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

[Sanman]

We shall see. But, I'd have to imagine when it comes to budget and funding at the federal legislative level, you'll get some pushback at keeping funding levels as is with that declining patient population.

When it comes to government jobs, they tend to freeze hiring rather than fire existing employees. The likelihood is greater that you get reassigned than fired. I had a family member who worked for state government. When he decided to retire, his boss begged him to stay on as due to state budget cuts, they could never approve a replacement and the budget kept getting smaller for his line of work. He ended his career working about 2 hrs/day and napping in the office because 2 hours of work was better than none. So, the younger folks may not have the option. The lifers will be given something to do.

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[deleted1038433]

I have been very loosely following this post to kill time. Genuinely curious, what are the perks of working for VA, if any? I understand tuition loan repayment is unique benefit to federal jobs but I can't think of anything else. If you have little or no student debt, why do y'all choose VA?

At this point, stable income and some job security. Not nearly as much of the latter as you might think. I know of a few horror stories. Your job security in VA is more dependent on the ethical conduct of your immediate supervisor than you might think coming into it.

I went into this because I believed the drawbacks were worth it if I could work with veterans. The realities of working with a population who is monetarily incentivized to remain ill has since disillusioned me. My experience is that veterans are often incredibly entitled in the VA system. There is a high rate of no shows/cancelations (with no consequences) and often little patient effort in the change process. I would say most of the colleagues I have had do not like working in the VA and mostly stay on for the stable income. I have enjoyed working with my VA colleagues and supervisors overall, and I have also seen the worst of psychological practice within VA with no accountability for misconduct.

I imagine I will build my private practice up slowly, and then bow out if I don't get overly concerned about steady income.

 

[cara susanna]

At this point, stable income and some job security. Not nearly as much of the latter as you might think. I know of a few horror stories. Your job security in VA is more dependent on the ethical conduct of your immediate supervisor than you might think coming into it.

I went into this because I believed the drawbacks were worth it if I could work with veterans. The realities of working with a population who is monetarily incentivized to remain ill has since disillusioned me. My experience is that veterans are often incredibly entitled in the VA system. There is a high rate of no shows/cancelations (with no consequences) and often little patient effort in the change process. I would say most of the colleagues I have had do not like working in the VA and mostly stay on for the stable income. I have enjoyed working with my VA colleagues and supervisors overall, and I have also seen the worst of psychological practice within VA with no accountability for misconduct.

I imagine I will build my private practice up slowly, and then bow out if I don't get overly concerned about steady income.

I do agree with a lot of your conclusions. It's also very demoralizing to hear about how awful the VA is and then compare it to your own everyday experience when, at least from my own observations, the providers are often working harder than the patients. When I hear people talk about how the VA is failing its patients in terms of mental healthcare, it brings up questions of what is actually going on and how much is the system vs. the provider vs. the patient. I don't like that I've become so cynical that I immediately wonder "is this actually true or is the patient just not engaging?"

 

[deleted1038433]

...the providers are often working harder than the patients.

This 💯. I thought the military instilled a strong work ethic, and then I worked in VA with veterans.

I would gladly add an additional few new patients a week to my case load if I thought they were going to work hard toward their goals and try to do better for themselves. Instead, it's however many lackards trying to demonstrate symptom severity to help them up their service connection payments as my team lead decrees (which is every bit as demoralizing as it sounds).

 

[Fan_of_Meehl]

I feel like a 30% decline would keep us plenty busy, still. We are slammed as it is.

And with the skills/endurance built up around serving this population during a VA career, if the money went into the community, you'd easily be able to pivot into private practice with the same population.

 

[Fan_of_Meehl]

When it comes to government jobs, they tend to freeze hiring rather than fire existing employees. The likelihood is greater that you get reassigned than fired. I had a family member who worked for state government. When he decided to retire, his boss begged him to stay on as due to state budget cuts, they could never approve a replacement and the budget kept getting smaller for his line of work. He ended his career working about 2 hrs/day and napping in the office because 2 hours of work was better than none. So, the younger folks may not have the option. The lifers will be given something to do.

