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

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
To add on, these are requests that each facility makes to their VISN/VACO/OMHSP so the chief goes to the ACOS who goes to the hospital leadership and so on up the food chain. So it’s operating differently than recruitment incentives for a specific position like neuropsych but not BHIP.

From what I’ve gathered, data to support the following can lead to approval:
- areas that can show they have always struggled with recruitment (e.g., rural areas that are always at a suggested staffing FTE deficit) even though tenure may be decent or even above average
- significant loss of staff post-COVID without adequate replacement (e.g., how many recent postings went without a hire, posting without a qualified candidate even applying, times when a selected candidate backed out, etc)
- local market rates at other hospitals/institutions are significantly higher than the VA even after locality adjustment

While I’ve never heard any ‘VA leaders’ talk about raises for psychologists (or other mental health staff) across the board, many facilities are going in one or more of these directions currently. It’s just that the facilities that have gotten this approval already are usually facilities with competent leadership who are trying to stay ahead of the game. Maybe trickle down VA economics works better than in the real world.

Either that or we’ll get replaced by mid-levels every time somebody leaves and rather than reposting as a PhD/PsyD position, these get more seemlessly transitioned into PhD and MSW/LPC/MFT eligible gigs, which is currently a major hassle to reclassify due to bureaucratic inertia, which then plays an oversized role in keeping PhD/PsyD positions at current levels.
Thank you for the additional info. Unfortunately, our hospital is run by social workers (both ACOS and the associate are LCSW's) who, frankly, want psychology weak so that they can politically dominate mental health. They also occupy all the 'program manager' (and just about every other non-clinical 'leadership') post in the organization. They wouldn't lift a finger to help recruit and retain competent psychologists. But it was a nice thought anyway and it's nice to know about what is going on in other parts of the organization.

The basic breakdown at this point is that nearly every single clinical (provider with a mental health caseload who sees patients, i.e., 'clinical mules') position is filled by a doctoral-level psychologist. Nearly every single 'leadership/admin' or program manager position is filled by a member of the local social work mafia.

Members don't see this ad.
 
  • Haha
Reactions: 1 user
Anyone at a VA hospital that has special pay for psychologists as a retention incentive? How much is your special pay rate, and does it make it more worth it for you?

We just got one, it was like an 8% increase IIRC. I wasn't really angling for it but I'm also not complaining, lol.
 
  • Like
Reactions: 1 users
We just got one, it was like an 8% increase IIRC. I wasn't really angling for it but I'm also not complaining, lol.
Still trying to get my STEP 10 increase, being held up in payroll and it looks to only be like 3%.
 
Members don't see this ad :)
We just got one, it was like an 8% increase IIRC. I wasn't really angling for it but I'm also not complaining, lol.
With inflation finally starting to dip under 7% again these last couple of months, maybe you’ll actually feel a small difference in a few months
 
  • Like
Reactions: 2 users
Anyone at a VA hospital that has special pay for psychologists as a retention incentive? How much is your special pay rate, and does it make it more worth it for you?
At my VA, the psychologists recently received a 65% SSR increase. So, quite a jump in salary and it makes me more inclined to make all of those required No Show calls :D! I work in a large metro area and I think the local VA's are trying to offer pay that is competitive with Kaiser and other local hospitals.
 
  • Like
  • Wow
Reactions: 6 users
Looks like we're getting a 20% bump here too.
 
  • Love
  • Like
Reactions: 3 users
Q: I'm applying to a job on USAJobs (not VA, but I figured some of y'all could answer my question) and it's asking for my resume. Would it be better to upload a shorter "traditional" resume or a full CV?
 
Q: I'm applying to a job on USAJobs (not VA, but I figured some of y'all could answer my question) and it's asking for my resume. Would it be better to upload a shorter "traditional" resume or a full CV?

Full CV
 
  • Like
Reactions: 9 users
To add on, these are requests that each facility makes to their VISN/VACO/OMHSP so the chief goes to the ACOS who goes to the hospital leadership and so on up the food chain. So it’s operating differently than recruitment incentives for a specific position like neuropsych but not BHIP.

From what I’ve gathered, data to support the following can lead to approval:
- areas that can show they have always struggled with recruitment (e.g., rural areas that are always at a suggested staffing FTE deficit) even though tenure may be decent or even above average
- significant loss of staff post-COVID without adequate replacement (e.g., how many recent postings went without a hire, posting without a qualified candidate even applying, times when a selected candidate backed out, etc)
- local market rates at other hospitals/institutions are significantly higher than the VA even after locality adjustment

While I’ve never heard any ‘VA leaders’ talk about raises for psychologists (or other mental health staff) across the board, many facilities are going in one or more of these directions currently. It’s just that the facilities that have gotten this approval already are usually facilities with competent leadership who are trying to stay ahead of the game. Maybe trickle down VA economics works better than in the real world.

Either that or we’ll get replaced by mid-levels every time somebody leaves and rather than reposting as a PhD/PsyD position, these get more seemlessly transitioned into PhD and MSW/LPC/MFT eligible gigs, which is currently a major hassle to reclassify due to bureaucratic inertia, which then plays an oversized role in keeping PhD/PsyD positions at current levels.
And to further add on to this, some facilities choose to exclude virtual employs from receiving it, while other facilities allow virtual employees to receive it. There are more complexities to this as well, regarding your local VA and your employeeing VA and where each stand on the issue.
 
  • Like
Reactions: 2 users
I have an interview for another VA position. It's weird actually getting to consider whether I want the position without the pressure of it being career delaying/ending if I say no. Being a grownup psychologist is very different.
 
  • Like
Reactions: 7 users
Our facility has increased pressure for providers to complete the Columbia because our main facility has a much higher completion rate (since they hand out it out in the waiting room, which we refuse to do here). So annoying, especially since I know the Columbia isn't even good at predicting suicide.
 
  • Like
Reactions: 3 users
Members don't see this ad :)
It is a big deal here too. We get weekly emails. They go over it in the BHIP meetings every week as well. We have stickers in our office reminding us to do them. It's...a lot.
 
