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

[texanpsychdoc]

Did you ask the question or not, son?

lol..I was reinforcing my sentiment in regards to your statement. I am not advocating for working without some form of measurement or "accountability." I am looking to see what other employment environments would look like as there is far more than just RVUs that influence the quality of life in a work environment.

---

Members don't see this ad.

 

[erg923]

lol..I was reinforcing my sentiment in regards to your statement. I am not advocating for working without some form of measurement or "accountability." I am looking to see what other employment environments would look like as there is far more than just RVUs that influence the quality of life in a work environment.

I'm sorry. I do not really understand what you are advocating for at this time.

 

[texanpsychdoc]

I'm sorry. I do not really understand what you are advocating for at this time.

Who knows. I guess I am not making sense.

 

[Sanman]

I will echo what "Meh" said in a previous post, that a significant amount of my time at work is often dealing with red tape and organizational BS other than my actual job duties of seeing patients. That tends to be a significant source of stress for me. Being in a specialty clinic has its advantages compared to general mental health (which I've done at a previous VA). It's more-so the ancillary organizational bureaucratic BS that just gets to be too much.

I'm aware as I work at the VA. It's your choice, if you want to deal with red tape, increased productivity standards, insurance headaches, etc. That is why they call it "work" after all. I've been on the other side. Just a different set of headaches.

 

[Pragma]

The grass is always greener - just depends what headaches you want to tolerate.

 

[AbnormalPsych]

Exactly. VA isn't focused on making money through you. So low focus on that. But higher focus on the other stuff and the BS that comes along with it. If you go to another hospital system, sure there may be less red tape, more resources, but you will be expected to bring in the $. In big systems or group practice it is all trade offs and finding out what you can and want to tolerate.

 

[Fan_of_Meehl]

So is every employment environment for psychologists exactly the same? This isn't my first rodeo - I used to work in corporate America for a while, so I am used to the BS often observed in organizations. But I am curious about what other employment environments would look like compared to the VA.

One of the things I've noticed about working at the VA (especially as a provider and especially as a psychologist) is that it is a really stressful environment for conscientious people. What I mean is that you are constantly being nitpicked to death on little things that don't actually impact quality of patient care or outcomes in reality but which are extremely important and over-emphasized by the higher-ups and the army of people who are paid to comb through your chart and find 'deficiencies' that you need to address 'ASAP.' So, you're never going to feel like you're doing your job adequately (due to all the nagging negative critical feedback constantly), though you are in fact doing your job adequately (balancing out 'paying the piper' and 'treating the chart' to look 'good' to everyone while reserving enough time/energy to actually attend to the needs of your patients). I just rationalize it by saying that it's my job to expend somewhere between 60-80% of my time, energy and mental resources just to pay the 'BS Tax' in order to 'get to' the 20-40% of my remaining time/energy to expend on actual meaningful clinical interventions with living patients who are coming to me for my professional help. The really demoralizing thing that I have to keep mindfully acknowledging but redirecting my attention away from (to keep my sanity) is that, from a purely rational 'job performance (review) maximizing' perspective, I would get much better material results (and far less stress) by just adopting a 'play the game' strategy of just making my work 'look good' (by just juking the stats and 'treating the chart' and kissing up to the higher ups and pretending to believe things I don't actually believe) all the while not even expending that 20-40% of efforts on treating actual patients. Just one small example of these inefficiencies are the ungodly amounts of time that I have to expend making up for the incompetence and passive aggression of the medical support assistants (secretaries) who are constantly mis-scheduling and double-scheduling and failing to schedule/cancel/no-show patients in the chart. I have to spend time pre-examining my schedule out for a couple of weeks just to catch the constant scheduling errors, draft an email to my boss, politely hold my tongue whilst constantly checking on if the issue has been resolved or not (in the case of protocol treatments it is extremely important that they are) while my boss plays out the whole overly polite political respectful 'dance' of the bureaucracy, all the while, the problem of MSA performance is never addressed and they never improve. The amount of ridiculously patient and 'polite' and exceedingly careful/ginger hand-over-hand prompting I have to do with a passive aggressive MSA just to ensure that patients are properly scheduled and the MSA's errors corrected is mind-blowing. I'm 100% responsible for the outcome yet I actually have 0% authority to address the issue. I mean, if I just didn't care (about my patients getting adequate care), I'd just let them flounder (and possibly commit suicide). It's a grossly inefficient model of care (in terms of wasting provider time and resources) but, hey, it's probably the reason they have to retain so many of the psychologists that they do...so that's the other side of it. It's only made possible by the fact that--regardless of the 'state of the economy'--the organization (funded by Federal taxes) doesn't need to be efficient in its use of resources at all. And I'll bet you anything that when I get to work and open my emails up this morning there will be at least one to seven emails proclaiming the VA's 'powers that be's undying commitment to transforming us into a High Reliability Organization and 'blah-de-dee-blah-de-blah-de-pledge-your-commitment-to-serve-our-nation's-veterans-de-bladeddy-blah-wholehealth-de-bladedy-zerosuicide-de-we-are-all-in-this-together-nonsense.' It's all so tiresome.