Agreed and I think that there is a LOT of budgetary excess that has been built up in funding non-clinical (direct care/ practice) positions over the past decade in VA as the VA budgets have increased significantly year-over-year-over-year. Sure, they could cut clinical positions (I wouldn't put it past them) but it would be pretty absurd not to start, say, with some Champion of Integrated Whole Health Evidence-Based Public Relations Shared Decisionmaking Vice Coordinator of Doublespeak. I still think that the vast majority of non-clinical staff are terrified at the prospect of having to deal directly with veterans. They'd probably find enough non-clinical positions relatively low on the totem-pole to cut instead.

 

[summerbabe]

I wouldn't necessarily count on this. Check out the projections for the Veteran population in the next 20 years. With a projected nearly 30% decline, and ever present discussions about expansion of community care eligibility, something will have to give.

I'm bullish for the following reasons:
- supporting DoD and veterans is one of the few bipartisan things left in Congress and they write the checks. Even if the veteran population declines, I don't anticipate an equal drop in patriotism and VA leaders can likely find ways to justify maintaining and even expanding staffing levels, including making the case for complexity in the remaining population.
- speaking of staffing levels, providers are leaving the VA at unprecedented rates all around the country since the pandemic started and tons of facilities are now getting the go ahead from national OMHSP to give up to 20% permanent raises to retain/recruit staff. I don't think it will be long before all psychologists receive this. And I've even heard some talk that some facilities are/will try to get this for social workers.
-there are obviously big proponents of increased community care but between issues in implementation (which includes lack of private providers to absorb veterans) and many veterans who routinely decline community care even if they can receive it quicker, I don't anticipate it being dramatically changing the scope of things. And with DoD/VA streamlining ratings during the discharge process and getting people hooked up with future VA apts while still active duty, I wouldn't be surprised if a greater percent of newly minted veterans will rely more on VA care than in previous generations.

 

[Sanman]

I'm bullish for the following reasons:
- supporting DoD and veterans is one of the few bipartisan things left in Congress and they write the checks. Even if the veteran population declines, I don't anticipate an equal drop in patriotism and VA leaders can likely find ways to justify maintaining and even expanding staffing levels, including making the case for complexity in the remaining population.
- speaking of staffing levels, providers are leaving the VA at unprecedented rates all around the country since the pandemic started and tons of facilities are now getting the go ahead from national OMHSP to give up to 20% permanent raises to retain/recruit staff. I don't think it will be long before all psychologists receive this. And I've even heard some talk that some facilities are/will try to get this for social workers.
-there are obviously big proponents of increased community care but between issues in implementation (which includes lack of private providers to absorb veterans) and many veterans who routinely decline community care even if they can receive it quicker, I don't anticipate it being dramatically changing the scope of things. And with DoD/VA streamlining ratings during the discharge process and getting people hooked up with future VA apts while still active duty, I wouldn't be surprised if a greater percent of newly minted veterans will rely more on VA care than in previous generations.

Short term (next 10 years), I agree. Longer term (25-30 years), I think we will see a significant decrease in funding and jobs. Reason being, the Vietnam veterans will die off and, as war slowly changes to long range missles and drone attacks, no one will be there to replace them. I can also see the government transitioning to a remote mental health workforce as the population in general is more computer literate. This means fewer inefficiencies and easy jobs.

That said, most of us will be winding down our careers or retired by then. My advice, save your pennies and be prepared for a future where you may again make less.

 

[summerbabe]

Short term (next 10 years), I agree. Longer term (25-30 years), I think we will see a significant decrease in funding and jobs. Reason being, the Vietnam veterans will die off and, as war slowly changes to long range missles and drone attacks, no one will be there to replace them. I can also see the government transitioning to a remote mental health workforce as the population in general is more computer literate. This means fewer inefficiencies and easy jobs.

This is probably overly influenced by my specific populations that's I've briefly worked with but I am anticipating an increase in MST related PTSD service connection (it's heartbreaking how many young vets of both genders I encounter who have experienced this) and more service connection for SMI since mental health is no longer being screened out due to low enlistment.

Now how that all shakes out with how many of these younger vets will want/utilize mental health combined with older population declines (and how much they utilize mental health), I certainly can't predict.

But for programs like CLC and HBPC, I can definitely see eventual changes and cuts while programs like ICMHR and PRRC receive more funding.

