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

[cara susanna]

---

Members don't see this ad.

Dealing with reimbursements too much. At first I was like "Why would you need direct deposit for that?"

Another reason to dislike emotional freedom techniques, it's a confusing acronym.

 

[Sanman]

Dealing with reimbursements too much. At first I was like "Why would you need direct deposit for that?"

I mean, a second paycheck would go a long way to alleviating many of this year's new VA headaches.

 

[Fan_of_Meehl]

Each time I hear anyone chanting the mantra 'whole health' as if they've just split the atom or something I can't help thinking... 'You don't say... ... ...say, do you have an actual caseload of patients with whom you actually spend time and try to translate this mundane truism into actual positive outcomes for actual individual patients or do you just produce Powerpoints, emails, and t-shirts with feel-good slogans and thought-terminating cliches?

Yeah. You don't say...'

'You mean the mundane truism that many physiological/medical variables meaningfully impact psychological variables and vice versa?

Yeah...it had never occurred to me...a practicing clinician.'

/eyeroll

 

[Sanman]

Each time I hear anyone chanting the mantra 'whole health' as if they've just split the atom or something I can't help thinking... 'You don't say... ... ...say, do you have an actual caseload of patients with whom you actually spend time and try to translate this mundane truism into actual positive outcomes for actual individual patients or do you just produce Powerpoints, emails, and t-shirts with feel-good slogans and thought-terminating cliches?

Yeah. You don't say...'

'You mean the mundane truism that many physiological/medical variables meaningfully impact psychological variables and vice versa?

Yeah...it had never occurred to me...a practicing clinician.'

/eyeroll

Eh, I trained at the VA when the big thing was "Pain is the 5th vital sign" and look how well that turned out...oh wait

 

[Fan_of_Meehl]

Eh, I trained at the VA when the big thing was "Pain is the 5th vital sign" and look how well that turned out...oh wait

These days service-connection is the fifth, sixth, and seventh vital sign and, if it is <100%, then it is 'too low.'

 

[Sanman]

These days service-connection is the fifth, sixth, and seventh vital sign and, if it is <100%, then it is 'too low.'

Yeah, there is a definite reaction to our current economic realties with regard service connection. On the veteran's part, I get it. Systemically, the new focus in the VA seems seems to not realize that people do not value things they are given for free.

 

[cara susanna]

Eh, I trained at the VA when the big thing was "Pain is the 5th vital sign" and look how well that turned out...oh wait

When I first started at my current job, our notes STILL made us ask about pain every single appt and then put it in an action plan if the pain was rated at a certain level.

 

[WisNeuro]

When I first started at my current job, our notes STILL made us ask about pain every single appt and then put it in an action plan if the pain was rated at a certain level.

Pain ratings were always so useless in the VA, and still mostly useless outside of the VA.

Pt calmly sitting across from you in interview. "what's your pain on a 10-point scale?"
Pt: In a serious tone "It's always a 12."

Thank you for that informative answer, I look forward to you performing below chance on the WMT now.

 

[Shiori]

I feel most of the "objective" measurements used in the VA are just time-consuming at this point. I don't mind tracking outcomes, but it's a mess in the VA. I'm about ready to toss the PCL-5 out the window because of all the nonsensical responses I get on it even when I explain the question. I'll be doing imaginals with someone, but they'll try to endorse being bothered by not remembering important parts of the event as a four. Even with a gentle nudge that they remember everything in vivid detail. I've just been summarizing their symptoms in my notes. I'm sure I'll get fussed at, but it's more helpful for me to track their progress.

I get the opposite too. They'll be practically housebound due to their symptoms, but say avoidance is a 0.

 

[Fan_of_Meehl]

I feel most of the "objective" measurements used in the VA are just time-consuming at this point. I don't mind tracking outcomes, but it's a mess in the VA. I'm about ready to toss the PCL-5 out the window because of all the nonsensical responses I get on it even when I explain the question. I'll be doing imaginals with someone, but they'll try to endorse being bothered by not remembering important parts of the event as a four. Even with a gentle nudge that they remember everything in vivid detail. I've just been summarizing their symptoms in my notes. I'm sure I'll get fussed at, but it's more helpful for me to track their progress.

I get the opposite too. They'll be practically housebound due to their symptoms, but say avoidance is a 0.

Exactly. Utilization of these largely syndrome nonspecific, face-valid self-report symptom checklists to 'objectively assess outcome to ensure "measurement-based care" (puke)' is a joke to most of us attempting to utilize them in this context with this population. The assessment process is only nominally/negligibly 'objective' in the sense that the patients circle numbers (0-4) corresponding to subjective self-reports of guesses about 'frequency' ('a little bit, moderately, quite a bit') over a recent time frame and these numbers are summed. I mean, back in the Dark Ages of CBT (think Beck /Barlow) we'd do a simple and efficient mood check / rating (1-10) at the beginning of sessions and that probably yields as much useful info as the summed scores of some of these checklists. And don't think for a second that veterans aren't aware that them reporting objective improvement on these questionnaires may negatively impact their service-connection ratings/compensation and if you are or pretend to be naive to that influence on their responses then I'm not even sure what to say about it.

 

[cara susanna]

I only like MBC with EBPs or EBP maintenance work, which is where I've always used it. With my non-EBP patients it tends to just be pointless.

At least BHL Touch has made my life a lot easier with administering measures.