 

[AcronymAllergy]

Agreed, it's generally a matter of trading off how you want your work/productivity to be tracked and what brands of potential administrative frustrations you want to deal with. Some people love VA, others hate it. Some love AMCs, others hate them. I certainly believe there are psychologists who can't stand the VA but enjoy their job at an AMC or other large or small hospital system, and vice-versa.

If you go the PP route, you'll either be accountable to the practice owner or yourself. You'll still have administrative BS, but it'll generally be your BS, which makes it more tolerable for some people. You have less security (and typically resources) but more freedom and control over your work.

 

[WisNeuro]

So is every employment environment for psychologists exactly the same? This isn't my first rodeo - I used to work in corporate America for a while, so I am used to the BS often observed in organizations. But I am curious about what other employment environments would look like compared to the VA.

You can go to PP, but it's eat what you kill. So, you are still beholden to some sort of productivity metric, just that you are the one dictating what and how much.

 

[Shiori]

These recent discussions highlight something I keep running into at my site. I keep asking questions about concrete goals and determining how "success" is measured. I get blank stares from leadership. I'll ask who is responsible for key patient care things like filling out FMLA paper. Nothing. I'll push for clarification on National vs local VA policy discrepancies. Nothing. It's really difficult to operate efficiently when the basic functions of my job have no guardrails until something messes up. It also means that decisions about what is right and wrong are up to the ever changing supervisors, so stability will never be a thing. I'm itching to "fix it" for my own sanity, but I get the sense that would be a thankless task if I could even get any movement on it.

I spoke with someone at the VISN level the other day about a new task, and I asked about general expectations. They were hoping that would be discussed among the providers. I understand hammering out the details is hard at that level, but I was basically asking "what is my job here?" and they didn't know. I knew things were chaotic, but not this chaotic. I'm still excited about my job, but I'm starting to see the cracks.

 

[Sanman]

These recent discussions highlight something I keep running into at my site. I keep asking questions about concrete goals and determining how "success" is measured. I get blank stares from leadership. I'll ask who is responsible for key patient care things like filling out FMLA paper. Nothing. I'll push for clarification on National vs local VA policy discrepancies. Nothing. It's really difficult to operate efficiently when the basic functions of my job have no guardrails until something messes up. It also means that decisions about what is right and wrong are up to the ever changing supervisors, so stability will never be a thing. I'm itching to "fix it" for my own sanity, but I get the sense that would be a thankless task if I could even get any movement on it.

I spoke with someone at the VISN level the other day about a new task, and I asked about general expectations. They were hoping that would be discussed among the providers. I understand hammering out the details is hard at that level, but I was basically asking "what is my job here?" and they didn't know. I knew things were chaotic, but not this chaotic. I'm still excited about my job, but I'm starting to see the cracks.

Don't overthink or try to fix the system. That is above your paygrade. You get an annual evaluation and a performance plan. Read what is in there. That is all you have to do. Middle managers can scream about other things all they want, but if it is not written down and signed it does not matter. I just got another email about a TMS training that needs to be done. Not worried about it. When it show up in my TMS with a date I will care. Till then, it does not matter.

You are concerned about doing a good job if not a great one. The concerns of your higher ups is simply that no one screw up and get them in trouble. They really don't care about good and great.