 

[Fan_of_Meehl]

This is probably overly influenced by my specific populations that's I've briefly worked with but I am anticipating an increase in MST related PTSD service connection (it's heartbreaking how many young vets of both genders I encounter who have experienced this) and more service connection for SMI since mental health is no longer being screened out due to low enlistment.

Now how that all shakes out with how many of these younger vets will want/utilize mental health combined with older population declines (and how much they utilize mental health), I certainly can't predict.

But for programs like CLC and HBPC, I can definitely see eventual changes and cuts while programs like ICMHR and PRRC receive more funding.

Just looking at the societal changes I've observed over the past 30 - 40 years as well as the dramatic increases in mental health issues and dissolution of nuclear families and most of our institutions...I think that those with great experience and competence in psychotherapy will have work for the foreseeable decades.

And...importantly...what used to be a 'stigma' with respect to mental illness has become almost a fetish/fad and mark of distinction among some. And most of the stigma against seeking help in psychotherapy has faded.

 

[cara susanna]

This is probably overly influenced by my specific populations that's I've briefly worked with but I am anticipating an increase in MST related PTSD service connection (it's heartbreaking how many young vets of both genders I encounter who have experienced this) and more service connection for SMI since mental health is no longer being screened out due to low enlistment.

Now how that all shakes out with how many of these younger vets will want/utilize mental health combined with older population declines (and how much they utilize mental health), I certainly can't predict.

But for programs like CLC and HBPC, I can definitely see eventual changes and cuts while programs like ICMHR and PRRC receive more funding.

Yes, I'm involved with MST national and I can say the national program is only increasing. Although I don't know if SC specifically will increase, since it's notoriously difficult to get SC for MST (they are trying to change this).

 

[Sanman]

This is probably overly influenced by my specific populations that's I've briefly worked with but I am anticipating an increase in MST related PTSD service connection (it's heartbreaking how many young vets of both genders I encounter who have experienced this) and more service connection for SMI since mental health is no longer being screened out due to low enlistment.

Now how that all shakes out with how many of these younger vets will want/utilize mental health combined with older population declines (and how much they utilize mental health), I certainly can't predict.

But for programs like CLC and HBPC, I can definitely see eventual changes and cuts while programs like ICMHR and PRRC receive more funding.

That will depend on number of SC inidividuals in the system. Anyone 70% SC or higher and the VA needs to cover their long term care needs in-house or privately. In-house is cheaper.

The other question I have, as demographics change among veterans, is whether there will be as much appetite to fund the VA in congress:

"Veterans who used VA were more likely to be Black, younger, female, unmarried, less educated, and have lower household incomes."

U.S. Veterans Who Do and Do Not Utilize VA Healthcare Services: Demographic, Military, Medical, and Psychosocial Characteristics

It is much easier to get support when presidents and senators have a history of service.

 

[R. Matey]

The realities of working with a population who is monetarily incentivized to remain ill has since disillusioned me.

I've never set foot in a VA, but I worked in community clinics as a master's level clinician for a few years prior to my Ph.D. and there was a similar story there. Folks had to remained 'engaged' with mental health services in order to receive their checks and the clinic policy required psychotherapy engagement along with medication management (this was primarily an SMI population). As you could imagine, folks rarely got better and were disincentivized to make the tiniest motion towards working for fear of losing their benefits even though they were miserable sitting at home with barely enough to live on. It's a frustrating system to work in with progress ranging somewhere between miniscule to non-existent.

 

[Sanman]

I've never set foot in a VA, but I worked in community clinics as a master's level clinician for a few years prior to my Ph.D. and there was a similar story there. Folks had to remained 'engaged' with mental health services in order to receive their checks and the clinic policy required psychotherapy engagement along with medication management (this was primarily an SMI population). As you could imagine, folks rarely got better and were disincentivized to make the tiniest motion towards working for fear of losing their benefits even though they were miserable sitting at home with barely enough to live on. It's a frustrating system to work in with progress ranging somewhere between miniscule to non-existent.

