing actual chart reviews or some other source), it can be HIGHLY problematic. You can end up with a bunch of people with "dementia" or "PTSD," for example, who in actuality should have no diagnosis.
I know I was told that even asking these type of questions is antithetical to how the federal government works 😉 , but I am too morbidly interested to turn back now lol.
If they instruct you to avoid even considering this problematic list, what is the design of even having it? It sounds like it's more a hinderance...
It can actually be helpful overall, at least to give you a broad idea of what's going on with the person (and for how long). You just have to take everything on it with a grain of salt. If there's a strange diagnosis on there, for example, best to find out when it was first assigned and read the notes from that time.
Again, clearly I am used to a different system, but isn't the purpose of a good chart review designed to accomplish this same goal? And without all of the unnecessary lists that may or may not be accurate, and as you pointed out, come at the cost of possibly impeding potential research?
Yep, a good chart review reaches the same goal. I would generally review the problem list first to get a quick overall idea of what may be going on with the person prior to then doing a standard, in-depth chart review. I'd also use it, like I mentioned earlier, to track down dates of specific prior appointments/evals, if needed (e.g., when a diagnosis of cognitive impairment, PTSD, depression, or what have you originated).
I'd usually trust it for medical diagnoses a bit more than MH, but even then, you still want to do a chart review, especially looking for possible recent changes to those diagnoses, how they've been managed over time (e.g., HTN, DM2), etc.
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