 

[Sanman]

One of the things I've noticed about working at the VA (especially as a provider and especially as a psychologist) is that it is a really stressful environment for conscientious people. What I mean is that you are constantly being nitpicked to death on little things that don't actually impact quality of patient care or outcomes in reality but which are extremely important and over-emphasized by the higher-ups and the army of people who are paid to comb through your chart and find 'deficiencies' that you need to address 'ASAP.' So, you're never going to feel like you're doing your job adequately (due to all the nagging negative critical feedback constantly), though you are in fact doing your job adequately (balancing out 'paying the piper' and 'treating the chart' to look 'good' to everyone while reserving enough time/energy to actually attend to the needs of your patients). I just rationalize it by saying that it's my job to expend somewhere between 60-80% of my time, energy and mental resources just to pay the 'BS Tax' in order to 'get to' the 20-40% of my remaining time/energy to expend on actual meaningful clinical interventions with living patients who are coming to me for my professional help. The really demoralizing thing that I have to keep mindfully acknowledging but redirecting my attention away from (to keep my sanity) is that, from a purely rational 'job performance (review) maximizing' perspective, I would get much better material results (and far less stress) by just adopting a 'play the game' strategy of just making my work 'look good' (by just juking the stats and 'treating the chart' and kissing up to the higher ups and pretending to believe things I don't actually believe) all the while not even expending that 20-40% of efforts on treating actual patients. Just one small example of these inefficiencies are the ungodly amounts of time that I have to expend making up for the incompetence and passive aggression of the medical support assistants (secretaries) who are constantly mis-scheduling and double-scheduling and failing to schedule/cancel/no-show patients in the chart. I have to spend time pre-examining my schedule out for a couple of weeks just to catch the constant scheduling errors, draft an email to my boss, politely hold my tongue whilst constantly checking on if the issue has been resolved or not (in the case of protocol treatments it is extremely important that they are) while my boss plays out the whole overly polite political respectful 'dance' of the bureaucracy, all the while, the problem of MSA performance is never addressed and they never improve. The amount of ridiculously patient and 'polite' and exceedingly careful/ginger hand-over-hand prompting I have to do with a passive aggressive MSA just to ensure that patients are properly scheduled and the MSA's errors corrected is mind-blowing. I'm 100% responsible for the outcome yet I actually have 0% authority to address the issue. I mean, if I just didn't care (about my patients getting adequate care), I'd just let them flounder (and possibly commit suicide). It's a grossly inefficient model of care (in terms of wasting provider time and resources) but, hey, it's probably the reason they have to retain so many of the psychologists that they do...so that's the other side of it. It's only made possible by the fact that--regardless of the 'state of the economy'--the organization (funded by Federal taxes) doesn't need to be efficient in its use of resources at all. And I'll bet you anything that when I get to work and open my emails up this morning there will be at least one to seven emails proclaiming the VA's 'powers that be's undying commitment to transforming us into a High Reliability Organization and 'blah-de-dee-blah-de-blah-de-pledge-your-commitment-to-serve-our-nation's-veterans-de-bladeddy-blah-wholehealth-de-bladedy-zerosuicide-de-we-are-all-in-this-together-nonsense.' It's all so tiresome.

Yes, but the MSA is likely a veteran and you are not. So really you are in the wrong and a communist to boot. Why do you hate America?

The VA, at large, seems to have little interest in comprehensive outpatient MH care and, frankly, does not do it well. The VA is better at managing severe disease (mental illness, substance abuse, PTSD, etc) and stabilizing someone to enter back into society. After that, there is little interest in doing more than throwing disability money at them and shoving them into a group. If the VA really wanted to throw money at the problem of outpatient MH care, then they would. Instead, it is a revolving door of overwhelmed providers and understaffed clinics across the board.

 

[texanpsychdoc]