  • Like
Reactions: 1 user
I have an interview for another VA position. It's weird actually getting to consider whether I want the position without the pressure of it being career delaying/ending if I say no. Being a grownup psychologist is very different.
Good luck! The market seems tilted very heavily towards employees, rather than employers, right now so make sure you're appropriately picky and try to land in the best possible spot if a move is a good fit.

And hey, you can even accept, go through all the onboarding steps and back out when you finally get the firm offer and basically be 100% good career-wise.
 
  • Like
Reactions: 1 users
Our facility has increased pressure for providers to complete the Columbia because our main facility has a much higher completion rate (since they hand out it out in the waiting room, which we refuse to do here). So annoying, especially since I know the Columbia isn't even good at predicting suicide.
We (yes, even us neuropsychologists) were required to do them in all evals if one hadn't been done in, I think, the last 12 months. There were a few other stipulations as well. I basically just ended up adding the first two questions of the C-SSRS into my interview; if they were denied, I moved on. If they were endorsed, I went through the rest of it. Either way, I was able to complete the reminder.

Although it's less awkward/painstsaking to ask about that sort of thing in the context of a one-off neuropsych eval than it is at the beginning or end of every single therapy appointment.
 
We (yes, even us neuropsychologists) were required to do them in all evals if one hadn't been done in, I think, the last 12 months. There were a few other stipulations as well. I basically just ended up adding the first two questions of the C-SSRS into my interview; if they were denied, I moved on. If they were endorsed, I went through the rest of it. Either way, I was able to complete the reminder.

Although it's less awkward/painstsaking to ask about that sort of thing in the context of a one-off neuropsych eval than it is at the beginning or end of every single therapy appointment.

Yeah, we have to do them during psych testing appts and that drives me bananas, too.
 
Our facility has increased pressure for providers to complete the Columbia because our main facility has a much higher completion rate (since they hand out it out in the waiting room, which we refuse to do here). So annoying, especially since I know the Columbia isn't even good at predicting suicide.
The Church of Suicide Prevention strikes again!

If you forget to do your C-SSRS, a gaggle of red-robed priests will leap out from behind the furniture in your office--Monty Python style--and loudly announce that...

"NO ONE EXPECTS THE CHURCH OF SUICIDE PREVENTION!!!!!!!!!"

There is no 'Comfy Chair,' though...alas
 
Last edited:
  • Like
  • Haha
Reactions: 3 users
Okay, so I had posted a little while back about a situation where another VA psychologist (in the same clinic) was having interns write 'my' treatment plans on my behalf with patients whom I have never assessed/evaluated and doing so without my consent, input, or awareness. I raised the obvious objections and he backed off the first time. Just happened again. I promptly emailed him, cc'd our supervisor requesting that I had no intention of signing (as my own) a written treatment plan on a patient I have never seen/evaluated where the intern had listed the sole objective as 'my' objective with my name as 'responsible person' complete with treatment plan details (specific protocol choice to be utilized (for which he is likely a poor fit based on a quick record review) with my name as the sole 'treatment team member.' He fired back saying that the plan will stay as it is and that I will see the person (answering the consult) and then if *I* wanted to change, rewrite, or start a new plan at that time I was free to do so. I wrote back basically staying firm in my position that I thought it was inappropriate for one LIP to, on their own initiative, write a specific treatment plan on behalf of another LIP without their knowledge, consent, or awareness (or even having seen the patient) and that I would not be signing it. Three minutes later he wrote back that they would be removing 'my' objective from the current 'plan.'

This is ridiculous. As best I can tell, this psychologist doesn't want to have to take these cases into their caseload (by default, as they are the supervising psychologist) when the intern finishes up their rotation so the intern is just 'tagging' another provider with a specific treatment plan (written FOR the provider with that provider listed as 'responsible person' even when that provider has never even seen the patient).

They have entered a consult so I am happy to evaluate and go from there. The issue is ***I*** write my OWN treatment plans only after evaluating/meeting with patients and engaging in the legally necessary process of informed consent and getting their agreement. It is, in my opinion, malpractice for ME (or anyone else on my behalf) to write and enter into the medical record a specific treatment plan under my name without me actually doing an evaluation/encounter with the patient first.

The other psychologist (or his intern) can feel free to enter an 'objective' under THEIR name in THEIR plan to 'enter a consult to Dr. X to evaluate for therapy Y' but then I (Dr. X) will meet with and assess the patient for suitability for this particular protocol and go from there.

I found myself having to try to explain to the intern (who was 'sent' to ask me for an explanation for why I am not okay signing 'my' plan that they penned for me) why I am not going to sign a treatment plan for a specific patient I have never seen/ evaluated. I mean, I think it is as simple as it is standard of care for a provider to SEE (assess) a patient prior to formulating a specific treatment plan with that patient. I think I have heard of psychologists losing their licenses or getting in big trouble with their board for writing treatment plans without seeing the patients first. You just don't do that. I know that in medicine it would be malpractice or beneath standard of care for the physician to write a treatment plan (prescribe meds, therapy) for a patient without evaluating them first and I know that it is considered standard of care for people to write their OWN treatment plans and not be expected to be okay with other LIP's writing their treatment plans for them against their objections.

Are there any particular VA regs or policies and procedures that specifically address this in writing? I am starting to get really angry and am anticipating we may have a fight up and down the ladder administratively on this but I am not willing to back down and want to escalate to the Chief of Staff if I have to. This is ridiculous. I don't go around writing treatment plans 'for' other providers over their objections and expect them to sign/ agree to the plan that I wrote 'for' them.
 
  • Like
  • Love
Reactions: 3 users
Are there any particular VA regs or policies and procedures that specifically address this in writing?
Sorry this is still happening, that’s madness.

I’m not aware of any specific guidelines or policies at the global level.

However, your clinic should have an SOP related to the disposition of patients buried in a shared drive or a physical binder somewhere since there should be a process for situations such as when a provider leaves the VA and has a panel for patients that need to be reassigned.

