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

[WisNeuro]

Have you considered opening a PP treating former government employees with PTSD related to bureaucratic forms? Every time I get a form in my inbox, I feel my pulse rate quicken slightly.

Sure, but before you come in and seem me, I have some intake and insurance forms for you to fill out...

---

Members don't see this ad.

 

[Fan_of_Meehl]

Have you considered opening a PP treating former government employees with PTSD related to bureaucratic forms? Every time I get a form in my inbox, I feel my pulse rate quicken slightly.

Yeah. I can't tell you how many preventable errors (no email link/invitation for veterans I actually have VVC appointments with while veterans I DON'T have appointments with (they were cancelled) still getting VVC emails/links for non-existent appointments, veterans showing me printed out letters that were mailed to them directing them to the wrong clinics (across campus) making them late...etc. What gets me is I probably had seven or eight emails this week sloganeering and cheering for 'customer service' and for how awesome we are as a 'High Reliability Organization (HRO)' and how 'it is everyone's DUTY to SPEAK UP' to make this the mostest bestest doggone highest reliability organization in the gosh darn unimaverse, hyuck hyuck.............

All the while having to experience people lie, obfuscate, and fail to correct people responsible for all of these straightforward and very addressable errors and get mad at YOU if you even try to bring up these situations and troubleshoot a solution.

It's bad.

 

[Fan_of_Meehl]

Trauma work is brutal sometimes. These last few weeks have been rough.

Believe it or not, as challenging as the population is to work with sometimes--at a clinical level of difficulty--to me it is NOTHING compared to dealing with the broken organization itself. Tough clinical problems? No problem. I have solid training and a literature to fall back on. The absolutely rotten through-and-through pathological self-healing vampire of an organization? That's more stressful to me by far.

 

[deleted106747]

Believe it or not, as challenging as the population is to work with sometimes--at a clinical level of difficulty--to me it is NOTHING compared to dealing with the broken organization itself. Tough clinical problems? No problem. I have solid training and a literature to fall back on. The absolutely rotten through-and-through pathological self-healing vampire of an organization? That's more stressful to me by far.

In all seriousness, if you feel this badly about a place, why not find another position? There's so much out there that isn't VA.

 

[Fan_of_Meehl]

In all seriousness, if you feel this badly about a place, why not find another position? There's so much out there that isn't VA.

It's a fair question. And it's been asked and answered many times...it's a complicated mix of reasons, some mundane, some more meaningful.

I guess I'd say that...among the meaningful reasons is that it's probably important that there remain more people in the corrupt system who actually care about the mission than who just (a) pretend (loudly) to care publicly or (b) have given up trying to care due to learned helplessness. I'll never be (a) and the day that I become (b), I'll leave. I guess it's a personal perspective and decision space.

 

[student9295]

Well…like they say, “If you’ve been to one VA, you’ve been to one VA.” The dynamics of each facility will be very different and some places will be more or less flexible.

 

[Shiori]

Believe it or not, as challenging as the population is to work with sometimes--at a clinical level of difficulty--to me it is NOTHING compared to dealing with the broken organization itself. Tough clinical problems? No problem. I have solid training and a literature to fall back on. The absolutely rotten through-and-through pathological self-healing vampire of an organization? That's more stressful to me by far.

I definitely believe you. The admin side is soul-crushing, so it's awful when the client stuff is hard on top of everything else.

 

[ela]

Is anyone in a CBOC position that would be open to chatting privately? DM me! Thanks!

 

[IWillSurvive]

Does anyone know what the typical clinical/admin mapping is for a program manager?

 

[Shiori]

I spent an hour of my day on the phone with a frustrated Veteran and then documenting the aftermath because they were referred to me for psych meds. I had to clarify multiple times that I was not denying them access to this medication. I also did not have the ability to prescribe medications and didn't have the ability to compel anyone else to prescribe the medication. Part of me feels like I should touch base with the person who referred them my way, but I don't have the strength.

 

[Sanman]

I spent an hour of my day on the phone with a frustrated Veteran and then documenting the aftermath because they were referred to me for psych meds. I had to clarify multiple times that I was not denying them access to this medication. I also did not have the ability to prescribe medications and didn't have the ability to compel anyone else to prescribe the medication. Part of me feels like I should touch base with the person who referred them my way, but I don't have the strength.