One of the things I've noticed about working at the VA (especially as a provider and especially as a psychologist) is that it is a really stressful environment for conscientious people. What I mean is that you are constantly being nitpicked to death on little things that don't actually impact quality of patient care or outcomes in reality but which are extremely important and over-emphasized by the higher-ups and the army of people who are paid to comb through your chart and find 'deficiencies' that you need to address 'ASAP.' So, you're never going to feel like you're doing your job adequately (due to all the nagging negative critical feedback constantly), though you are in fact doing your job adequately (balancing out 'paying the piper' and 'treating the chart' to look 'good' to everyone while reserving enough time/energy to actually attend to the needs of your patients). I just rationalize it by saying that it's my job to expend somewhere between 60-80% of my time, energy and mental resources just to pay the 'BS Tax' in order to 'get to' the 20-40% of my remaining time/energy to expend on actual meaningful clinical interventions with living patients who are coming to me for my professional help. The really demoralizing thing that I have to keep mindfully acknowledging but redirecting my attention away from (to keep my sanity) is that, from a purely rational 'job performance (review) maximizing' perspective, I would get much better material results (and far less stress) by just adopting a 'play the game' strategy of just making my work 'look good' (by just juking the stats and 'treating the chart' and kissing up to the higher ups and pretending to believe things I don't actually believe) all the while not even expending that 20-40% of efforts on treating actual patients. Just one small example of these inefficiencies are the ungodly amounts of time that I have to expend making up for the incompetence and passive aggression of the medical support assistants (secretaries) who are constantly mis-scheduling and double-scheduling and failing to schedule/cancel/no-show patients in the chart. I have to spend time pre-examining my schedule out for a couple of weeks just to catch the constant scheduling errors, draft an email to my boss, politely hold my tongue whilst constantly checking on if the issue has been resolved or not (in the case of protocol treatments it is extremely important that they are) while my boss plays out the whole overly polite political respectful 'dance' of the bureaucracy, all the while, the problem of MSA performance is never addressed and they never improve. The amount of ridiculously patient and 'polite' and exceedingly careful/ginger hand-over-hand prompting I have to do with a passive aggressive MSA just to ensure that patients are properly scheduled and the MSA's errors corrected is mind-blowing. I'm 100% responsible for the outcome yet I actually have 0% authority to address the issue. I mean, if I just didn't care (about my patients getting adequate care), I'd just let them flounder (and possibly commit suicide). It's a grossly inefficient model of care (in terms of wasting provider time and resources) but, hey, it's probably the reason they have to retain so many of the psychologists that they do...so that's the other side of it. It's only made possible by the fact that--regardless of the 'state of the economy'--the organization (funded by Federal taxes) doesn't need to be efficient in its use of resources at all. And I'll bet you anything that when I get to work and open my emails up this morning there will be at least one to seven emails proclaiming the VA's 'powers that be's undying commitment to transforming us into a High Reliability Organization and 'blah-de-dee-blah-de-blah-de-pledge-your-commitment-to-serve-our-nation's-veterans-de-bladeddy-blah-wholehealth-de-bladedy-zerosuicide-de-we-are-all-in-this-together-nonsense.' It's all so tiresome.

You just described my day...plus the fact I have to fight with suicide prevention to tell them why simply increasing the frequency of visits in an of itself is not sufficient in addressing suicidality, and that using focused interventions (e.g., CAMS, CBT-SP, DBT) will be of significant importance. But anywho, I vibe with what you've said. It makes sense.

Don't overthink or try to fix the system. That is above your paygrade. You get an annual evaluation and a performance plan. Read what is in there. That is all you have to do. Middle managers can scream about other things all they want, but if it is not written down and signed it does not matter. I just got another email about a TMS training that needs to be done. Not worried about it. When it show up in my TMS with a date I will care. Till then, it does not matter.

You are concerned about doing a good job if not a great one. The concerns of your higher ups is simply that no one screw up and get them in trouble. They really don't care about good and great.

I have had TMS trainings like 100 days past due. At one point I had 30+ trainings that ranged from 20-90 days past due lol. I usually wait until I get a strongly worded email from our learning resource officer that copies my supervisor on it.

In general, I am appreciating everybody's views on the matter. They make sense, and something I will sit with and ponder some more.

 

[Shiori]

Don't overthink or try to fix the system. That is above your paygrade. You get an annual evaluation and a performance plan. Read what is in there. That is all you have to do. Middle managers can scream about other things all they want, but if it is not written down and signed it does not matter. I just got another email about a TMS training that needs to be done. Not worried about it. When it show up in my TMS with a date I will care. Till then, it does not matter.

You are concerned about doing a good job if not a great one. The concerns of your higher ups is simply that no one screw up and get them in trouble. They really don't care about good and great.

I'm working on it. It's hard to slam on the breaks when achievement has been the only measure of my success until recently. "Do it, and then do it again but better" year after year. The fact that they just want me to show up as a warm body feels like a trick.

 

[texanpsychdoc]

I'm working on it. It's hard to slam on the breaks when achievement has been the only measure of my success until recently. "Do it, and then do it again but better" year after year. The fact that they just want me to show up as a warm body feels like a trick.

I would like to provide some (unsolicited) advice on that: take a page from my book of ADHD and basically start off with good intentions, then flounder out about mid-part of your day and have a just f*** it attitude.