 

[Fan_of_Meehl]

I feel most of the "objective" measurements used in the VA are just time-consuming at this point. I don't mind tracking outcomes, but it's a mess in the VA. I'm about ready to toss the PCL-5 out the window because of all the nonsensical responses I get on it even when I explain the question. I'll be doing imaginals with someone, but they'll try to endorse being bothered by not remembering important parts of the event as a four. Even with a gentle nudge that they remember everything in vivid detail. I've just been summarizing their symptoms in my notes. I'm sure I'll get fussed at, but it's more helpful for me to track their progress.

I get the opposite too. They'll be practically housebound due to their symptoms, but say avoidance is a 0.

Methodolatry (definition):

A combination of method and idolatry, to describe a preoccupation with selecting and defending methods to the exclusion of the actual substance of the story being told. Methodolatry is the slavish attachment and devotion to method that so often overtakes the discourse in the education and human service fields.

'Methodolatry,' thy name is Veterans Affairs.

 

[Shiori]

I'm using it with my EBP folks. It's not going well. I'll do it with them in session the first time and then use BHL or MHC. The most recent example is they scored well above 40 with me and then below 10 at home. I asked what was different and they said they had a good week (significantly increased avoidance behaviors). I just ask them about their symptoms now. I will say that it's been site-specific. The population at this VA is quite different than my previous experiences and it is reflected in their MBC responses.

 

[cara susanna]

I'm using it with my EBP folks. It's not going well. I'll do it with them in session the first time and then use BHL or MHC. The most recent example is they scored well above 40 with me and then below 10 at home. I asked what was different and they said they had a good week (significantly increased avoidance behaviors). I just ask them about their symptoms now. I will say that it's been site-specific. The population at this VA is quite different than my previous experiences and it is reflected in their MBC responses.

Lol, I have some patients whose PCL-5 score will change depending on the type of week they've had. I just always make sure to document that in the note. I also give them a speech about trying to separate other things from their responses, even if it's difficult. If a patient is avoiding to the extent where their PCL-5 score looks less symptomatic, I would probably give them a "come to Jesus" speech about if it's really the right time for them to do a PTSD EBP.

I've actually started giving a CAPS-5 before I see patients for a PTSD EBP. I've had way too many where the PCL-5 score looks symptomatic or the index event seems Criterion A but then we start the protocol and... nope.

 

[WisNeuro]

Lol, I have some patients whose PCL-5 score will change depending on the type of week they've had. I just always make sure to document that in the note. I also give them a speech about trying to separate other things from their responses, even if it's difficult. If a patient is avoiding to the extent where their PCL-5 score looks less symptomatic, I would probably give them a "come to Jesus" speech about if it's really the right time for them to do a PTSD EBP.

I've actually started giving a CAPS-5 before I see patients for a PTSD EBP. I've had way too many where the PCL-5 score looks symptomatic or the index event seems Criterion A but then we start the protocol and... nope.

I wish more people were trained in and utilized the CAPS more. I review a lot of records where the diagnosis comes from a 35-40 minute "comprehensive diagnostic interview", usually from some mid-level, where the provider essentially just cuts and pastes the diagnostic criteria into a note.

 

[Shiori]

I wonder why more people aren't trained on it. It's a pretty brief training comparatively. I definitely prefer it. I'd rather go through the pain all at once, get better data, and move on rather than read the tea leaves on the PCL-5. It also feels better than putting "probable PTSD diagnosis" for someone who is service connected for PTSD. Then there are the epic battles about cutoff scores versus criterion-based approaches using the PCL. Can I please just do the CAPS-5 and move on?

 

[WisNeuro]

I wonder why more people aren't trained on it. It's a pretty brief training comparatively. I definitely prefer it. I'd rather go through the pain all at once, get better data, and move on rather than read the tea leaves on the PCL-5. It also feels better than putting "probable PTSD diagnosis" for someone who is service connected for PTSD. Then there are the epic battles about cutoff scores versus criterion-based approaches using the PCL. Can I please just do the CAPS-5 and move on?

Well, outside of the VA, reimbursement is probably a big issue. Clinically, if I am essentially getting paid the same from a 90791 whether I spend 45 minutes or if I spend 2 hours, which will many people choose? Forensically, on the other hand, I am getting paid for all of my time, so I have much better incentive to do the job the right way.

 

[cara susanna]

I'm one of two people in our clinic trained on the CAPS-5 (and the other provider who's trained is busy with other responsibilities). It's now reaching the point where people are getting referred to see me one time just for a CAPS. Back when I was in a PTSD Team, we used to give the CAPS-5 to every new patient and that ended up being about 3 CAPS per week, so at least I have a pretty good system that makes me fairly efficient--I'm also fast with documentation in general, though.

I'm currently in a PTSD specialty role where I pretty much function as a one person PCT, so I think that giving a CAPS to new patients makes sense. I tried to avoid it at first, but... see above. The only awkward thing is, like, hey we're meeting for the first time, tell me about your worst trauma. But I ran into that in my previous position too and I always ask providers to warn new referrals that the first appt will entail a lot of assessment.

 

[WisNeuro]

I'm one of two people in our clinic trained on the CAPS-5 (and the other provider who's trained is busy with other responsibilities). It's now reaching the point where people are getting referred to see me one time just for a CAPS. Back when I was in a PTSD Team, we used to give the CAPS-5 to every new patient and that ended up being about 3 CAPS per week, so at least I have a pretty good system that makes me fairly efficient--I'm also fast with documentation in general, though.