I have worked with both populations and it is a similar frustration. That said, The SMI folks I felt for more because some would not be able to hold down a job if they lost benefits. Some of the VA folks simply realize that government assistance affords them a better lifestyle than the minimum wage job they would qualify for in the real world. The really sketchy ones sell their meds on the side for extra cash. Pretty sure I once walked in on a drug deal going down in a VA bathroom before my tour of duty.

 

[R. Matey]

That said, The SMI folks I felt for more because some would not be able to hold down a job if they lost benefits.

For sure. I briefly staffed a day program and it was a godsend for these types of folks. I do wish there were more supported employment programs for others who may be able to transition back to work. I do think some would benefit from intervention where others clearly would not.

 

[cara susanna]

Yes, I really wish I were at a main hospital with a CWT program.

 

[Shiori]

Our CWT folks are great and the veterans have really good things to say about the program. I feel like it's a better use of resources than other things I've run across in the VA.

 

[cara susanna]

Forgot to update, this is a quick and dirty summary of the updated (2023) psychotherapy CPG:
- Therapy recommended over medication
- Recommended therapies: CPT, PE, and EMDR
- Suggested therapies (lower level of evidence): Cognitive Therapy, WET, and Present-Centered Therapy
- Insufficient evidence for other therapies including but not limited to ART, Adaptive Disclosure, STAIR, CBCT, Seeking Safety, TrIGR, etc
- Individual still recommended over group
- Telehealth video modality is effective, at least for CPT and PE
- Evidence-based therapies work just as well for SUD and complex patients; COPE is recommended for SUD over Seeking Safety

 

[Shiori]

Super interesting all around!

 

[summerbabe]

Insufficient evidence for other therapies including but not limited to ART, Adaptive Disclosure, STAIR, CBCT, Seeking Safety, TrIGR, etc

Super interesting - I feel like I see a lot of STAIR being done recently

 

[cara susanna]

Super interesting - I feel like I see a lot of STAIR being done recently

I actually have very complex thoughts on STAIR. I am not convinced it is necessary based on existing research, but I do refer patients who were unable to tolerate PTSD EBPs for it. That being said, I had someone who couldn't handle a trauma-focused therapy, completed STAIR successfully, and then still couldn't handle another trauma-focused therapy.

I also struggle with providing STAIR because it's so similar to DBT, so I just end up switching to DBT. Lol

Edit: I also should add that I have VERY strong feelings about skills building prior to PTSD EBP engagement in general, so this isn't just limited to STAIR.

 

[Shiori]

I actually have very complex thoughts on STAIR. I am not convinced it is necessary based on existing research, but I do refer patients who were unable to tolerate PTSD EBPs for it. That being said, I had someone who couldn't handle a trauma-focused therapy, completed STAIR successfully, and then still couldn't handle another trauma-focused therapy.

I also struggle with providing STAIR because it's so similar to DBT, so I just end up switching to DBT. Lol

Edit: I also should add that I have VERY strong feelings about skills building prior to PTSD EBP engagement in general, so this isn't just limited to STAIR.

I'd love to hear your thoughts on this. I see skills building recommended a lot, but don't engage in it a ton. I usually jump right into CPT or PE for PTSD or do CBT-D for their depressive symptoms if they're not willing to engage in trauma-focused work.

 

[cara susanna]

I'd love to hear your thoughts on this. I see skills building recommended a lot, but don't engage in it a ton. I usually jump right into CPT or PE for PTSD or do CBT-D for their depressive symptoms if they're not willing to engage in trauma-focused work.

Oh man, sit down and prepare for a ride. Actually, it will probably be less intense in text format.

So basically, the phase-based treatment approach rests on the idea that PTSD EBPs are harder to tolerate than other treatments with higher drop-out rates, and skills building may be necessary for patients who may not have the ability to tolerate these therapies otherwise. But this is not supported by actual evidence:
- There isn't evidence that PTSD drop-out is related to inability to tolerate distress related to the trauma, e.g., Imel et al., 2013: the degree of clinical attention placed on the traumatic event did not predict drop-out
- Similarly, Van Minnen et al., 2010 says that treatment dropout in PTSD EBPs is not associated with patient characteristics, so the idea that certain populations (like survivors of childhood sexual abuse) would tolerate them less is not supported, either.
- There is also evidence that engaging in intensive PTSD EBP in itself improves emotion regulation difficulties, e.g., Van Toorenberg, 2020