 

[Fan_of_Meehl]

These recent discussions highlight something I keep running into at my site. I keep asking questions about concrete goals and determining how "success" is measured. I get blank stares from leadership. I'll ask who is responsible for key patient care things like filling out FMLA paper. Nothing. I'll push for clarification on National vs local VA policy discrepancies. Nothing. It's really difficult to operate efficiently when the basic functions of my job have no guardrails until something messes up. It also means that decisions about what is right and wrong are up to the ever changing supervisors, so stability will never be a thing. I'm itching to "fix it" for my own sanity, but I get the sense that would be a thankless task if I could even get any movement on it.

I spoke with someone at the VISN level the other day about a new task, and I asked about general expectations. They were hoping that would be discussed among the providers. I understand hammering out the details is hard at that level, but I was basically asking "what is my job here?" and they didn't know. I knew things were chaotic, but not this chaotic. I'm still excited about my job, but I'm starting to see the cracks.

The specific alchemical magic that pervades the upper echelons of government-run healthcare environs is the miraculous feat of the complete dissociation of responsibility from authority.

 

[Shiori]

It all started with me wanting to know which clinical reminders to do as a psychologist. This was a surprisingly hard thing to get answered. I also wanted to know the no-show policy since Veterans can show up at any point during the day of their appointment and be seen. I wanted to know what they meant by "seen."

 

[Sanman]

I'm working on it. It's hard to slam on the breaks when achievement has been the only measure of my success until recently. "Do it, and then do it again but better" year after year. The fact that they just want me to show up as a warm body feels like a trick.

I mean I am still working on striking the perfect balance this many years later. I occasionally get the itch to be ambitious and realize most of what I do is pointless. I really just need to point those efforts toward PP and call it a day.

 

[Sanman]

It all started with me wanting to know which clinical reminders to do as a psychologist. This was a surprisingly hard thing to get answered. I also wanted to know the no-show policy since Veterans can show up at any point during the day of their appointment and be seen. I wanted to know what they meant by "seen."

Have you not mastered the fine arts of multi-tasking and bilocation? Don't worry, even if you did, the VA would not have two offices for you to see two people at the same time.

 

[texanpsychdoc]

It all started with me wanting to know which clinical reminders to do as a psychologist. This was a surprisingly hard thing to get answered. I also wanted to know the no-show policy since Veterans can show up at any point during the day of their appointment and be seen. I wanted to know what they meant by "seen."

Fun fact - I never do clinical reminders. I let nursing or social workers catch them.

 

[Shiori]

Fun fact - I never do clinical reminders. I let nursing or social workers catch them.

But the little clock is so red and angry. To be fair, it is always red and angry because there are always reminders due.

 

[Fan_of_Meehl]

Have you not mastered the fine arts of multi-tasking and bilocation? Don't worry, even if you did, the VA would not have two offices for you to see two people at the same time.

A mere parlor trick for a junior Time Lord, that one.

 

[texanpsychdoc]

But the little clock is so red and angry. To be fair, it is always red and angry because there are always reminders due.

It's okay...let it be angry and red. Give it space to do that. We validate that it can be angry and red. I will let it "sit with that."

 

[Sanman]

A mere parlor trick for a junior Time Lord, that one.

 

[cara susanna]

Yes, but the MSA is likely a veteran and you are not. So really you are in the wrong and a communist to boot. Why do you hate America?

The VA, at large, seems to have little interest in comprehensive outpatient MH care and, frankly, does not do it well. The VA is better at managing severe disease (mental illness, substance abuse, PTSD, etc) and stabilizing someone to enter back into society. After that, there is little interest in doing more than throwing disability money at them and shoving them into a group. If the VA really wanted to throw money at the problem of outpatient MH care, then they would. Instead, it is a revolving door of overwhelmed providers and understaffed clinics across the board.

Can you elaborate? I'm curious what you think the VA should be doing differently on that front (not disagreeing, just want to know more!) I have always thought that the VA did OPMH pretty well.

It all started with me wanting to know which clinical reminders to do as a psychologist. This was a surprisingly hard thing to get answered. I also wanted to know the no-show policy since Veterans can show up at any point during the day of their appointment and be seen. I wanted to know what they meant by "seen."

Really? I've been at four different VAs, and every single one had the 15 min NS policy.

 

[WisNeuro]

Can you elaborate? I'm curious what you think the VA should be doing differently on that front (not disagreeing, just want to know more!) I have always thought that the VA did OPMH pretty well.