I'm currently in a PTSD specialty role where I pretty much function as a one person PCT, so I think that giving a CAPS to new patients makes sense. I tried to avoid it at first, but... see above. The only awkward thing is, like, hey we're meeting for the first time, tell me about your worst trauma. But I ran into that in my previous position too and I always ask providers to warn new referrals that the first appt will entail a lot of assessment.

Pretty much the only consistent use of the CAPS I had in the VA was when I was on an inpatient treatment unit. I did a good deal of the initial, pre-treatment assessment, which included the CAPS, before their admission. Voluntary unit. Other than that, it was always hit or miss if it was used. Been more than 5 years since I've given a CAPS, I'd need a refresher before giving it again at this point.

 

[Shiori]

I'm one of two people in our clinic trained on the CAPS-5 (and the other provider who's trained is busy with other responsibilities). It's now reaching the point where people are getting referred to see me one time just for a CAPS. Back when I was in a PTSD Team, we used to give the CAPS-5 to every new patient and that ended up being about 3 CAPS per week, so at least I have a pretty good system that makes me fairly efficient--I'm also fast with documentation in general, though.

I'm currently in a PTSD specialty role where I pretty much function as a one person PCT, so I think that giving a CAPS to new patients makes sense. I tried to avoid it at first, but... see above. The only awkward thing is, like, hey we're meeting for the first time, tell me about your worst trauma. But I ran into that in my previous position too and I always ask providers to warn new referrals that the first appt will entail a lot of assessment.

That blows my mind. That makes sense though. I've never been trained to do the CAPS within the VA. I've been trained a few times in my research lab as part of an IRB requirement. I've only been asked to do the CAPS in the VA as part of a handful of psychodiagnostic assessments. Any other times happened when I requested to do it.

 

[Therapist4Chnge]

Pain ratings were always so useless in the VA, and still mostly useless outside of the VA.

Pt calmly sitting across from you in interview. "what's your pain on a 10-point scale?"
Pt: In a serious tone "It's always a 12."

Thank you for that informative answer, I look forward to you performing below chance on the WMT now.

"Patient continues to report incongruent pain complaints, evidenced by a self-report rating of 12/10 pain, despite exhibiting ZERO spontaneous pain behaviors during the 55 minute session. They were able to sit comfortably for the entirety of the session and only demonstrated exaggerated pain behaviors when the topic of pain was broached. These behaviors are consistent with...."

 

[WisNeuro]

"Patient continues to report incongruent pain complaints, evidenced by a self-report rating of 12/10 pain, despite exhibiting ZERO spontaneous pain behaviors during the 55 minute session. They were able to sit comfortably for the entirety of the session and only demonstrated exaggerated pain behaviors when the topic of pain was broached. These behaviors are consistent with...."

Oh, definitely, I have a canned response similar to this for my legal cases.

 

[cara susanna]

"Patient continues to report incongruent pain complaints, evidenced by a self-report rating of 12/10 pain, despite exhibiting ZERO spontaneous pain behaviors during the 55 minute session. They were able to sit comfortably for the entirety of the session and only demonstrated exaggerated pain behaviors when the topic of pain was broached. These behaviors are consistent with...."

I always just used to say that I didn't assess pain because the focus of the appt was on therapy.

 

[Sanman]

"Patient continues to report incongruent pain complaints, evidenced by a self-report rating of 12/10 pain, despite exhibiting ZERO spontaneous pain behaviors during the 55 minute session. They were able to sit comfortably for the entirety of the session and only demonstrated exaggerated pain behaviors when the topic of pain was broached. These behaviors are consistent with...."

These behaviors are consistent with the reflection of dollar signs apparent in the client's eyes and improved affect when discussing upcoming plans to purchase a new boat with his disability money. 😊

 

[npsyd]

Hi to all!
As this is a venting/problem-solving/peer support thread I’m looking for all three. I’m a new psychologist at a pretty big PCMHI team and I’m struggling coming from doing long-term psychotherapy. Our team works as a Mental Health Access Clinic, so we have to see all new MH patients or those who have not seen MH for over 2 years. We’re supposed to do the Brief Functional Assessment in 30 minutes to determine needs, like PCMHI dictates. But I’m having such a hard time doing all in 30 minutes! Because I’m taking longer it’s harder for me to be available to see walk-ins or warn hand-offs. Any tips/tricks from other PCMHI folks on how to get closer to doing an initial Functional Assessment in 30-35 minutes. I’m right now taking between 40-55 depending on the patient’s presentation.

 

[summerbabe]

Any tips/tricks from other PCMHI folks on how to get closer to doing an initial Functional Assessment in 30-35 minutes. I’m right now taking between 40-55 depending on the patient’s presentation.

Not a PCMHI person (in fact it was my least favorite internship/postdoc rotation) but one of the things I struggled with was doing what I had time to do versus what I wanted/could do. 30 mins versus 60 versus 90 produces different outcomes so it was a struggle for me to accept and adapt to those limitations.

Especially for vets who are new to mental health or have lapsed in their MH care, I would focus as much as possible on concrete short-term outcomes such as a) do they need to go back to PC for meds or is there complexity that would be appropriate for a psychiatry/BHIP consult; b) identify their primary current MH concern (or 2, especially if intertwined like depression and anxiety) that is psychotherapy appropriate and provide 1 psychoed/home practice piece, which probably requires spending less time on some combo of MH history, current psychosocial circumstances or diagnostic clarification since this isn’t a comprehensive intake.