Additionally, newer studies have been done that actually examined skills building prior to PTSD EBP engagement and later EBP engagement and outcomes, and overall the findings seem to suggest no benefit:
Wiedeman, 2020: Preparatory treatment prior to trauma work did not predict improved completion or outcomes in veterans with SUD
Dedert et al., 2021: Veterans who did preparatory work were less likely to follow through with an EBP, had worse outcomes than those who engaged in an EBP directly, and showed equal dropout
Staudenmeyer, 2022 is the one exception: stabilization was associated with higher EBP initiation, but only in individual format. Group had lower initiation than no stabilization, individual-only was higher than both (so there isn't much support for, say, PTSD Symptom Management or STAIR groups)

I've also looked at the studies cited in the development of STAIR that suggested PE was hard to tolerate for certain types of patients due to trauma-related distress, and... was not convinced. They didn't seem the strongest to me.

Essentially, if clinicians are insisting on skills building prior to trauma work, there is a high risk that they are delaying effective treatment without added benefit, and additionally there may be less likelihood of the patient engaging in an EBP later on.

Edit: I should add we also have evidence that EBPs improve problems that are often listed as a reason to delay treatment, like suicidal ideation and SUD, so delaying treatment for those reasons is counter-productive. I don't have the citations offhand but I know there are studies with CPT.

 

[Shiori]

That makes a lot of sense. I have will need to dig into the literature. Thank you for the explanation!

 

[summerbabe]

I should add we also have evidence that EBPs improve problems that are often listed as a reason to delay treatment, like suicidal ideation and SUD, so delaying treatment for those reasons is counter-productive. I don't have the citations offhand but I know there are studies with CPT.

It kills me whenever I see a PCT decline somebody for SI, especially if they are denying current intent and voicing safety or have had an extended period since the last suicidal behavior.

If they have genuine PTSD, especially as a primary mental health diagnosis, it doesn’t take a genius to think that their SI is directly related to trauma related distress so reducing that distress should be the primary treatment goal.

Especially in the VA system where individual providers will rarely shoulder ‘blame’ if an individual competes suicide, especially if you’re documenting current risk levels during every appointment.

 

[summerbabe]

Anecdotally, I think there is a room for pre/skills based work prior to an EBP.

But that needs to be part of a thoughtful and collaborative plan that is made with the veteran.

And there needs to be a seemless transition from the pre/skills phase into the EBP phase (like literally from one week to the next and not like a 3 month delay due to access issues).

So that the pre-treatment stuff both develops skills/improves coping but also enhances engagement and behavioral repetition of attending regular apts, experiencing their emotions differently and doing homework.

 

[Fan_of_Meehl]

It kills me whenever I see a PCT decline somebody for SI, especially if they are denying current intent and voicing safety or have had an extended period since the last suicidal behavior.

If they have genuine PTSD, especially as a primary mental health diagnosis, it doesn’t take a genius to think that their SI is directly related to trauma related distress so reducing that distress should be the primary treatment goal.

Especially in the VA system where individual providers will rarely shoulder ‘blame’ if an individual competes suicide, especially if you’re documenting current risk levels during every appointment.

I work in a PCT and we routinely take people with high-risk suicide flags straight out of inpatient all the time. I guess it varies site-to-site.

 

[cara susanna]

It kills me whenever I see a PCT decline somebody for SI, especially if they are denying current intent and voicing safety or have had an extended period since the last suicidal behavior.

If they have genuine PTSD, especially as a primary mental health diagnosis, it doesn’t take a genius to think that their SI is directly related to trauma related distress so reducing that distress should be the primary treatment goal.

Especially in the VA system where individual providers will rarely shoulder ‘blame’ if an individual competes suicide, especially if you’re documenting current risk levels during every appointment.

Yup, our PCT rarely thinks anyone is ready for an EBP right away. I've given up trying to convince them otherwise, though.

 

[Shiori]

PCT definitely varies. I have seen some very rigid requirements.

Yup, our PCT rarely thinks anyone is ready for an EBP right away. I've given up trying to convince them otherwise, though.