Really? I've been at four different VAs, and every single one had the 15 min NS policy.

Likewise, also my experience in the VA in the past. Though our neuro appts generally had a 30 minute grace period.

 

[PsychPhDone]

Can you elaborate? I'm curious what you think the VA should be doing differently on that front (not disagreeing, just want to know more!) I have always thought that the VA did OPMH pretty well.



Really? I've been at four different VAs, and every single one had the 15 min NS policy.

VVC disconnected me automatically yesterday after 35 mins and no pt!

 

[cara susanna]

Also, can we talk about that stupid PACT ACT training that was completely outside of mental health's scope but we still had to do because CONGRESS DEMANDED IT?

 

[texanpsychdoc]

Likewise, also my experience in the VA in the past. Though our neuro appts generally had a 30 minute grace period.

If my appointment is scheduled for 60 min., I allow 10 min, if for 90 min., I allow for 20 min. Then I no show them.

 

[Shiori]

Our policy is we don't no-show until the end of the day. The Veteran can show up at any point during the day and we're required to see them. They will have to wait in the waiting room until the provider is free, but they must be seen at some point. This was clearly written with physicians in mind. I'm still not sure how this works in the actual world, but that is the policy. I was able to get clarification that we are only expected to do a risk assessment and reschedule, but this isn't written down anywhere.

 

[PsychPhDone]

Also, can we talk about that stupid PACT ACT training that was completely outside of mental health's scope but we still had to do because CONGRESS DEMANDED IT?

OMG I did this yesterday, like...very interesting and way way way out of scope. Two more trainings to do before I go on leave...

 

[AcronymAllergy]

We also typically counted a patient as a no-show if they were 15 minutes late for an hour-long appointment. I typically gave at least 30 minutes for my neuropsych appointments.

BUT, we were also told not to have the patient marked as a no-show until the end of the day. If the patient showed up at some other time during the day, we were told to try and see them.

Edit: Looks like our policy was the same as Shiori's. And yes, it caused the MH providers in particular a LOT of frustration.

 

[WisNeuro]

If my appointment is scheduled for 60 min., I allow 10 min, if for 90 min., I allow for 20 min. Then I no show them.

My basic neuro slots were for 4 hours, but I usually only needed 2.5-3 hours, so didn't really affect me too much to give a little leeway. Late shows were pretty rare, as opposed to just frank no-shows. I also usually had loads of free time in my VA work, so I'd rather just see a late patient out of sheer boredom.

 

[PsychPhDone]

Our policy is we don't no-show until the end of the day. The Veteran can show up at any point during the day and we're required to see them. They will have to wait in the waiting room until the provider is free, but they must be seen at some point. This was clearly written with physicians in mind. I'm still not sure how this works in the actual world, but that is the policy. I was able to get clarification that we are only expected to do a risk assessment and reschedule, but this isn't written down anywhere.

That is bonkers. I have zero free time on my clinical days.

 

[AcronymAllergy]

Our policy is we don't no-show until the end of the day. The Veteran can show up at any point during the day and we're required to see them. They will have to wait in the waiting room until the provider is free, but they must be seen at some point. This was clearly written with physicians in mind. I'm still not sure how this works in the actual world, but that is the policy. I was able to get clarification that we are only expected to do a risk assessment and reschedule, but this isn't written down anywhere.

Yep, the policy was the same at my last clinic.

 

[Shiori]

Also, can we talk about that stupid PACT ACT training that was completely outside of mental health's scope but we still had to do because CONGRESS DEMANDED IT?

It was so strange to go through. It was weeks from being due, and I was getting gentle nudges to complete it because of the high visibility.

 

[texanpsychdoc]

My basic neuro slots were for 4 hours, but I usually only needed 2.5-3 hours, so didn't really affect me too much to give a little leeway. Late shows were pretty rare, as opposed to just frank no-shows. I also usually had loads of free time in my VA work, so I'd rather just see a late patient out of sheer boredom.

For my testing cases I allocate 4 hours (including the interview), so I will likely allow for 30 min. before I no show that appointment. When I do no show someone, I call them after I've waited, then message our MSA to indicate them as no show, and I put in their no show note. Takes care of all the admin stuff up front. Then it's off my plate. I also have a decent amount of free time at the moment. Nobody wants treatment for SUD.