That would give me something concrete to focus on during a follow-up(s) which also provide additional opportunity to assess and figure out if their mental health needs can be handled in PCMHI or should bump up to BHIP/speciality care.

Specifics will also likely depend on your facility. For example, I’m in a system covering a large rural state with access issues including sometimes only 1 or 2 MH providers at our many CBOCs so our PCMHI folks often spend 45-60 mins for initial evals and sometimes even f/u apts since there is poor BHIP availability for referrals so they have to do more.

Hopefully somebody else who has more PCMHI experience and likely did a better job than me can also chime in lol!

 

[erg923]

I think the best piece of advice I can give is that you’re not doing a psychiatric evaluation or a mental health intake, right? It is a functional assessment.

What’s the presenting problem (narrow it down to 2), how is it affecting them, how long has it been going on, what do they want to do about it, and what do you think they might need to do about it? Can that be accomplished within PCMHI or do they need something else? That’s really it. Don't do anymore than that. And redirect people when needed. I think 9 times out of 10 that can be doable in 30 minutes.

 

[thebalmofhurtminds]

I treat pain and once I left the VA, I have been pleasantly surprised at being able to use a 1-10 pain scale with my patients without constantly hearing 10+ as an answer.

 

[cara susanna]

Hi to all!
As this is a venting/problem-solving/peer support thread I’m looking for all three. I’m a new psychologist at a pretty big PCMHI team and I’m struggling coming from doing long-term psychotherapy. Our team works as a Mental Health Access Clinic, so we have to see all new MH patients or those who have not seen MH for over 2 years. We’re supposed to do the Brief Functional Assessment in 30 minutes to determine needs, like PCMHI dictates. But I’m having such a hard time doing all in 30 minutes! Because I’m taking longer it’s harder for me to be available to see walk-ins or warn hand-offs. Any tips/tricks from other PCMHI folks on how to get closer to doing an initial Functional Assessment in 30-35 minutes. I’m right now taking between 40-55 depending on the patient’s presentation.

Have you done the national PCMHI training? They give you a specific outline of what to follow for the brief functional assessment.

I'm not in PCMHI anymore but I used to be absolutely awesome at the 30 min appt. Basically, you just need to be really directive and interrupt or cut off the patient. Also remember the advice my former PCMHI supervisor gave me: we're just giving a tune-up, we're not overhauling the engine.

 

[deleted106747]

Hi to all!
As this is a venting/problem-solving/peer support thread I’m looking for all three. I’m a new psychologist at a pretty big PCMHI team and I’m struggling coming from doing long-term psychotherapy. Our team works as a Mental Health Access Clinic, so we have to see all new MH patients or those who have not seen MH for over 2 years. We’re supposed to do the Brief Functional Assessment in 30 minutes to determine needs, like PCMHI dictates. But I’m having such a hard time doing all in 30 minutes! Because I’m taking longer it’s harder for me to be available to see walk-ins or warn hand-offs. Any tips/tricks from other PCMHI folks on how to get closer to doing an initial Functional Assessment in 30-35 minutes. I’m right now taking between 40-55 depending on the patient’s presentation.

You are functioning as a mental health access clinic???

 

[Mercury in Taurus]

You are functioning as a mental health access clinic???

Does that mean you are functioning as a glorified dispatcher like I was at the BHL? LOL I hated these "referrals" when the BHL clinician is utilized solely as a scheduler just to stay on the phone with the patient to schedule a follow-up appointment to meet with their MHC coordinator via Teams messages with a tech. Just because techs don't have the authority to negotiate appointment dates and times with a patient.

 

[Fan_of_Meehl]

Have you done the national PCMHI training? They give you a specific outline of what to follow Question: what is everyone's experience regarding how many scheduled intakes (per week) into an open-access clinic (e.g., post-deployment, general psychology clinic) is considered normal/typical? And I mean full 90-min intakes where it is expected that the patient will be added to your full time caseload for long-term psychotherapy.

I have a question regarding average number of scheduled psychotherapy intakes per week (into intake clinic slots) for a full-time psychotherapist in a non-specialty (e.g., post- deployment, psychology service) clinic where the expectation is that all of the intakes will end up in that provider's ongoing caseload.

So, for a provider labor mapped to provide 100% of their time or 1.0 FTE to psychotherapy. Four intakes a week? Three? Ten? One?

What have you observed?

 

[cara susanna]

I have a question regarding average number of scheduled psychotherapy intakes per week (into intake clinic slots) for a full-time psychotherapist in a non-specialty (e.g., post- deployment, psychology service) clinic where the expectation is that all of the intakes will end up in that provider's ongoing caseload.

So, for a provider labor mapped to provide 100% of their time or 1.0 FTE to psychotherapy. Four intakes a week? Three? Ten? One?

What have you observed?

We don't do our own intakes, but have one new patient slot per week.

 

[Fan_of_Meehl]

T

We don't do our own intakes, but have one new patient slot per week.

Thanks!

 

[npsyd]

Have you done the national PCMHI training? They give you a specific outline of what to follow for the brief functional assessment.

I'm not in PCMHI anymore but I used to be absolutely awesome at the 30 min appt. Basically, you just need to be really directive and interrupt or cut off the patient. Also remember the advice my former PCMHI supervisor gave me: we're just giving a tune-up, we're not overhauling the engine.

You are functioning as a mental health access clinic???