One of the PCTs I worked with in the past was similar. It created bad blood to tell other clinicians a person wasn't a good fit for PTSD treatment because their clinical judgement was regularly questioned. It would be one thing for it to happen occasionally, but most of the consults were kicked back. It was often the SUD and SMI clinics whose patients were deemed ill-prepared for treatment, even with long periods of stability.

 

[Fan_of_Meehl]

PCT definitely varies. I have seen some very rigid requirements.

One of the PCTs I worked with in the past was similar. It created bad blood to tell other clinicians a person wasn't a good fit for PTSD treatment because their clinical judgement was regularly questioned. It would be one thing for it to happen occasionally, but most of the consults were kicked back. It was often the SUD and SMI clinics whose patients were deemed ill-prepared for treatment, even with long periods of stability.

Unfortunately, in the VA system, I have seen people respond to incoming consults like a badminton shuttlecock.

Batting them down the line. Sadly, it is 'rewarded' by less work.

By contrast, I've worked in a particular PCT for a year and haven't seen a single consult turned down, forwarded, or discontinued.

Lots of variability.

 

[JustNoticing]

Anyone here have any experience with, or know anyone who has done the VA's HPSP scholarship program for psychologists or social workers?

 

[Shiori]

Soooo....is the Cerner EHR happening or not?

 

[WisNeuro]

Soooo....is the Cerner EHR happening or not?

Probably not, this is going to be a $30+ billion debacle for the ages.

 

[Fan_of_Meehl]

Probably not, this is going to be a $30+ billion debacle for the ages.

They should keep CPRS and add a free text response "Case Formulatuon / Treatment Plan" tab (also open-field plaintext entry) and spend at least 10 billion eradicating every line of code and every online reference to the "Mental Health Suite" software program for all time and outlaw, by formal statute, the creation of any such monstrosity ever again under pain of death.

 

[cara susanna]

Soooo....is the Cerner EHR happening or not?

Reddit keeps showing me the Cerner sub and apparently they laid off a BUNCH of the VA team.

I wish we could just go to Epic.

 

[summerbabe]

Reddit keeps showing me the Cerner sub and apparently they laid off a BUNCH of the VA team.

Interesting but it seems like the writing was on the wall when the VA stopped those pilot programs/expansion recently.

The agency’s decision to halt implementation of the system comes during contract negotiations between the agency and Oracle Cerner over a potential extension of the initial $10 billion IT modernization contract that was signed in 2018 as it nears the end of its base period.

In a briefing call with reporters, VA official Dr. Neil Evans declined to give specific details about ongoing contract negotiations but noted that “everything has been on the table.”

“The original contract was a five-year base period with a five-year option, but everything has been on the table as part of the contract negotiations. I anticipate we’ll be able to share more as we near the end of those negotiations,” Evans said.

He added: “We are working towards an amended contract that will hold Oracle Cerner accountable to delivering the high-functioning, high-reliability EHR system that veterans deserve and will lay the groundwork for our expectations around improvements to the system that we think are necessary.”

In its statement announcing the program stoppage, VA said the agency would work with Congress on resource requirements for the modernization program and estimated that costs for fiscal year 2023 will be reduced by $400 million.

One exception to the implementation freeze will be at the Captain James A. Lovell Federal Health Care Center in Chicago, which houses the only fully integrated VA and Department of Defense healthcare system. This go-live remains scheduled for March 2024.

On a side note, the only relevant Reddit sub for VA work should be r/maliciouscompliance.

And I hope we never move away from CPRS. It's like that old couch that's ugly and super outdated but still pretty comfortable.

 

[Fan_of_Meehl]

Interesting but it seems like the writing was on the wall when the VA stopped those pilot programs/expansion recently.

On a side note, the only relevant Reddit sub for VA work should be r/maliciouscompliance.

And I hope we never move away from CPRS. It's like that old couch that's ugly and super outdated but still pretty comfortable.

I find it odd that, with sufficient funding/staffing, government agencies have been able to craft hardware/software solutions to successfully and safely explore Mars/the moon, split atoms in particle accelerators, dispose of nuclear waste, etc. but--somehow--successfully implementing a medical charting system that--when I was in training--was literally implemented via a three-ring binder, blank paper/forms, and a ball point pen is somehow a task of such monumental complexity that when we try to do so we create verifiably unsafe conditions for patients.