 

[WisNeuro]

For my testing cases I allocate 4 hours (including the interview), so I will likely allow for 30 min. before I no show that appointment. When I do no show someone, I call them after I've waited, then message our MSA to indicate them as no show, and I put in their no show note. Takes care of all the admin stuff up front. Then it's off my plate. I also have a decent amount of free time at the moment. Nobody wants treatment for SUD.

Not an issue anymore with me for clinical patients. I had zero clinical no-shows in 2022. IMEs are a different story, have plenty of those. But, I still get paid for the day, and they nearly all reschedule after that anyway, so I just get paid to catch up on other work those days.

 

[cara susanna]

I can't believe you all are expected to see patients if they show up at ANY TIME during the day of the appt. That would drive me bananas.

 

[Shiori]

I can't believe you all are expected to see patients if they show up at ANY TIME during the day of the appt. That would drive me bananas.

It's definitely not my favorite thing. Fortunately, it seems pretty rare for us. People are committed to not coming for their appointments.

 

[Fan_of_Meehl]

I can't believe you all are expected to see patients if they show up at ANY TIME during the day of the appt. That would drive me bananas.

Not only that, but we just got sent a Same Day Access for MH policy/memorandum to sign in blood that says that any veteran showing up at any clinic or calling in requesting to be seen must be seen for an 'evaluation' same day or at latest next working day. Which, as I have always maintained, essentially makes it, by policy, impossible to enforce any hypothetical 'unilateral' terminations of psychotherapy clients by a provider.

 

[texanpsychdoc]

Not an issue anymore with me for clinical patients. I had zero clinical no-shows in 2022. IMEs are a different story, have plenty of those. But, I still get paid for the day, and they nearly all reschedule after that anyway, so I just get paid to catch up on other work those days.

I need your contacts to get established with the IME stuff lol.

I can't believe you all are expected to see patients if they show up at ANY TIME during the day of the appt. That would drive me bananas.

I set firm boundaries - if they show up later in the day, I have a frank conversation about the importance of keeping their appointment, and that due to other schedule conflicts, I cannot accommodate people who show up when they want to. I get them in touch with my MSA to get them booked into my next available intake slot. For therapy clients, I have a 3 strike policy that I talk about in advanced before doing therapy - basically, if you no show me 3 appointments in a row, you go into "call in status" and they will not longer have a blocked date/time for their appointments. They need to call in on days they would like to see me and see if there is a spot that day, if not...they keep on calling into there is a slot I can get them into that same day. Then we have a conversation on no shows again.

 

[WisNeuro]

I need your contacts to get established with the IME stuff lol.


I set firm boundaries - if they show up later in the day, I have a frank conversation about the importance of keeping their appointment, and that due to other schedule conflicts, I cannot accommodate people who show up when they want to. I get them in touch with my MSA to get them booked into my next available intake slot. For therapy clients, I have a 3 strike policy that I talk about in advanced before doing therapy - basically, if you no show me 3 appointments in a row, you go into "call in status" and they will not longer have a blocked date/time for their appointments. They need to call in on days they would like to see me and see if there is a spot that day, if not...they keep on calling into there is a slot I can get them into that same day. Then we have a conversation on no shows again.

You can do IMEs without it, but the people I'm working with want to see that board certification first.

 

[AcronymAllergy]

I need your contacts to get established with the IME stuff lol.


I set firm boundaries - if they show up later in the day, I have a frank conversation about the importance of keeping their appointment, and that due to other schedule conflicts, I cannot accommodate people who show up when they want to. I get them in touch with my MSA to get them booked into my next available intake slot. For therapy clients, I have a 3 strike policy that I talk about in advanced before doing therapy - basically, if you no show me 3 appointments in a row, you go into "call in status" and they will not longer have a blocked date/time for their appointments. They need to call in on days they would like to see me and see if there is a spot that day, if not...they keep on calling into there is a slot I can get them into that same day. Then we have a conversation on no shows again.

Unfortunately, I have a feeling my last VA leadership would have seen the above as a method of withholding care from veterans, which is explicitly prohibited. They were very, very cautious about any such appearances. They also made the no-show policy (i.e., waiting until the end of the day to mark the appointment as a no-show and enter the chart note) sound like it was VA-wide, although that doesn't seem to be the case.

We also had the same policy mentioned above about walk-ins requesting care (i.e., that they had to have contact with a licensed independent provider that day or, if appropriate, the next day). That one, I believe, is actually nationally mandated.