Thank you for all y’alls responses. I did do the PCMHI training when I was a fellow in 2018. After 3 years of not doing PCMHI I easily fall into the long-term psychotherapy rhythm.

As to the Mental Health Access Clinic nature of our team, the way it’s established is that ALL patients that request MH for the 1st time/transferring from another VA or that have been out of MH from 2+year need to have a PCMHI functional assessment before being referred to specialty (if appropriate). So we not only receive the appropriate mild to moderate “uncomplicated” cases appropriate for PCMHI f/u, we need to do initial appt for EVERYONE requesting MH and function as a walk-in MH clinic for those not already established with specialty. We get A TON of patients each day and it is overwhelming for a newbie. 😅

 

[IWillSurvive]

I have a question regarding average number of scheduled psychotherapy intakes per week (into intake clinic slots) for a full-time psychotherapist in a non-specialty (e.g., post- deployment, psychology service) clinic where the expectation is that all of the intakes will end up in that provider's ongoing caseload.

So, for a provider labor mapped to provide 100% of their time or 1.0 FTE to psychotherapy. Four intakes a week? Three? Ten? One?

What have you observed?

I'm in BHIP and we have 3-4 intakes/week (the one where you have the structured eval and you code the psychiatric diagnostic eval). But curious, do you mean patients new to you as the therapist or new to BHIP in general? I get alot of within team referrals which are not new to MH and I treat those sessions more like the PCMHI functional assessment described above. My 3-4 would go way up if we are including those...

 

[AcronymAllergy]

Thank you for all y’alls responses. I did do the PCMHI training when I was a fellow in 2018. After 3 years of not doing PCMHI I easily fall into the long-term psychotherapy rhythm.

As to the Mental Health Access Clinic nature of our team, the way it’s established is that ALL patients that request MH for the 1st time/transferring from another VA or that have been out of MH from 2+year need to have a PCMHI functional assessment before being referred to specialty (if appropriate). So we not only receive the appropriate mild to moderate “uncomplicated” cases appropriate for PCMHI f/u, we need to do initial appt for EVERYONE requesting MH and function as a walk-in MH clinic for those not already established with specialty. We get A TON of patients each day and it is overwhelming for a newbie. 😅

This is largely how our clinic functioned as well, and I believe it may be the norm across VA based on VA guidelines (e.g., if they've been out of MH for 2+ years, they don't/can't go straight to specialty MH). As the others with much more experience in that area than me have said above, in those cases, I think it's still possible to do a targeted 30-minute functional assessment and determine that the patient isn't appropriate for PCMHI. Even if it doesn't always feel like it, you're going to be more informed in making those calls (and are going to have more time to do so) than the PCP.

 

[Fan_of_Meehl]

I'm in BHIP and we have 3-4 intakes/week (the one where you have the structured eval and you code the psychiatric diagnostic eval). But curious, do you mean patients new to you as the therapist or new to BHIP in general? I get alot of within team referrals which are not new to MH and I treat those sessions more like the PCMHI functional assessment described above. My 3-4 would go way up if we are including those...

Because of my personal circumstances I am more interested in data from what I guess I would call open-access (e.g., not PCT/PTSD or SUDS specialty type) clinics where a provider has, say, X intake slots per week, Y 'intervention/therapy session' slots per week, and Z total number of active clients in their caseload (who, obviously, have to fit in those Y session slots/week). The pattern I have seen from specialty clinics is that they can (a) funnel people into initial groups whose content is centered on that particular diagnosis (whether PTSD or SUDS) and (b) offer an evidence-based time-limited protocol treatment (e.g., CPT/PE, a predetermined-length IOP treatment program) and, if they complete the trial, great, they are 'forwarded' to an open-access clinic to work on everything else (or even PTSD and/or SUDS) if they were non-responders; (c) if the patient balks at the protocol, they 'forward' them to an open-access clinic for alternative approaches. So now they're 'my problem' as a non-specialty (generalist) clinic. Note that, as such, I have no one to 'forward' them to. I'm the last stop on the train ride. Some clients are seen weekly (typically for protocols (CPT/PE) or if they are particularly 'high-risk' for suicide/homicide), some clients are seen 'biweekly' (every two weeks), and some clients are seen monthly (mainly, because they say they can only attend monthly). To use a plumbing/hydrodynamic analogy, there is an 'intake/inlet' 'pipe' of a certain size (dedicated intake slots/wk), a 'reservoir' that can only hold so much water under so much pressure at any one point in time (e.g., number of clients in one's 'active' current psychotherapy caseload fitting into a certain number of therapy slots/wk), a certain amount of 'leakage' (e.g., no-shows, cancellations, passive dropouts from therapy), and (theoretically) an 'outflow' pipe (e.g., veterans who complete therapy or terminate (or, possibly, passively drop out from therapy). Whether 'passive dropouts from therapy' (which is, in my experience the main pathway for someone exiting one's caseload) fits into the 'reservoir' part of the analogy or the 'outflow pipe' part of the analogy is debatable. However, it stands to reason that the 'inflow' pipe into my caseload cannot be of infinitely large diameter or we're going to have an issue. There is a certain limited rate of 'clearance' of those patients who enter into my caseload. So, it is a very practical (but, as yet, unaddressed) problem to figure out what is a good rule of thumb regarding the appropriate/manageable number of new cases per week that the psychotherapy caseload of an individual provider can absorb before it becomes unmanageable and, for example, leadership would be called upon to hire another provider to handle the 'rate/flow' of new cases in any given area. Under this analogy, as I understand BHIP or PCMHI, there may be a 'larger inflow pipe' in the form of more intakes into your 'caseload' per unit time but this would be compensated by a correspondingly larger 'outflow pipe' in that you are doing briefer, more circumscribed interventions with a clearer/cleaner 'endpoint' (e.g., we're going to do 6 sessions of CBT-i for insomnia vs. okay, we're going to do a complete trauma/military history, differential diagnosis for PTSD/MDD/SUDS/personality disorder/traits/ cognitive case formulation including antecedents/triggers, negative automatic thoughts, intermediate beliefs, schemas, etc., oh yeah, and existential issues and failure-to-grow-up issues as well, leveraging MI strategies to move from pre-contemplation to contemplation, etc.).