Sounds like the VA to me. The scariest thing to me is that you have these conversations and then you realize...these people can vote!

 

[deleted106747]

I spent an hour of my day on the phone with a frustrated Veteran and then documenting the aftermath because they were referred to me for psych meds. I had to clarify multiple times that I was not denying them access to this medication. I also did not have the ability to prescribe medications and didn't have the ability to compel anyone else to prescribe the medication. Part of me feels like I should touch base with the person who referred them my way, but I don't have the strength.

Your supervisor should reach out to them. I do it all the time in the private sector.

 

[WisNeuro]

Sounds like the VA to me. The scariest thing to me is that you have these conversations and then you realize...these people can vote!

More scary, these people are operating a motor vehicle on the same roads as you!

 

[Shiori]

I checked CPRS this morning. There is still language very much stating I'm going to be prescribing medication.

 

[PsychPhDone]

I checked CPRS this morning. There is still language very much stating I'm going to be prescribing medication.

Who is doing this to you??

 

[Shiori]

Their medical team. I crafted a beautiful note being very specific about what I would and wouldn't be doing. They ignored that and said mental health would discuss meds in their own note "per mental health note" referring to my note where I clearly stated that I would NOT be discussing meds.

I hate it here.

 

[PsychPhDone]

Their medical team. I crafted a beautiful note being very specific about what I would and wouldn't be doing. They ignored that and said mental health would discuss meds in their own note "per mental health note" referring to my note where I clearly stated that I would NOT be discussing meds.

I hate it here.

That's really annoying, I'm sorry. Are you at a cboc? I don't understand how they are referring directly to you instead of a service (where they'd be triaged and directed to the right provider).

 

[erg923]

Their medical team. I crafted a beautiful note being very specific about what I would and wouldn't be doing. They ignored that and said mental health would discuss meds in their own note "per mental health note" referring to my note where I clearly stated that I would NOT be discussing meds.

I hate it here.

This needs to involve your supervisor and likely medicine leadership as well. Have they actually made a referral to the MHC in CPRS? If so, where is the breakdown in the scheduling process? If you are in PCMHI, you should be co-located and talking to/working with the referring doc so they can start something until they are assessed and triaged by you to MHC or some other specialty mental health clinic.

 

[Shiori]

I'm in the PCT clinic for the person they're referring to, so I have no idea what's going on. There isn't a referral because the veteran is already scheduled to see me for PTSD treatment, but I have not met them yet. I have been informed that this is a pretty common problem by my various supervisors and it's an ongoing battle to get it smoothed out. "MH" seems to be a blackhole of whatever touchy feely brain stuff they don't want to deal with because they're swamped. I don't know how PCMHI got bypassed in this whole process. My guess is they saw that he was connected to mental health and that it was our problem to sort out.

 

[erg923]

I'm in the PCT clinic for the person they're referring to, so I have no idea what's going on. There isn't a referral because the veteran is already scheduled to see me for PTSD treatment, but I have not met them yet. I have been informed that this is a pretty common problem by my various supervisors and it's an ongoing battle to get it smoothed out. "MH" seems to be a blackhole of whatever touchy feely brain stuff they don't want to deal with because they're swamped. I don't know how PCMHI got bypassed in this whole process. My guess is they saw that he was connected to mental health and that it was our problem to sort out.

How did they get to PCT? Specialty clinic referrals, at least when i was there, can only come from MHC or PCMHI.

 

[Shiori]

How did they get to PCT? Specialty clinic referrals, at least when i was there, can only come from MHC or PCMHI.

They were referred from MHC at their CBOC for PTSD treatment. Their PCP works at the same location I do.

 

[AcronymAllergy]

They were referred from MHC at their CBOC for PTSD treatment. Their PCP works at the same location I do.

Are there separate referrals for different services (e.g., one for psychotherapy, one for medication management)? If not, that may be worth looking into setting up. If there are, it sounds like the MHC at that CBOC needs education (from your and/or their program manager) as to the proper use of referrals.

They really shouldn't be able to request to schedule directly into a specialty clinic.