It amazes me some of the things VA and its staff are required to do relative to other hospitals/healthcare systems. But to be fair, there are pros working in the VA as well. Not having to worry about billing insurance being a huge one.

 

[AbnormalPsych]

We also had the same policy mentioned above about walk-ins requesting care (i.e., that they had to have contact with a licensed independent provider that day or, if appropriate, the next day). That one, I believe, is actually nationally mandated.

It amazes me some of the things VA and its staff are required to do relative to other hospitals/healthcare systems. But to be fair, there are pros working in the VA as well. Not having to worry about billing insurance being a huge one.

Maybe the VA would be surpirsed to learn there are licensed providers in the emergency room. Where same day service and safety checks are already expected and built in. Win win.

 

[Sanman]

Can you elaborate? I'm curious what you think the VA should be doing differently on that front (not disagreeing, just want to know more!) I have always thought that the VA did OPMH pretty well.



Really? I've been at four different VAs, and every single one had the 15 min NS policy.

In practice, a lot. The biggest thing the VA needs to change:

1. More stringent access to outpt care so patients are more responsible for their care (I am sure I will get cancellations tomorrow 5 min before their appt times) and PCPs stop referring every little issue.

2. Clearer pathways through care and transfers of care. There is a lot of redundancy between clinics and locations (hospital vs CBOC) that is not necessary.

3. More midlevel managers, particularly for specialty care areas. Women's Clinic, Geriatric care, etc are often ignored.

4. Better training for primary care staff and increased focus on case management in PC-MHI.

5. Increased telehealth access and revision of job responsibilities with that increase in telehealth.

6. More support staff

I could go on, but you get the idea. The issue I have with the outpt care is that availability is so variable based on location and communication is poor, particularly between locations. With the increased use of telehealth there should be improved communication and better case management. I see this being done more successfully in the hospital or inpatient environment than elsewhere. That said, given the ability of the VA to get around some telehealth rules, they really need to rethink whether the want regional hubs for telehealth care that are more cohesively run.

 

[texanpsychdoc]

You can do IMEs without it, but the people I'm working with want to see that board certification first.

Give me until 2023 and I can make that happen.

Unfortunately, I have a feeling my last VA leadership would have seen the above as a method of withholding care from veterans, which is explicitly prohibited. They were very, very cautious about any such appearances. They also made the no-show policy (i.e., waiting until the end of the day to mark the appointment as a no-show and enter the chart note) sound like it was VA-wide, although that doesn't seem to be the case.

We also had the same policy mentioned above about walk-ins requesting care (i.e., that they had to have contact with a licensed independent provider that day or, if appropriate, the next day). That one, I believe, is actually nationally mandated.

It amazes me some of the things VA and its staff are required to do relative to other hospitals/healthcare systems. But to be fair, there are pros working in the VA as well. Not having to worry about billing insurance being a huge one.

So, this was something I learned from my former chief at a previous VA. It was his own technique that he taught me, and it has worked wonders. alternatively, we have a same-day access team that addresses the issue of making sure veterans are seen same day, so that's how I can use my approach.

Also, I would disagree with the sentiment that this approach is a "withholding of care." An example of that would be just flat out telling them after 3 no shows, I won't see them anymore. That's not what's being done here. It's reinforcing personal responsibility on the veteran's end, and it ensures I am not working harder than they are in treatment.

 

[cara susanna]

Give me until 2023 and I can make that happen.



So, this was something I learned from my former chief at a previous VA. It was his own technique that he taught me, and it has worked wonders. alternatively, we have a same-day access team that addresses the issue of making sure veterans are seen same day, so that's how I can use my approach.

We also have access staff whose job it is to see people on a walk-in basis. Seems to solve that problem pretty nicely.

 

[texanpsychdoc]

We also have access staff whose job it is to see people on a walk-in basis. Seems to solve that problem pretty nicely.

Indeed.

 

[Fan_of_Meehl]

Maybe the VA would be surpirsed to learn there are licensed providers in the emergency room. Where same day service and safety checks are already expected and built in. Win win.

Agreed.

Logic would suggest that it's either:

(a) a bona fide psychiatric emergency (SI/HI) or

(b) it's not.

In case (a), even if you see an outpatient provider, you're likely just going to the ER anyway to be admitted...could have gone there in the first place.

In case (b), it can wait until your next scheduled appointment.