 

[Sanman]

Because of my personal circumstances I am more interested in data from what I guess I would call open-access (e.g., not PCT/PTSD or SUDS specialty type) clinics where a provider has, say, X intake slots per week, Y 'intervention/therapy session' slots per week, and Z total number of active clients in their caseload (who, obviously, have to fit in those Y session slots/week). The pattern I have seen from specialty clinics is that they can (a) funnel people into initial groups whose content is centered on that particular diagnosis (whether PTSD or SUDS) and (b) offer an evidence-based time-limited protocol treatment (e.g., CPT/PE, a predetermined-length IOP treatment program) and, if they complete the trial, great, they are 'forwarded' to an open-access clinic to work on everything else (or even PTSD and/or SUDS) if they were non-responders; (c) if the patient balks at the protocol, they 'forward' them to an open-access clinic for alternative approaches. So now they're 'my problem' as a non-specialty (generalist) clinic. Note that, as such, I have no one to 'forward' them to. I'm the last stop on the train ride. Some clients are seen weekly (typically for protocols (CPT/PE) or if they are particularly 'high-risk' for suicide/homicide), some clients are seen 'biweekly' (every two weeks), and some clients are seen monthly (mainly, because they say they can only attend monthly). To use a plumbing/hydrodynamic analogy, there is an 'intake/inlet' 'pipe' of a certain size (dedicated intake slots/wk), a 'reservoir' that can only hold so much water under so much pressure at any one point in time (e.g., number of clients in one's 'active' current psychotherapy caseload fitting into a certain number of therapy slots/wk), a certain amount of 'leakage' (e.g., no-shows, cancellations, passive dropouts from therapy), and (theoretically) an 'outflow' pipe (e.g., veterans who complete therapy or terminate (or, possibly, passively drop out from therapy). Whether 'passive dropouts from therapy' (which is, in my experience the main pathway for someone exiting one's caseload) fits into the 'reservoir' part of the analogy or the 'outflow pipe' part of the analogy is debatable. However, it stands to reason that the 'inflow' pipe into my caseload cannot be of infinitely large diameter or we're going to have an issue. There is a certain limited rate of 'clearance' of those patients who enter into my caseload. So, it is a very practical (but, as yet, unaddressed) problem to figure out what is a good rule of thumb regarding the appropriate/manageable number of new cases per week that the psychotherapy caseload of an individual provider can absorb before it becomes unmanageable and, for example, leadership would be called upon to hire another provider to handle the 'rate/flow' of new cases in any given area. Under this analogy, as I understand BHIP or PCMHI, there may be a 'larger inflow pipe' in the form of more intakes into your 'caseload' per unit time but this would be compensated by a correspondingly larger 'outflow pipe' in that you are doing briefer, more circumscribed interventions with a clearer/cleaner 'endpoint' (e.g., we're going to do 6 sessions of CBT-i for insomnia vs. okay, we're going to do a complete trauma/military history, differential diagnosis for PTSD/MDD/SUDS/personality disorder/traits/ cognitive case formulation including antecedents/triggers, negative automatic thoughts, intermediate beliefs, schemas, etc., oh yeah, and existential issues and failure-to-grow-up issues as well, leveraging MI strategies to move from pre-contemplation to contemplation, etc.).

How many sessions of therapy are you providing people? Our general clinic limits them to 10-12 wks max regardless of issue unless it is high risk. We then punt them into a drop-in group...which is a euphemism for we don't have time to treat you, but we need to get these access issues off our back.

 

[Fan_of_Meehl]

How many sessions of therapy are you providing people? Our general clinic limits them to 10-12 wks max regardless of issue unless it is high risk. We then punt them into a drop-in group...which is a euphemism for we don't have time to treat you, but we need to get these access issues off our back

How many sessions of therapy are you providing people? Our general clinic limits them to 10-12 wks max regardless of issue unless it is high risk. We then punt them into a drop-in group...which is a euphemism for we don't have time to treat you, but we need to get these access issues off our back.

So after 10-12wks are up and they are placed in the drop-in group...is that it? Meaning they stay in that group forever or can they re-enter active therapy at some later point in time? Also, a widely ignored finding in the literature (the low efficacy of groups for PTSD--straight out of the VA/DoD Guidelines) seems relevant as does the fact that some veterans may need some phase of motivational interviewing, crisis stabilization, psychoeducation prior to fully engaging with active CBT treatment. Do you have an absolute cutoff after 12 sessions or does it depend on the case?

 

[Sanman]

People can be picked up again later on. The drop in group serves as sort of a waiting room and a place to move poorly motivated folks that may just want a disability check. From what I am told, people rarely ever show up to the group, but it solves the access issue/pipeline problem.