Makes me just slightly suspicious that the medical charting system has been just a TAD bit over-engineered over the past three decades and maybe we should go back to pen/paper or some simple, safe, and streamlined text only electronic equivalent.

 

[SomeGreatNotion]

I find it odd that, with sufficient funding/staffing, government agencies have been able to craft hardware/software solutions to successfully and safely explore Mars/the moon, split atoms in particle accelerators, dispose of nuclear waste, etc. but--somehow--successfully implementing a medical charting system that--when I was in training--was literally implemented via a three-ring binder, blank paper/forms, and a ball point pen is somehow a task of such monumental complexity that when we try to do so we create verifiably unsafe conditions for patients.

Makes me just slightly suspicious that the medical charting system has been just a TAD bit over-engineered over the past three decades and maybe we should go back to pen/paper or some simple, safe, and streamlined text only electronic equivalent.

There is a recent book by Jennifer Pahlka called "Recoding America: Why Government is Failing in the Digital Age and How We Can Do Better" that explains why developing and updating software systems is so difficult. I'll admit that I haven't read a book but she was interviewed on a recent episode of the podcast "Odd Lots" where she talks about the challenges of updating state unemployment systems were so hard to update during COVID. My take was that instead of building something from scratch, it is encouraged to find solutions that build off of existing systems with existing flaws while accommodating older laws/regulations that may not apply to modern problems. A worthwhile listen if you have the time.

 

[cara susanna]

Interesting but it seems like the writing was on the wall when the VA stopped those pilot programs/expansion recently.

On a side note, the only relevant Reddit sub for VA work should be r/maliciouscompliance.

And I hope we never move away from CPRS. It's like that old couch that's ugly and super outdated but still pretty comfortable.

Oh yeah, CPRS is all I know so I'd love to never leave it. But it'd be nice if there could be some updates to it.

 

[Fan_of_Meehl]

There is a recent book by Jennifer Pahlka called "Recoding America: Why Government is Failing in the Digital Age and How We Can Do Better" that explains why developing and updating software systems is so difficult. I'll admit that I haven't read a book but she was interviewed on a recent episode of the podcast "Odd Lots" where she talks about the challenges of updating state unemployment systems were so hard to update during COVID. My take was that instead of building something from scratch, it is encouraged to find solutions that build off of existing systems with existing flaws while accommodating older laws/regulations that may not apply to modern problems. A worthwhile listen if you have the time.

Maybe we NEED to start from scratch, then. I dunno. All of healthcare has been overcomplicated beyond belief at this point. Not sure what the solution is but it seems obvious to me that we can't just keep on endlessly increasing the complexity/bureaucracy of healthcare ad infinitum. As a provider on the front lines I think I'm nearing my limit at this point.

The individual licensed provider is no longer trusted to make decisions with individual patients while it could be argued that he/she is really the only entity who SHOULD be trusted to do so. The provider is fully responsible, but somehow 'cannot be trusted' to exercise his/her clunical judgment in context and simply document the rationale that supports the decisionmaking. Too many layer upon layer one size fits all rules, policies, and procedures to keep track of...many of which contradict one another. Ever-expanding armies of non-clinician code enforcers are being hired and trained to audit charts and to hold providers 'accountable' without ever examining the patient or even being remotely familiar with the medical literature, professional ethics, or standards of care/practice involved.

 

[Fan_of_Meehl]

Oh yeah, CPRS is all I know so I'd love to never leave it. But it'd be nice if there could be some updates to it.

Quick question to VA colleagues:
Have you ever been asked to fill out an Aid and Attendance application form for a veteran? Specifically, reading in the chart that an upcoming consult had it suggested to him by a patient advocate that a MH provider assist him with claiming fear of driving due to PTSD makes him unable to drive.

Also, the SW who entered the consult documented that she suggested to the veteran that he go for the Caregiver Support Program/Certification for PTSD instead.

Thoughts on caregiver support for PTSD? Any literature on this? How would it not be iatrogenic from a CBT model? Wouldn't treatment (PE/CPT) be indicated instead/first?