If you’re in a BHIP setting, perhaps you can locate your operations manual or similar documents.

This SOP should also delegate who is ultimately responsible for making these decisions and whether this scenario falls under this or another category.

Another route could be discussing this with the training director since this is obviously a poor practice that is being taught to an intern.

Hopefully one of these route makes sense based on how politics operate locally at your facility and who can ultimately make changes.
 
  • Like
Reactions: 1 users
Sorry this is still happening, that’s madness.

I’m not aware of any specific guidelines or policies at the global level.

However, your clinic should have an SOP related to the disposition of patients buried in a shared drive or a physical binder somewhere since there should be a process for situations such as when a provider leaves the VA and has a panel for patients that need to be reassigned.

If you’re in a BHIP setting, perhaps you can locate your operations manual or similar documents.

This SOP should also delegate who is ultimately responsible for making these decisions and whether this scenario falls under this or another category.

Another route could be discussing this with the training director since this is obviously a poor practice that is being taught to an intern.

Hopefully one of these route makes sense based on how politics operate locally at your facility and who can ultimately make changes.
Thanks! These suggestions are helpful.

However there are two VERY SEPARABLE issues involved. a) continuity of care/ transfer issue and b) one provider formulating, completing, and entering into the medical record a specific treatment plan on behalf of another provider (without their consent) with that provider's name attached to it as the 'responsible person' as if it was their plan and then insisting they sign it even though they have never even seen the patient.

I'm glad you brought up politics because, frankly, that is likely why this individual provider is acting in such a bold manner repeatedly doing this although I directly objected to the first instance. Our supervisor, behind closed doors, agreed with me that it was inappropriate and he ultimately did back off. But when ANOTHER (2nd provider at a CBOC in an entirely different area) did exactly the same thing, I confronted them on it, and then they apologized and removed it from the record I went to the same supervisor and basically said, 'look...this has happened twice now with two separate providers...can we PLEASE just address the issue openly in a service/program meeting so everyone is on the same page that this is not appropriate as a practice?' She said, 'just let me know if it happens again.' Well, it happened again with the first provider today.

I should also add for context that it is a PCT (specialty clinic for PTSD) and we have a process whereby someone does an intake, then the patient is sent to an orientation group (describing treatments potentially offered in the clinic) and then they go back to the provider who did the intake for 'treatment planning.' And there is a local (perhaps national?) policy that the 'treatment plan' in MHS (which prints into CPRS) has to be 'finalized' no later than the 'third' meeting with the veteran (holy session #3). So, people are apparently under pressure to 'finalize' a 'treatment plan' at that session. What I typically do, which I think is responsible, is at that point (since I did the intake and they are in my caseload at that point) I will just enter a generic treatment plan (MY treatment plan) for them to see me for CBT for PTSD (which encompasses most treatment pathways in the clinic), then enter a consult for, say, CBT-i if I am not trained in that and then that provider can evaluate for suitability for CBT-i and choose to add that treatment component or not. But I do not play a game of 'tag, you're it' using Mental Health Suite and treatment plans. Again, you cannot write a treatment plan for a patient you have never even evaluated.

On the continuity of care / 'Red Rover, Red Rover, I'm sending this patient right over to your caseload from mine' issue...I don't really care. They can refer half their caseload to me for all I care for me to competently evaluate and treat. But I am simply not okay with them pre-emptively writing 'my' treatment plan 'for' me without my permission on a patient I haven't even evaluated and expecting me to sign it as 'my' plan. If this is all of a sudden 'allowed' and becomes a common practice, it will be pandemonium. Imagine opening up CPRS every morning and seeing several alerts indicating that your signature is needed on 'your' treatment plan for patient X whom you have never even evaluated or seen before in your life just because someone thinks you should do a specific treatment with them. It is totally bypassing the entire 'consult request' aspect of care. Sorry, just venting.
 
  • Like
Reactions: 1 users
I'd stick with the non-standard of care and liability arguments because a step or two removed from the clinical work is some admin who hates liability and they will not want to deal with it if it goes sideways, especially if you put it in writing and word the inquiry correctly.

When I ran into a political mess at a prior employer with staff doing things that impacted my work, I dropped a note to the legal department to give them "a heads-up" about clinicians doing something outside of their scope and they shut that ish down quickly. The supervisor for those (mid-level) clinicians got shutdown too because legal had a direct line to the Chair, and legal had the final say if they could provide a decent reason to the Chair. I had a direct line to legal because I handled some stuff for them when they were in a pinch, so I knew they'd back me even if the mid-level manager put 2 and 2 together.

I know the VA isn't quite setup like an AMC, but there may be an opportunity to go over your boss's head to the Chief/similar and they likely would pause once they heard about the increased liability bc administrators are allergic to increased liability anything. Politically you need to decide if it is worth stepping on the toes of your boss (even if you "anonymously" let the Chief/leadership know). You could float the idea to your boss and get their blessing, but I'd guess they'd first put you off and try and wait you out, which won't solve anything. Once you help them see that a non-answer could be more of a problem, then you'd probably get the okay to float your concern up the chain. You & your boss want to "clarify" your position because you both "see the bigger picture" and you don't want anyone to do anything that would cause the dept/unit/etc. possible problems.
 
  • Like
Reactions: 2 users
I'd stick with the non-standard of care and liability arguments because a step or two removed from the clinical work is some admin who hates liability and they will not want to deal with it if it goes sideways, especially if you put it in writing and word the inquiry correctly.

When I ran into a political mess at a prior employer with staff doing things that impacted my work, I dropped a note to the legal department to give them "a heads-up" about clinicians doing something outside of their scope and they shut that ish down quickly. The supervisor for those (mid-level) clinicians got shutdown too because legal had a direct line to the Chair, and legal had the final say if they could provide a decent reason to the Chair. I had a direct line to legal because I handled some stuff for them when they were in a pinch, so I knew they'd back me even if the mid-level manager put 2 and 2 together.