 

[Shiori]

My understanding of what happened is we got a normal, appropriate referral for PTSD treatment from the CBOC. We got them into the PCT clinic and set them up for an appointment with no issue. The Veteran had medication issues that needed to be resolved. The regular PCP at the main site felt uncomfortable managing it and tagged me on the note and called it good. The CBOC was good. The PCP was not.

 

[Mercury in Taurus]

My understanding of what happened is we got a normal, appropriate referral for PTSD treatment from the CBOC. We got them into the PCT clinic and set them up for an appointment with no issue. The Veteran had medication issues that needed to be resolved. The regular PCP at the main site felt uncomfortable managing it and tagged me on the note and called it good. The CBOC was good. The PCP was not.

Every VA is different; however, my understanding is that some involvement in medication management is expected of us. Your PCP seems to not want be bothered at all and pushes it to you to handle. Sorry that this is happening to you. The procedure at my last position was to consult with Psychiatry and document the consultation indicating the name of medication, recommended dosage, and a separate encounter to document psychoeducation provided to the patient about the potential benefits, risks, most reported side effects, any precautions of taking the medication, the importance of medication compliance (using VA handouts usually makes it much easier)... * Very important to 1) document the clarification of our role as non-prescribing provider; 2) co-sign the prescribing provider, the PCP; 3) document any telephone calls, secure messages.... and self-identify as non-prescribing provider in every single note...

 

[Shiori]

Thank you for the suggestions! I'll be talking with my PCT supervisor soon and I'll present that to them. The main plan for care is having a first meeting with the Veteran, getting on the same page about what I actually do, and then getting them connected to the actual prescriber in our clinic.

 

[thebalmofhurtminds]

Every VA is different; however, my understanding is that some involvement in medication management is expected of us. Your PCP seems to not want be bothered at all and pushes it to you to handle. Sorry that this is happening to you. The procedure at my last position was to consult with Psychiatry and document the consultation indicating the name of medication, recommended dosage, and a separate encounter to document psychoeducation provided to the patient about the potential benefits, risks, most reported side effects, any precautions of taking the medication, the importance of medication compliance (using VA handouts usually makes it much easier)... * Very important to 1) document the clarification of our role as non-prescribing provider; 2) co-sign the prescribing provider, the PCP; 3) document any telephone calls, secure messages.... and self-identify as non-prescribing provider in every single note...

You can certainly do this based on your comfort level, but I absolutely would not. Given my experiences at the VA, no one reads your carefully documented clarification and all they see is that you discussed medication and associated details. It's not an easy situation, but I would not take on this discussion with a patient I have not even established a relationship with. Definitely consult with Psychiatry, but medication management discussions can wait until after they've met with a prescribing provider.

 

[Mercury in Taurus]

You can certainly do this based on your comfort level, but I absolutely would not. Given my experiences at the VA, no one reads your carefully documented clarification and all they see is that you discussed medication and associated details. It's not an easy situation, but I would not take on this discussion with a patient I have not even established a relationship with. Definitely consult with Psychiatry, but medication management discussions can wait until after they've met with a prescribing provider.

wholeheartedly agree and I just realized that I need to learn how to say high quality NOs that people can actually hear and accept without suffering long lasting negative consequences. Is that possible in the VA system? LOL

 

[thebalmofhurtminds]

wholeheartedly agree and I just realized that I need to learn how to say high quality NOs that people can actually hear and accept without suffering long lasting negative consequences. Is that possible in the VA system? LOL

Much easier said than done, I'll admit! I left the VA system, but I had decided before I left that strict boundaries were the only way I would be able to continue to work there. Some days were still a constant internal battle of whether I was being too strict/burning bridges/etc.

 

[Fan_of_Meehl]

wholeheartedly agree and I just realized that I need to learn how to say high quality NOs that people can actually hear and accept without suffering long lasting negative consequences. Is that possible in the VA system? LOL

I'd say yes...and it both gets easier with time and saves a whole lotta trouble down the road

 

[AcronymAllergy]

My understanding of what happened is we got a normal, appropriate referral for PTSD treatment from the CBOC. We got them into the PCT clinic and set them up for an appointment with no issue. The Veteran had medication issues that needed to be resolved. The regular PCP at the main site felt uncomfortable managing it and tagged me on the note and called it good. The CBOC was good. The PCP was not.