 

[WisNeuro]

Quick question to VA colleagues:
Have you ever been asked to fill out an Aid and Attendance application form for a veteran? Specifically, reading in the chart that an upcoming consult had it suggested to him by a patient advocate that a MH provider assist him with claiming fear of driving due to PTSD makes him unable to drive.

Also, the SW who entered the consult documented that she suggested to the veteran that he go for the Caregiver Support Program/Certification for PTSD instead.

Thoughts on caregiver support for PTSD? Any literature on this? How would it not be iatrogenic from a CBT model? Wouldn't treatment (PE/CPT) be indicated instead/first?

Iatrogenic in all but the worst cases that I have ever treated/evaluated.

 

[summerbabe]

Thoughts on caregiver support for PTSD? Any literature on this? How would it not be iatrogenic from a CBT model? Wouldn't treatment (PE/CPT) be indicated instead/first?

National CSP is supposed to be reviewing and grandfathering people out of the program who were accepted for PTSD/mental health but are able to engage in ADLs and to focus new admissions for people who are functionally incapable of doing multiple ADLs (versus not wanting to/experiencing difficulty while doing).

How/whether that is happening at the local levels, it's anybody's guess. But I have seen a number of rejections in different systems for veterans who applied for CSP based on mental health concerns and a couple of people whose CSP benefits will lapse due to a re-eval that says they can do ADLs.

I personally would not fill out aid & attendance for fear of driving as there are both mental health treatments and practical workarounds should one decline treatment.

 

[Fan_of_Meehl]

National CSP is supposed to be reviewing and grandfathering people out of the program who were accepted for PTSD/mental health but are able to engage in ADLs and to focus new admissions for people who are functionally incapable of doing multiple ADLs (versus not wanting to/experiencing difficulty while doing).

How/whether that is happening at the local levels, it's anybody's guess. But I have seen a number of rejections in different systems for veterans who applied for CSP based on mental health concerns and a couple of people whose CSP benefits will lapse due to a re-eval that says they can do ADLs.

I personally would not fill out aid & attendance for fear of driving as there are both mental health treatments and practical workarounds should one decline treatment.

Thank you for the input, very well reasoned and why I find this board so helpful.

I was also able to look up the Aid and Attendance form itself and it is CLEARLY not something a psychologist should be filling out. Moreover, chart says physician already filled out this form but veteran is upset about what the physician wrote.

 

[Sanman]

Quick question to VA colleagues:
Have you ever been asked to fill out an Aid and Attendance application form for a veteran? Specifically, reading in the chart that an upcoming consult had it suggested to him by a patient advocate that a MH provider assist him with claiming fear of driving due to PTSD makes him unable to drive.

Also, the SW who entered the consult documented that she suggested to the veteran that he go for the Caregiver Support Program/Certification for PTSD instead.

Thoughts on caregiver support for PTSD? Any literature on this? How would it not be iatrogenic from a CBT model? Wouldn't treatment (PE/CPT) be indicated instead/first?

1. You have no way of assessing that and it is iatrogenic as already pointed out. I would do nothing more than put in my note that veteran states this in his interview. You are not C&P or CSP. They do their own interviews.

2. As @summerbabe mentioned, CSP is becoming more stringent. There used to be only 9/11 forward. It was recently opened up to older veterans and they are becoming more strict with the funds. CEAT ( who makes the determination) has also moved to the VISN level from the hospital level.

3. The PCP or SW can help them with the forms. I never fill them out.

 

[Sanman]

For the folks that transferred VAs, how smooth was the transition? Some of these remote jobs are starting to call my name.

 

[summerbabe]

For the folks that transferred VAs, how smooth was the transition? Some of these remote jobs are starting to call my name.

I did this a few years ago and it was very smooth. But the VA/system that I moved to is efficient and professional.

 

[WisNeuro]

I did this a few years ago and it was very smooth. But the VA/system that I moved to is efficient and professional.

You do know that April 1st was several months ago?

 

[cara susanna]

I've had a few transfers and they've always had some bumps, although my most recent was VERY fast (they were very motivated to have me, though)

 

[deleted1038433]

My onboarding and transfer process was not too bad. I think you should go for it if you think it is what is best for you and your family. I would say the main drawback for most transfers is starting a therapy case load from scratch.