I know the VA isn't quite setup like an AMC, but there may be an opportunity to go over your boss's head to the Chief/similar and they likely would pause once they heard about the increased liability bc administrators are allergic to increased liability anything. Politically you need to decide if it is worth stepping on the toes of your boss (even if you "anonymously" let the Chief/leadership know). You could float the idea to your boss and get their blessing, but I'd guess they'd first put you off and try and wait you out, which won't solve anything. Once you help them see that a non-answer could be more of a problem, then you'd probably get the okay to float your concern up the chain. You & your boss want to "clarify" your position because you both "see the bigger picture" and you don't want anyone to do anything that would cause the dept/unit/etc. possible problems.
Good input (thanks!). I think I'll try to find a few minutes to examine the bylaws of the medical staff to see if there is anything in there that directly addresses any of these issues. I am pretty sure that it's not okay for one LIP to just (against the literal OBJECTIONS of a second LIP) author the 'treatment plan' for the second LIP who has never even seen the patient. Probably at least a line or two commenting on the following process: evaluate --> plan --> informed consent --> write treatment plan --> implement treatment plan.

One of the things that really irks me about this is that Psychologist A is directing the intern to finalize a treatment plan in the medical record stating that Psychologist B (me) IS going to implement Therapy Protocol Y with this patient and then going ahead and entering a consult to me to meet with the patient in two weeks to--ostensibly--examine the patient and determine the suitability of the protocol for that particular patient. It is completely ass backwards and makes a mockery of the entire process. Especially since there are serious 'rule outs' and contraindications that are commonly encountered vis-a-vis evaluating for suitability for this particular protocol. If the intern has decided--on my behalf--that I need to author (but he'll do it for me) a treatment plan to implement the protocol with this patient, then why the hell even enter a consult for me to evaluate him for suitability of offering that protocol to the patient? They don't need me at all. Or the consult. They may as well go ahead and forge my signature. They obviously already know what the results of my consult will be, what my decision will be, and what I'm going to 'decide' to 'write' in 'my' treatment plan for the patient. I should tongue in cheek enter an OIG complaint alleging 'waste' (maybe 'fraud') in that they are entering an actual consult and wasting everyone's time and clinical resources since they already apparently know what my determination/ decision will be.
 
  • Like
Reactions: 2 users
And there is a local (perhaps national?) policy that the 'treatment plan' in MHS (which prints into CPRS) has to be 'finalized' no later than the 'third' meeting with the veteran
Based on some of my own interactions with MH tx plans and its implementation, while this indeed appears to be a national level policy, I strongly suspect there is no specific/automatic mechanism to determine whether this is done or not by a specific session # beyond checking each case by hand.

There's likely a way to automatically pull data on whether a treatment plan has ever been entered for a patient but this is one of those 'we probably should be able to see within 2 clicks whether or not this is happening' yet the mechanism (e.g., embedded health factor) that automatically codes for the session # during which the tx plan was entered probably does not exist and likely cannot be coded into CPRS.

Nor can the system differentiate between veteran engagement with different clinics (BHIP vs PCT vs ADTP vs PRRC) where a tx plan may be written or between different /simultaneous/subsequent episodes of care, which is why I largely let formal tx plans slip, except when going into CARF reaccreditation season, where charts will actually be randomly pulled for review.
One of the things that really irks me about this is that Psychologist A is directing the intern to finalize a treatment plan in the medical record stating that Psychologist B (me) IS going to implement Therapy Protocol Y with this patient and then going ahead and entering a consult to me to meet with the patient in two weeks to--ostensibly--examine the patient and determine the suitability of the protocol for that particular patient. It is completely ass backwards and makes a mockery of the entire process.
Beyond the provider to provider norms that this is violating, this is also a clear example of not respecting patient autonomy and allowing for their collaborative input upon transfer of care.
 
  • Like
Reactions: 1 user
Based on some of my own interactions with MH tx plans and its implementation, while this indeed appears to be a national level policy, I strongly suspect there is no specific/automatic mechanism to determine whether this is done or not by a specific session # beyond checking each case by hand.

There's likely a way to automatically pull data on whether a treatment plan has ever been entered for a patient but this is one of those 'we probably should be able to see within 2 clicks whether or not this is happening' yet the mechanism (e.g., embedded health factor) that automatically codes for the session # during which the tx plan was entered probably does not exist and likely cannot be coded into CPRS.

Nor can the system differentiate between veteran engagement with different clinics (BHIP vs PCT vs ADTP vs PRRC) where a tx plan may be written or between different /simultaneous/subsequent episodes of care, which is why I largely let formal tx plans slip, except when going into CARF reaccreditation season, where charts will actually be randomly pulled for review.

Beyond the provider to provider norms that this is violating, this is also a clear example of not respecting patient autonomy and allowing for their collaborative input upon transfer of care.
To be completely fair, the veteran did 'choose' (i.e., pick from a 'menu' of 'options') that he was interested in this particular adjunctive treatment. But it is not a first-line treatment for PTSD (like PE/CPT/EMDR) and the veteran has not been encouraged to try PE/CPT/EMDR first (which targets ALL of the symptoms of PTSD. Veteran is 70+ years old, with neurocognitive disorder, who has never had any therapy of any kind. If you look at the VA/DoD treatment guidelines for PTSD, they need to be encouraged to do a first-line treatment like the aforementioned. What happened was the veteran expressed interest in the therapy and the 'plan' by Provider A at that point was to enter a consult request for me to evaluate the veteran for suitability for that therapy (and there are a LOT of rule outs, many people aren't appropriate for it).
 
Okay, so I had posted a little while back about a situation where another VA psychologist (in the same clinic) was having interns write 'my' treatment plans on my behalf with patients whom I have never assessed/evaluated and doing so without my consent, input, or awareness. I raised the obvious objections and he backed off the first time. Just happened again. I promptly emailed him, cc'd our supervisor requesting that I had no intention of signing (as my own) a written treatment plan on a patient I have never seen/evaluated where the intern had listed the sole objective as 'my' objective with my name as 'responsible person' complete with treatment plan details (specific protocol choice to be utilized (for which he is likely a poor fit based on a quick record review) with my name as the sole 'treatment team member.' He fired back saying that the plan will stay as it is and that I will see the person (answering the consult) and then if *I* wanted to change, rewrite, or start a new plan at that time I was free to do so. I wrote back basically staying firm in my position that I thought it was inappropriate for one LIP to, on their own initiative, write a specific treatment plan on behalf of another LIP without their knowledge, consent, or awareness (or even having seen the patient) and that I would not be signing it. Three minutes later he wrote back that they would be removing 'my' objective from the current 'plan.'