Ah, understood. Could be worth a call/message to the PCP to clarify what services you do and don't provide. However, in this type of case, I'd typically either put in the referral to the psychiatrist/NP myself, or would discuss the case with them and tag them on the note (and then send a quick follow-up message to the PCP about what was done). I wouldn't mention anything about specific medications unless, say, the patient asked me a quick question about a medication--like "can I take this in the AM instead of PM" or "can I take half the dose like I think my doctor told me I could do"--which I then asked their psychiatrist, who was comfortable saying yes/no/needs a new appointment.

It's not at all unusual for folks outside mental health to have trouble keeping track of who/what all the different providers and services are. I didn't even know all the services we did or didn't have available half the time. So if we can provide a good bridge for care and may even help educate another provider to avoid confusion and delays in the future, awesome.

 

[Fan_of_Meehl]

Ah, understood. Could be worth a call/message to the PCP to clarify what services you do and don't provide. However, in this type of case, I'd typically either put in the referral to the psychiatrist/NP myself, or would discuss the case with them and tag them on the note (and then send a quick follow-up message to the PCP about what was done). I wouldn't mention anything about specific medications unless, say, the patient asked me a quick question about a medication--like "can I take this in the AM instead of PM" or "can I take half the dose like I think my doctor told me I could do"--which I then asked their psychiatrist, who was comfortable saying yes/no/needs a new appointment.

It's not at all unusual for folks outside mental health to have trouble keeping track of who/what all the different providers and services are. I didn't even know all the services we did or didn't have available half the time. So if we can provide a good bridge for care and may even help educate another provider to avoid confusion and delays in the future, awesome.

Question to other VA psychologists (I apologize for switching topics but I'm really curious about this):

Are any of ya'll also being held accountable/responsible for completing the clinical reminder/evaluation entitled: "Iraq & Afghan Post-Deployment screen?"

It's all general medical questions about clearly medical issues like skin/rash symptoms, gastrointestinal distress. etc.

I'm a bit concerned about scope of practice issues not being a physician or nurse practitioner. Thoughts?

 

[cara susanna]

No, I haven't run into that yet.

 

[PsychPhDone]

Question to other VA psychologists (I apologize for switching topics but I'm really curious about this):

Are any of ya'll also being held accountable/responsible for completing the clinical reminder/evaluation entitled: "Iraq & Afghan Post-Deployment screen?"

It's all general medical questions about clearly medical issues like skin/rash symptoms, gastrointestinal distress. etc.

I'm a bit concerned about scope of practice issues not being a physician or nurse practitioner. Thoughts?

Nope

 

[AcronymAllergy]

Question to other VA psychologists (I apologize for switching topics but I'm really curious about this):

Are any of ya'll also being held accountable/responsible for completing the clinical reminder/evaluation entitled: "Iraq & Afghan Post-Deployment screen?"

It's all general medical questions about clearly medical issues like skin/rash symptoms, gastrointestinal distress. etc.

I'm a bit concerned about scope of practice issues not being a physician or nurse practitioner. Thoughts?

I was never instructed to complete that, no.

 

[Mercury in Taurus]

Question to other VA psychologists (I apologize for switching topics but I'm really curious about this):

Are any of ya'll also being held accountable/responsible for completing the clinical reminder/evaluation entitled: "Iraq & Afghan Post-Deployment screen?"

It's all general medical questions about clearly medical issues like skin/rash symptoms, gastrointestinal distress. etc.

I'm a bit concerned about scope of practice issues not being a physician or nurse practitioner. Thoughts?

Nope and hopefully won't

 

[Sanman]

Question to other VA psychologists (I apologize for switching topics but I'm really curious about this):

Are any of ya'll also being held accountable/responsible for completing the clinical reminder/evaluation entitled: "Iraq & Afghan Post-Deployment screen?"

It's all general medical questions about clearly medical issues like skin/rash symptoms, gastrointestinal distress. etc.

I'm a bit concerned about scope of practice issues not being a physician or nurse practitioner. Thoughts?