 

[cara susanna]

This is largely how our clinic functioned as well, and I believe it may be the norm across VA based on VA guidelines (e.g., if they've been out of MH for 2+ years, they don't/can't go straight to specialty MH). As the others with much more experience in that area than me have said above, in those cases, I think it's still possible to do a targeted 30-minute functional assessment and determine that the patient isn't appropriate for PCMHI. Even if it doesn't always feel like it, you're going to be more informed in making those calls (and are going to have more time to do so) than the PCP.

That is not actually in line with national practice depending on where the referrals are coming from. The national PCMHI model is that all referrals come from Primary Care, not Mental Health. So if a patient isn't referred from Primary Care, PCMHI should not see them. I guess it would be in line if all of the referrals are coming from Primary Care.

Also, any patient established with OPMH--like for meds--should be seen within OPMH for therapy as well.

 

[cara susanna]

People can be picked up again later on. The drop in group serves as sort of a waiting room and a place to move poorly motivated folks that may just want a disability check. From what I am told, people rarely ever show up to the group, but it solves the access issue/pipeline problem.

So you're allowed to say that they have to do group and not individual? No one ever complains to the patient advocate?

 

[erg923]

That is not actually in line with national practice depending on where the referrals are coming from. The national PCMHI model is that all referrals come from Primary Care, not Mental Health. So if a patient isn't referred from Primary Care, PCMHI should not see them. I guess it would be in line if all of the referrals are coming from Primary Care.

Also, any patient established with OPMH--like for meds--should be seen within OPMH for therapy as well.

Yea, I was just going to mention, you guys have been talking about this for a page now and primary care and working with or "integration" with primary care has not been mentioned at all. What has happened? The mission of PCMHI is to serve primary care, not MHC. Although no doubt PCMHI saves MHC and specialty MH from unnecessary patients and referrals, I think national's position is that you are serving and integrating with the primary care service? The majority of your work and communication about patients should be with them, no?

This leaves the question of walks-ins though, and I do think PCMHI at my former facility was indeed doing these years ago whether or not they were "enrolled" or "active" with a primary care provider. There was also the push for "no referrals are needed to see a mental health professional" too (in order to eliminate almost any barrier to same-day access)....so I don't know where that fits in with all this? It's confusing. @cara susanna how is all this really suppose to work now?

 

[Sanman]

So you're allowed to say that they have to do group and not individual? No one ever complains to the patient advocate?

Truthfully, no idea as it is not my area. I just keep up with how the CBOC MHC works for patient referrals now that everything is virtual. Honestly, if there were complaints, I am guessing that local MH leadership would welcome it as they have been lobbying higher ups for the creation of additional CBOC MHC positions to ease the workload. When there is a shortage of staff, nothing more to be done.

 

[cara susanna]

Yea, I was just going to mention, you guys have been talking about this for a page now and primary care and working with or "integration" with primary care has not been mentioned at all. What has happened? The mission of PCMHI is to serve primary care, not MHC. Although no doubt PCMHI saves MHC and specialty MH from unnecessary patients and referrals, I think national's position is that you are serving and integrating with the primary care service? The majority of your work and communication about patients should be with them, no?

This leaves the question of walks-ins though, and I do think PCMHI at my former facility was indeed doing these years ago whether or not they were "enrolled" or "active" with a primary care provider. There was also the push for "no referrals are needed to see a mental health professional" too (in order to eliminate almost any barrier to same-day access)....so I don't know where that fits in with all this? It's confusing. @cara susanna how is all this really suppose to work now?

It's not how it's supposed to work but a lot of MH services do it. Our own clinic used to, but our local PCMHI lead pushed back pretty hard against it and now we're in line with the national model. Basically, PCMHI's job is not to ensure that OPMH has good access.

We have access staff within OPMH--limited therapy caseloads and job is pretty much to see walk-ins, cold calls, etc, and connect them to services or see them until they can get connected to services--and that works pretty well.

Now I'm wondering if the issue with keeping to 30 min appts is because you're basically doing OPMH's job for them, and that's not the purpose of PCMHI. The purpose of a brief functional assessment is to triage and figure out if the patient needs brief therapy or longer-term services.

 

[erg923]

It's not how it's supposed to work but a lot of MH services do it. Our own clinic used to, but our local PCMHI lead pushed back pretty hard against it and now we're in line with the national model. Basically, PCMHI's job is not to ensure that OPMH has good access.

We have access staff within OPMH--limited therapy caseloads and job is pretty much to see walk-ins, cold calls, etc, and connect them to services or see them until they can get connected to services--and that works pretty well.

Now I'm wondering if the issue with keeping to 30 min appts is because you're basically doing OPMH's job for them, and that's not the purpose of PCMHI. The purpose of a brief functional assessment is to triage and figure out if the patient needs brief therapy or longer-term services.

That's what I thought.

Although it was always a stretch to expect PCMHI to actually be/become a specialty "health psychology service"... and don't think it ever really was despite several years of "health behavior championing" in the mid 2010's (don't think the Health & Behavior codes have worked out at all, for anyone), I certainly don't think it was ever suppose to be diet OPMH, or a "Mental Health Access Clinic" that picks up slack from the general mental health service? I think that idea may have come up in the latter 2010s as a reaction to the waitlist/Shinseki scandal? @cara susanna ?