This is ridiculous. As best I can tell, this psychologist doesn't want to have to take these cases into their caseload (by default, as they are the supervising psychologist) when the intern finishes up their rotation so the intern is just 'tagging' another provider with a specific treatment plan (written FOR the provider with that provider listed as 'responsible person' even when that provider has never even seen the patient).

They have entered a consult so I am happy to evaluate and go from there. The issue is ***I*** write my OWN treatment plans only after evaluating/meeting with patients and engaging in the legally necessary process of informed consent and getting their agreement. It is, in my opinion, malpractice for ME (or anyone else on my behalf) to write and enter into the medical record a specific treatment plan under my name without me actually doing an evaluation/encounter with the patient first.

The other psychologist (or his intern) can feel free to enter an 'objective' under THEIR name in THEIR plan to 'enter a consult to Dr. X to evaluate for therapy Y' but then I (Dr. X) will meet with and assess the patient for suitability for this particular protocol and go from there.

I found myself having to try to explain to the intern (who was 'sent' to ask me for an explanation for why I am not okay signing 'my' plan that they penned for me) why I am not going to sign a treatment plan for a specific patient I have never seen/ evaluated. I mean, I think it is as simple as it is standard of care for a provider to SEE (assess) a patient prior to formulating a specific treatment plan with that patient. I think I have heard of psychologists losing their licenses or getting in big trouble with their board for writing treatment plans without seeing the patients first. You just don't do that. I know that in medicine it would be malpractice or beneath standard of care for the physician to write a treatment plan (prescribe meds, therapy) for a patient without evaluating them first and I know that it is considered standard of care for people to write their OWN treatment plans and not be expected to be okay with other LIP's writing their treatment plans for them against their objections.

Are there any particular VA regs or policies and procedures that specifically address this in writing? I am starting to get really angry and am anticipating we may have a fight up and down the ladder administratively on this but I am not willing to back down and want to escalate to the Chief of Staff if I have to. This is ridiculous. I don't go around writing treatment plans 'for' other providers over their objections and expect them to sign/ agree to the plan that I wrote 'for' them.
Well, that's the dumbest thing I have heard in a while. Why not just let people know that the intern will be providing care and the next intern taking over. What they are doing makes no sense and is completely foiled by you not signing off or writing an addendum in the chart saying the same.
 
  • Like
Reactions: 3 users
This is the kind of upside down world when the treatment plan document becomes more important than the treatment. The creation of a “required treatment plan document” is a way for administrators to gain power over their minions. I really have no belief that a document will make sure that a psychologist or anyone else for that matter actually helps their patient. Who am I writing this plan for anyway? The patient and I know what we are working on and we typically review and discuss at almost every single session. Sorry, don’t have time to write that all down for some third party. Maybe I could hire a fourth party to write up a plan for the third party.
 
  • Like
Reactions: 1 users
This is the kind of upside down world when the treatment plan document becomes more important than the treatment. The creation of a “required treatment plan document” is a way for administrators to gain power over their minions. I really have no belief that a document will make sure that a psychologist or anyone else for that matter actually helps their patient. Who am I writing this plan for anyway? The patient and I know what we are working on and we typically review and discuss at almost every single session. Sorry, don’t have time to write that all down for some third party. Maybe I could hire a fourth party to write up a plan for the third party.

The best part is that what goes in the treatment plan is largely not read by anyone. I have been tempted to write the following:

Goals:

1. Veteran will attend therapy regularly and provide enough RVUs for administration to get off my back.

Done!
 
  • Like
  • Haha
Reactions: 10 users
I swear to God this place is driving me bonkers. Does anyone know where to ask for help getting my name corrected in the TMS system? A year ago, my CEU certificates and BLS started printing my name incorrectly. I emailed the local TMS administrator person who sent me to HR / HR Smart who pretended to help and closed out the ticket a month ago as corrected/ fixed (it wasn't, but I gave it a month). Today printed out BLS cert with incorrect name and entered 2nd ticket with HR Smart. Get immediately contacted by HR saying to contact my local TMS admin person (who had sent me to HR) because HR has nothing to do with it. Circular hierarchy.
 
I swear to God this place is driving me bonkers. Does anyone know where to ask for help getting my name corrected in the TMS system? A year ago, my CEU certificates and BLS started printing my name incorrectly. I emailed the local TMS administrator person who sent me to HR / HR Smart who pretended to help and closed out the ticket a month ago as corrected/ fixed (it wasn't, but I gave it a month). Today printed out BLS cert with incorrect name and entered 2nd ticket with HR Smart. Get immediately contacted by HR saying to contact my local TMS admin person (who had sent me to HR) because HR has nothing to do with it. Circular hierarchy.
Oh man, that’s frustrating.

My first thought was trying to contact somebody with one of those cushy nursing education jobs at your facility and see if they have any different ideas since HR might be correct that they have nothing to do with TMS and your local TMS contact should be doing more to problem solve this.
 
  • Like
Reactions: 1 user
I swear to God this place is driving me bonkers. Does anyone know where to ask for help getting my name corrected in the TMS system? A year ago, my CEU certificates and BLS started printing my name incorrectly. I emailed the local TMS administrator person who sent me to HR / HR Smart who pretended to help and closed out the ticket a month ago as corrected/ fixed (it wasn't, but I gave it a month). Today printed out BLS cert with incorrect name and entered 2nd ticket with HR Smart. Get immediately contacted by HR saying to contact my local TMS admin person (who had sent me to HR) because HR has nothing to do with it. Circular hierarchy.