Nope, what are they doing to psychologists at your facility, jeez?!?

 

[AbnormalPsych]

That is.... wild. Just wait until a psychologist ends up asking about a rash and a patient undresses in session to show you theirs. Nightmare waiting to happen.

 

[Sanman]

That is.... wild. Just wait until a psychologist ends up asking about a rash and a patient undresses in session to show you theirs. Nightmare waiting to happen.

I don't screen for it and people still want to show me their rashes and injuries...

 

[Fan_of_Meehl]

That is.... wild. Just wait until a psychologist ends up asking about a rash and a patient undresses in session to show you theirs. Nightmare waiting to happen.

At least most are VVC sessions and the feed can be cut.

 

[IWillSurvive]

Question to other VA psychologists (I apologize for switching topics but I'm really curious about this):

Are any of ya'll also being held accountable/responsible for completing the clinical reminder/evaluation entitled: "Iraq & Afghan Post-Deployment screen?"

It's all general medical questions about clearly medical issues like skin/rash symptoms, gastrointestinal distress. etc.

I'm a bit concerned about scope of practice issues not being a physician or nurse practitioner. Thoughts?

Yes and at my last position, I had a really bizarre situation about this. I completed it, per veteran report, but apparently not to the Physician receiving the consults' liking. He contacted/called me several times wanting me to not complete the clinical reminder in my note until had talked to him. He wanted me to change it to be a negative screen in essence...I wouldn't do that, he told me I didn't have to be rude, then he called the patient and himself documented it as a negative screen. It was unbelievable. I've hated that screen ever since.

But to answer your question, unless I was a neuropsych I don't really see that as being within my scope...but alas, neither is the flu shot, but I still had to complete that one...

 

[Fan_of_Meehl]

Yes and at my last position, I had a really bizarre situation about this. I completed it, per veteran report, but apparently not to the Physician receiving the consults' liking. He contacted/called me several times wanting me to not complete the clinical reminder in my note until had talked to him. He wanted me to change it to be a negative screen in essence...I wouldn't do that, he told me I didn't have to be rude, then he called the patient and himself documented it as a negative screen. It was unbelievable. I've hated that screen ever since.

But to answer your question, unless I was a neuropsych I don't really see that as being within my scope...but alas, neither is the flu shot, but I still had to complete that one...

Yeah. I've only had to complete it like two times or something in the past six months. Both times the vet answered 'no' to all three initial questions, ending the screen. I figured that if there ever was a positive screen, I'd just put the local primary care doc and nurses on as additional signers (for an FYI to them) and just leave it at that. For me (so far) it's another one of those things that falls into the category of 'not really worth dying on that hill' to fight it out with admin/ service chief given the current political climate which is--for some odd reason--acting as if completion of clinical reminders is our core mission here or something which is truly ridiculous at times...like 'screening' a patient whom I've diagnosed with major depressive disorder and are currently treating for depression with the PHQ-2 'screener'...I mean, you don't exactly need to 'screen' for a diagnosis you've already fully established is present...but, whatever). There are plenty of other hills to fight and 'die' on. I find I really have to be carefully selective regarding those areas where I raise objections (and set boundaries) in this system...otherwise, I'd spend all day long every single day fighting in a 360-degree circle.

 

[AcronymAllergy]

Yeah. I've only had to complete it like two times or something in the past six months. Both times the vet answered 'no' to all three initial questions, ending the screen. I figured that if there ever was a positive screen, I'd just put the local primary care doc and nurses on as additional signers (for an FYI to them) and just leave it at that. For me (so far) it's another one of those things that falls into the category of 'not really worth dying on that hill' to fight it out with admin/ service chief given the current political climate which is--for some odd reason--acting as if completion of clinical reminders is our core mission here or something which is truly ridiculous at times...like 'screening' a patient whom I've diagnosed with major depressive disorder and are currently treating for depression with the PHQ-2 'screener'...I mean, you don't exactly need to 'screen' for a diagnosis you've already fully established is present...but, whatever). There are plenty of other hills to fight and 'die' on. I find I really have to be carefully selective regarding those areas where I raise objections (and set boundaries) in this system...otherwise, I'd spend all day long every single day fighting in a 360-degree circle.