 

[deleted106747]

Yea, I was just going to mention, you guys have been talking about this for a page now and primary care and working with or "integration" with primary care has not been mentioned at all. What has happened? The mission of PCMHI is to serve primary care, not MHC. Although no doubt PCMHI saves MHC and specialty MH from unnecessary patients and referrals, I think national's position is that you are serving and integrating with the primary care service? The majority of your work and communication about patients should be with them, no?

This leaves the question of walks-ins though, and I do think PCMHI at my former facility was indeed doing these years ago whether or not they were "enrolled" or "active" with a primary care provider. There was also the push for "no referrals are needed to see a mental health professional" too (in order to eliminate almost any barrier to same-day access)....so I don't know where that fits in with all this? It's confusing. @cara susanna how is all this really suppose to work now?

Serving MHC as an access clinic is a gross misuse of PCMHI and is one of the reasons I left the VA. And PCMHI should also not be the walk in clinic for the whole system. SMH. All a way to fudge the numbers and make access look better than it is.

 

[erg923]

Serving MHC as an access clinic is a gross misuse of PCMHI and is one of the reasons I left the VA. And PCMHI should also not be the walk in clinic for the whole system. SMH. All a way to fudge the numbers and make access look better than it is.

As the young people say"..... Do you want to preach this?

 

[IWillSurvive]

Because of my personal circumstances I am more interested in data from what I guess I would call open-access (e.g., not PCT/PTSD or SUDS specialty type) clinics where a provider has, say, X intake slots per week, Y 'intervention/therapy session' slots per week, and Z total number of active clients in their caseload (who, obviously, have to fit in those Y session slots/week). The pattern I have seen from specialty clinics is that they can (a) funnel people into initial groups whose content is centered on that particular diagnosis (whether PTSD or SUDS) and (b) offer an evidence-based time-limited protocol treatment (e.g., CPT/PE, a predetermined-length IOP treatment program) and, if they complete the trial, great, they are 'forwarded' to an open-access clinic to work on everything else (or even PTSD and/or SUDS) if they were non-responders; (c) if the patient balks at the protocol, they 'forward' them to an open-access clinic for alternative approaches. So now they're 'my problem' as a non-specialty (generalist) clinic. Note that, as such, I have no one to 'forward' them to. I'm the last stop on the train ride. Some clients are seen weekly (typically for protocols (CPT/PE) or if they are particularly 'high-risk' for suicide/homicide), some clients are seen 'biweekly' (every two weeks), and some clients are seen monthly (mainly, because they say they can only attend monthly). To use a plumbing/hydrodynamic analogy, there is an 'intake/inlet' 'pipe' of a certain size (dedicated intake slots/wk), a 'reservoir' that can only hold so much water under so much pressure at any one point in time (e.g., number of clients in one's 'active' current psychotherapy caseload fitting into a certain number of therapy slots/wk), a certain amount of 'leakage' (e.g., no-shows, cancellations, passive dropouts from therapy), and (theoretically) an 'outflow' pipe (e.g., veterans who complete therapy or terminate (or, possibly, passively drop out from therapy). Whether 'passive dropouts from therapy' (which is, in my experience the main pathway for someone exiting one's caseload) fits into the 'reservoir' part of the analogy or the 'outflow pipe' part of the analogy is debatable. However, it stands to reason that the 'inflow' pipe into my caseload cannot be of infinitely large diameter or we're going to have an issue. There is a certain limited rate of 'clearance' of those patients who enter into my caseload. So, it is a very practical (but, as yet, unaddressed) problem to figure out what is a good rule of thumb regarding the appropriate/manageable number of new cases per week that the psychotherapy caseload of an individual provider can absorb before it becomes unmanageable and, for example, leadership would be called upon to hire another provider to handle the 'rate/flow' of new cases in any given area. Under this analogy, as I understand BHIP or PCMHI, there may be a 'larger inflow pipe' in the form of more intakes into your 'caseload' per unit time but this would be compensated by a correspondingly larger 'outflow pipe' in that you are doing briefer, more circumscribed interventions with a clearer/cleaner 'endpoint' (e.g., we're going to do 6 sessions of CBT-i for insomnia vs. okay, we're going to do a complete trauma/military history, differential diagnosis for PTSD/MDD/SUDS/personality disorder/traits/ cognitive case formulation including antecedents/triggers, negative automatic thoughts, intermediate beliefs, schemas, etc., oh yeah, and existential issues and failure-to-grow-up issues as well, leveraging MI strategies to move from pre-contemplation to contemplation, etc.).

It sounds like you and I are in the same type of clinic. This is a major issue. My colleagues and I in general MH are booked out into January-March for individual therapy and we are regularly using the Mission Act to try to get veterans seen. There is talk about doing time-limited evidence based treatment but it's not realistically what's happening because it is hardly plausible in this situation. We have so many new patients that we are functioning more as glorified case managers with no end in sight as new veterans continue to get out of the service and pour into PCMHI and onto us in BHIP. It is the same for me in that we have to take every presenting problem under the sun and many veterans are not ready/motivated to do an EBP or have more complex concerns than fits a manualized approach, and also are rarely dc'ed back to primary care. I know of one clinician who regularly discharges or terminates with patients, just to send them to another therapist, which makes no sense to me. It's a failing system as long as there is no true plan for discharging these patients or limiting the number of sessions they are allowed per year, and it's interesting, because when we send them into the community through the Mission Act, we do authorize a limited number of sessions.