Classic VA
 
  • Like
Reactions: 1 user
"We engage in a 'team based' model of intervention here"

I'm sorry. 'Teams' are not licensed. Individual providers are licensed and have to operate responsibly and according to professional standards of care/practice and not engage in MAL-practice in order to maintain their individual license.

I predicted this crap several years ago when the damn VA waved a bureaucratic wand with all the policies / procedures / software around 'Mental Health Suite' and 'integrated, interdisciplinary team-based treatment planning' as well as the entirely manufactured role of 'Mental Health Coordinator' position.

The traditional roles/rules that ensured competent clinical practice are now finally being blurred/erased and now 'the team' 'writes' 'the plan' rather than an individually licensed provider/specialist seeing a patient (evaluating, say in context of a consult) and engaging in informed consent process with the patient, doing treatment planning, writing the treatment plan, and then implementing their treatment plan. 'We have team plans.' No, we have a 'team' of individually licensed providers who have different skills, knowledge, experiences, competencies, etc. I cannot write a treatment plan for the nurse practitioner saying that she will prescribe Zoloft for patient X when she has never even seen patient X before. I can enter a consult to her for med management and we can go from there.

A 'team' approach doesn't mean that my slick/Machiavellian colleague can pull a fast one and throw into the permanent medical record a 'treatment plan' that is a 'team' plan that, curiously, only lists one name (my name) as:

(1) the sole 'team member' (nobody else is listed); Let that sink in. I haven't even seen the patient in my life but, somehow, I am now the SOLE 'team member' involved in their care. Where's the 'team,' jack?;

(2) there is only one objective ('my' objective that was written for me outside of my knowledge, consent, input by someone else) to implement a very specific time-limited treatment protocol the evaluation of suitability for which there are multiple qualifying and disqualifying factors that I am supposed to evaluate in answering the consultation request for that service; but my colleague has dispensed with the entire consultation process and just skipped to writing my results/plan for me; (3) I am listed as the responsible person for implementing X protocol over Y number of weeks with patient Z (there are no other objectives or interventions in the plan)

It is clear to me that this provider is so motivated to immediately eject this patient from their caseload in order to beat the clock prior to the intern leaving the rotation that he is insisting that I sign a 'treatment plan' that is CLEARLY indicating that it is MY treatment plan (see above) when I haven't had the opportunity to actually examine the patient and respond to the consult that he entered for me to evaluate the patient for suitability for X protocol (the answer to which may be a 'yes' or it may be a 'no'). He wants me to commit to the plan prior to doing the evaluation and answering the consult. To me, this is indisputably inappropriate but in the current political environment when we have a team meeting next week I am anticipating that the program manager is going to bring this topic up (I hope they don't) and I am going to be having to fight the ideology of me not being 'a team player.'

He is going to say that he is just trying to comply with the 'rule' (policy/procedure) that is ridiculous that we must have a treatment plan published by session 3. Fine. The patient is still under YOUR care in YOUR caseload so feel free to finalize/write for YOURSELF whatever treatment plan you want at session 3. I see two possible ways of handling it:

(1) [this is what I do] If I have seen the patient for an intake (he's in my caseload at that point), send him to orientation group, then have session 3 treatment planning session with him but he 'chooses/picks' protocol X that Dr. Z offers, fine. I first write a treatment plan with one objective and me as the responsible person (he is, in fact, still my patient at that point). My treatment plan is generic and basically says, 'cognitive behavioral therapy for PTSD' and it has a 12 month duration at this point (6 months, whatever). I enter the consult for Dr. Z to evaluate for suitability of protocol X and IF Dr. Z evaluates and decides that protocol X is appropriate then Dr. Z can enter his own objective covering that intervention and be responsible for it.

(2) I can put in a 'placeholder' objective basically saying that I'm entering a consult for Dr. Z to evaluate for protocol X and make it like a 2 month objective (to be safe) in order to give time for the consultation to be completed.

What frustrates me is that no one has foreseen this and it seems like no one is interested in maintaining integrity of actual practice of clinical care (including having clear points of transfer of patients between providers (and rules/principles governing these), maintaining continuity of care so people don't fall through the cracks, and following standard of care with respect to the steps of evaluate --> plan --> treat.

I guarantee you that the discussion is going to be about 'being a team player,' the 'needs/preferences' of the veteran (for a particular protocol), 'veteran-centered care' and 'we're a team here.' I'm sorry, but 'we're a team here' doesn't give my colleague carte blanche to just write my plans for me and insist that I sign them as my plans.

And the intern is being taught that this is appropriate clinical practice. I told the intern point blank that if he goes to his first real job and starts writing and publishing into the permanent medical record treatment plans on behalf of his colleagues making them the 'sole responsible person' for the sole clinical objective for a patient without even consulting with them first (on a patient they have NEVER SEEN OR EVALUATED) and expects them to just sign it then he is in for a world of professional pain and it may even result in a board complaint.
 
Last edited:
  • Like
Reactions: 1 users
"We engage in a 'team based' model of intervention here"

I'm sorry. 'Teams' are not licensed. Individual providers are licensed and have to operate responsibly and according to professional standards of care/practice and not engage in MAL-practice in order to maintain their individual license.

I predicted this crap several years ago when the damn VA waved a bureaucratic wand with all the policies / procedures / software around 'Mental Health Suite' and 'integrated, interdisciplinary team-based treatment planning' as well as the entirely manufactured role of 'Mental Health Coordinator' position.

The traditional roles/rules that ensured competent clinical practice are now finally being blurred/erased and now 'the team' 'writes' 'the plan' rather than an individually licensed provider/specialist seeing a patient (evaluating, say in context of a consult) and engaging in informed consent process with the patient, doing treatment planning, writing the treatment plan, and then implementing their treatment plan. 'We have team plans.' No, we have a 'team' of individually licensed providers who have different skills, knowledge, experiences, competencies, etc. I cannot write a treatment plan for the nurse practitioner saying that she will prescribe Zoloft for patient X when she has never even seen patient X before. I can enter a consult to her for med management and we can go from there.