Yeah, the redundancy of some of the screeners is a little ridiculous. And I never quite understood why a more in-depth measure (e.g., PCL-5) couldn't be used to meet the requirement of having completed the screener.

 

[Fan_of_Meehl]

Yeah, the redundancy of some of the screeners is a little ridiculous. And I never quite understood why a more in-depth measure (e.g., PCL-5) couldn't be used to meet the requirement of having completed the screener.

LOL. This is only a half-flippant response but...

I think the true reason is the organizational schema/ideology that appears to be something like:

"The clinical judgment of individual providers must be eliminated at all costs (in favor of a set of universal 'one-size-fits-all' set of rules/procedures that are followed without question)."

{"We are the Borg. Lower your shields. We will add your biological and technological distinctiveness to our own. Your culture will adapt to service us."}

Resistance is futile.

 

[cara susanna]

My favorite was back when I had to do post-partum depression screening when I worked in PCMHI. Sometimes the patient would literally be enrolled in mental health for... (drumroll)... treatment of depression. And then I'd always have to read these Likert scale questions aloud while there was usually a crying baby in the background. I felt so bad for taking up more of these women's time.

I mean, I get that this is a really important thing to screen for, but was that really the BEST way to do it?

 

[Fan_of_Meehl]

My favorite was back when I had to do post-partum depression screening when I worked in PCMHI. Sometimes the patient would literally be enrolled in mental health for... (drumroll)... treatment of depression. And then I'd always have to read these Likert scale questions aloud while there was usually a crying baby in the background. I felt so bad for taking up more of these women's time.

I mean, I get that this is a really important thing to screen for, but was that really the BEST way to do it?

Right. Obviously screening is intended to apply to populations of patients who have not already been confirmed to have the diagnosis being 'screened' for.

 

[cara susanna]

Quick vent - I don't like how the VA handles VCL calls. Like, I don't think it makes sense to reach out to EVERY SINGLE person every time they call. Sometimes people are just calling for in-the-moment support and aren't actually displaying any suicide risk. It feels very fragilizing and also potentially punishing utilizing crisis resources.

 

[cara susanna]

I should have held off on posting because I have a brand new vent! Has anyone else been hearing about the changes to the MH consult process and no longer allowing intradeparmental referrals? This sounds like it's going to be a HUGE mess and another example of number-driven policy that doesn't actually align with clinical practice.

 

[Mercury in Taurus]

I should have held off on posting because I have a brand new vent! Has anyone else been hearing about the changes to the MH consult process and no longer allowing intradeparmental referrals? This sounds like it's going to be a HUGE mess and another example of number-driven policy that doesn't actually align with clinical practice.

I saw that email but have not got the time to read it. What does no more intradepartmental referrals mean for us? How do we offer appropriate level of care after triage? Give them handouts and links to online yoga and meditation, show some YouTube videos, and make recommendation on some self-help books? At where I was before, we had decent community resources. The Steven A. Cohen Military Family Clinic gets a lot of patients from us after the local VA specified the limited number of sessions for MHC treatment. There is only the Vet Center where I am now. So where can we send our patients?

 

[cara susanna]

I saw that email but have not got the time to read it. What does no more intradepartmental referrals mean for us? How do we offer appropriate level of care after triage? Give them handouts and links to online yoga and meditation, show some YouTube videos, and make recommendation on some self-help books? At where I was before, we had decent community resources. The Steven A. Cohen Military Family Clinic gets a lot of patients from us after the local VA specified the limited number of sessions for MHC treatment. There is only the Vet Center where I am now. So where can we send our patients?

It means that we will have to use consults for everything, even groups and specialty services like EBPs. The idea is that the VA wants to be able to track wait times (imo, yet another example of Phoenix screwing everyone over).

 

[Fan_of_Meehl]

I should have held off on posting because I have a brand new vent! Has anyone else been hearing about the changes to the MH consult process and no longer allowing intradeparmental referrals? This sounds like it's going to be a HUGE mess and another example of number-driven policy that doesn't actually align with clinical practice.

If you haven't already, check out the HBO series 'The Wire.'

Sometimes I feel we're just 'juking the stats' (as McNulty would say.