A 'team' approach doesn't mean that my slick/Machiavellian colleague can pull a fast one and throw into the permanent medical record a 'treatment plan' that is a 'team' plan that, curiously, only lists one name (my name) as:

(1) the sole 'team member' (nobody else is listed); Let that sink in. I haven't even seen the patient in my life but, somehow, I am now the SOLE 'team member' involved in their care. Where's the 'team,' jack?;

(2) there is only one objective ('my' objective that was written for me outside of my knowledge, consent, input by someone else) to implement a very specific time-limited treatment protocol the evaluation of suitability for which there are multiple qualifying and disqualifying factors that I am supposed to evaluate in answering the consultation request for that service; but my colleague has dispensed with the entire consultation process and just skipped to writing my results/plan for me; (3) I am listed as the responsible person for implementing X protocol over Y number of weeks with patient Z (there are no other objectives or interventions in the plan)

It is clear to me that this provider is so motivated to immediately eject this patient from their caseload in order to beat the clock prior to the intern leaving the rotation that he is insisting that I sign a 'treatment plan' that is CLEARLY indicating that it is MY treatment plan (see above) when I haven't had the opportunity to actually examine the patient and respond to the consult that he entered for me to evaluate the patient for suitability for X protocol (the answer to which may be a 'yes' or it may be a 'no'). He wants me to commit to the plan prior to doing the evaluation and answering the consult. To me, this is indisputably inappropriate but in the current political environment when we have a team meeting next week I am anticipating that the program manager is going to bring this topic up (I hope they don't) and I am going to be having to fight the ideology of me not being 'a team player.'

He is going to say that he is just trying to comply with the 'rule' (policy/procedure) that is ridiculous that we must have a treatment plan published by session 3. Fine. The patient is still under YOUR care in YOUR caseload so feel free to finalize/write for YOURSELF whatever treatment plan you want at session 3. I see two possible ways of handling it:

(1) [this is what I do] If I have seen the patient for an intake (he's in my caseload at that point), send him to orientation group, then have session 3 treatment planning session with him but he 'chooses/picks' protocol X that Dr. Z offers, fine. I first write a treatment plan with one objective and me as the responsible person (he is, in fact, still my patient at that point). My treatment plan is generic and basically says, 'cognitive behavioral therapy for PTSD' and it has a 12 month duration at this point (6 months, whatever). I enter the consult for Dr. Z to evaluate for suitability of protocol X and IF Dr. Z evaluates and decides that protocol X is appropriate then Dr. Z can enter his own objective covering that intervention and be responsible for it.

(2) I can put in a 'placeholder' objective basically saying that I'm entering a consult for Dr. Z to evaluate for protocol X and make it like a 2 month objective (to be safe) in order to give time for the consultation to be completed.

What frustrates me is that no one has foreseen this and it seems like no one is interested in maintaining integrity of actual practice of clinical care (including having clear points of transfer of patients between providers (and rules/principles governing these), maintaining continuity of care so people don't fall through the cracks, and following standard of care with respect to the steps of evaluate --> plan --> treat.

I guarantee you that the discussion is going to be about 'being a team player,' the 'needs/preferences' of the veteran (for a particular protocol), 'veteran-centered care' and 'we're a team here.' I'm sorry, but 'we're a team here' doesn't give my colleague carte blanche to just write my plans for me and insist that I sign them as my plans.

And the intern is being taught that this is appropriate clinical practice. I told the intern point blank that if he goes to his first real job and starts writing and publishing into the permanent medical record treatment plans on behalf of his colleagues making them the 'sole responsible person' for the sole clinical objective for a patient without even consulting with them first (on a patient they have NEVER SEEN OR EVALUATED) and expects them to just sign it then he is in for a world of professional pain and it may even result in a board complaint.

Cool, so then someone else on the team can sign off and be responsible, right?!

Be equally slick. Tell your slick colleague to sign off and add you as a co-signer rather than supervisor. Then remove you name as co signer. Your colleague looks like he never informed you.
 
  • Like
Reactions: 1 users
I am very firm with my bosses in my unit, that if this is not something I would do as a LIP for whatever my reason, I will not do it. I am okay with losing my job so that I can keep my license to practice. The state issued you the license, not the VA or any other employer. If you get a board complaint, you can't string along the VA and say "well, my boss told me to do it because it's a team effort." Won't fly.
 
  • Like
Reactions: 1 users
Cool, so then someone else on the team can sign off and be responsible, right?!

Be equally slick. Tell your slick colleague to sign off and add you as a co-signer rather than supervisor. Then remove you name as co signer. Your colleague looks like he never informed you.
Actually, at my insistence, he removed my name as cosigner...but the plan still has one person (me) as 'team members,' one person (me) with an objective and one person (me) as 'responsible person's for implementing that objective.

At this point, the 'plan' exists in the medical record, as written by that provider/intern with only ME being responsible for implementing anything with a patient whom I have never met and may never meet. Against my repeated verbal and written OBJECTIONS, mind you. True 'teamwork.'

He said he would remove the objective. What actually happened was the intern rewrote the objective in MH Suite but failed to publish it to CPRS.
 
  • Like
Reactions: 1 users
Actually, at my insistence, he removed my name as cosigner...but the plan still has one person (me) as 'team members,' one person (me) with an objective and one person (me) as 'responsible person's for implementing that objective.

At this point, the 'plan' exists in the medical record, as written by that provider/intern with only ME being responsible for implementing anything with a patient whom I have never met and may never meet. Against my repeated verbal and written OBJECTIONS, mind you. True 'teamwork.'

He said he would remove the objective. What actually happened was the intern rewrote the objective in MH Suite but failed to publish it to CPRS.

This happens to me I think....our unit has this whole thing about including everybody and their damn mother on a treatment plan. I don't do that myself because I think it's ridiculous, but a lot of others in my unit do this. So, I usually get CPRS alerts indicating someone has added me as a co-signer to a treatment plan and I just sign it. I am unsure if someone has written in objectives or other things under an existing plan where I created it originally. I suppose you are more vigilant about that than I am. I honestly don't have the time nor patience to go behind each person to check what they are doing - I'm not their manager.
 
  • Like
Reactions: 1 users
That is a bizarre approach. We definitely only enter our personal treatment plans into MHS/CPRS, never someone else's. The treatment plan is also supposed to be flexible. I also think it's more important that it is updated vs being "complete." The way I've seen it done well is there is a BPS that is done around every year for residential and two years for outpatient. That is in the master treatment plan with general, broad goals like connecting them to outpatient psychotherapy, etc. Then individual providers put in their specific treatment plans within x number of sessions after they meet with the Veteran.

The treatment plans have their own note title in CPRS, so they're easy to look up. Then the treatment plan is updated every 3-6 months, even if it's just to say that we're continuing the same treatment. The template was super short and some clinics had it auto-populate all the options from MHS. They would add any additional details as needed. MHS just makes this process "easier" for providers to know all the sections that need to completed for the treatment plan and BPS. I don't bother entering things into it. I just created a template that contains everything I need and pop that straight into CPRS. That's all JC and CARF look at it anyway, at least at this point. I will be more "interdisciplinary" when MHS isn't janky.
 
  • Like
Reactions: 1 user
Actually, at my insistence, he removed my name as cosigner...but the plan still has one person (me) as 'team members,' one person (me) with an objective and one person (me) as 'responsible person's for implementing that objective.

At this point, the 'plan' exists in the medical record, as written by that provider/intern with only ME being responsible for implementing anything with a patient whom I have never met and may never meet. Against my repeated verbal and written OBJECTIONS, mind you. True 'teamwork.'

He said he would remove the objective. What actually happened was the intern rewrote the objective in MH Suite but failed to publish it to CPRS.

Leave it as is or write addendum:

Care being transferred to Dr. Slick.

Don't even tag Dr. Slick
 
  • Haha
  • Like
Reactions: 2 users
There's always the nuclear approach of requesting the records department to expunge this due to an error
 
  • Like
Reactions: 2 users
I usually only read fluffy or trashy romance novels, but after attending a presentation by Suicide Prevention, I am very tempted to read The Tyranny of Metrics.
 
  • Like
  • Haha
Reactions: 4 users
I usually only read fluffy or trashy romance novels, but after attending a presentation by Suicide Prevention, I am very tempted to read The Tyranny of Metrics.
I've just skimmed it but there's one hilarious anecdote that describes how one surgical team significantly improved their metrics in regard to surgical outcomes. When they were interviewed about. "OMG!!! What did you do to improve your surgical outcomes so much!"

They replied that they stopped accepting the sickest patients.
 
Last edited:
  • Like
Reactions: 6 users
This drives me bonkers. Since when did psychological service become a team sport? That's what mid-levels superficial skills and training are more suited for.
A 'team' does not have a well-defined and delimited legal scope of practice but individual providers do. And professional expertise does count for something depending on the issue. With respect to how to manage diabetes, my opinion should be provided less weight than that of a primary care physician and a board certified endocrinologist's opinion should probably carry quite a bit of weight. Professional treatment planning should not operate as a fundamentally democratic exercise.

I get the advantages of treatment teams but you have to actually set aside / block provider time to devote to attend actual team meetings where decisions can be discussed and treatment planning hashed out. VA hasn't done that and never will. The admins like the trendy idea of treatment teams but are unwilling to block our clinics to reserve time for us to actually meet as an interdisciplinary team and coordinate care. Similar to all politicians who might pass laws mandating certain programs/services without also committing to actually funding those services
 
  • Like
Reactions: 2 users
I will say that we have an hour a week for treatment team meetings, which have been really helpful. No LEAF request shenanigans either. We're early in the BHIP process, but it seems to be going smoothly so far. Fingers crossed.
 
  • Like
Reactions: 2 users
I'm out of the VA these days, but my center has actually regular dedicated time for these interdisciplinary team meetings and it is helpful. The same problems still occur (people telling me how to treat strangers I've never met), but to a lesser degree, and I feel there is less liability for me when we are able to actually discuss and move slower with timelines, and more flexibility to modify the plan for clinical benefit to the patient as well.
 
  • Like
Reactions: 2 users
I am very firm with my bosses in my unit, that if this is not something I would do as a LIP for whatever my reason, I will not do it. I am okay with losing my job so that I can keep my license to practice. The state issued you the license, not the VA or any other employer. If you get a board complaint, you can't string along the VA and say "well, my boss told me to do it because it's a team effort." Won't fly.
If you get a board complaint, the VA will spend more time and resources exonerating themselves than exonerating you. I would never leave the fate of my professional license, my literal livelihood, up to whatever institution I was working for. No matter how “we are a family/team” they claim to be. In fact, whenever folks say stuff like that, it’s basically permission to overstep all of your boundaries.
 
  • Like
Reactions: 4 users
If you get a board complaint, the VA will spend more time and resources exonerating themselves than exonerating you. I would never leave the fate of my professional license, my literal livelihood, up to whatever institution I was working for. No matter how “we are a family/team” they claim to be. In fact, whenever folks say stuff like that, it’s basically permission to overstep all of your boundaries.
True.

I made them take my 'additional signer' status off the note/plan. They didn't follow through on actually changing the plan in the medical record. They changed it in Mental Health Suite but did not re-publish to CPRS. It still lists me as the sole 'team member' with the sole treatment objective and me as the responsible person for implementing it with the patient. Their names (supervisor and intern) by their signatures makes it clear that they authored the plan (not me). I have let the psychologist and my/our supervisor know, in writing, that I object to this plan being written 'for me' without consulting me and for a patient whom I have never evaluated. I have made it clear that it is not--at this point--in any way, shape, or form 'my' plan. I have made it clear that I will answer the consult that has been entered for me to evaluate the patient for suitability for a particular protocol treatment that I do (although from reviewing his chart, he already appears to be a poor candidate, but I will complete the consultation in good faith).
 
  • Like
Reactions: 1 user
Top