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

[Sanman]

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I found out that there is going to be even MORE of a push to increase VA access (it's called sprint). Apparently primary care is first, with eventual plans for mental health. Yes, that's what we all think MH needs more of...

I am sure access will increase when all the providers quit. As they do every time stupid admin changes are made. How about someone do a process improvement project on that.

 

[Fan_of_Meehl]

I am sure access will increase when all the providers quit. As they do every time stupid admin changes are made. How about someone do a process improvement project on that.

I'm still trying to get them to do basic 5th grade arithmetic and brainstem logic.

 

[summerbabe]

I found out that there is going to be even MORE of a push to increase VA access (it's called sprint).

More like sprint to the nearest non-VA job

 

[Fan_of_Meehl]

More like sprint to the nearest non-VA job

And like, 'ride the plane all the way down to the scene of the crash' (Ron White).

 

[summerbabe]

I found out that there is going to be even MORE of a push to increase VA access (it's called sprint). Apparently primary care is first, with eventual plans for mental health. Yes, that's what we all think MH needs more of...

A couple of things that I learned in an email that I received regarding what they are terming "Access Sprint":

- This is coming from Congress/interpretation of what Congress wants (duh) and in particular, to show that recent VA hiring expansion is being put to good use
- VISN leadership are currently sharing best practices on how they have improved Primary Care access with the idea of adopting some of these best practices for MH, with a focus on speeding up access for new patients (I'm sure there will be very nuanced and realistic discussions regarding differences between PC and MH by people who have a genuine grasp of the boots on the ground state of affairs)
- Primary care panels are 1200 currently

 

[Sanman]

A couple of things that I learned in an email that I received regarding what they are terming "Access Sprint":

- This is coming from Congress/interpretation of what Congress wants (duh) and in particular, to show that recent VA hiring expansion is being put to good use
- VISN leadership are currently sharing best practices on how they have improved Primary Care access with the idea of adopting some of these best practices for MH, with a focus on speeding up access for new patients (I'm sure there will be very nuanced and realistic discussions regarding differences between PC and MH by people who have a genuine grasp of the boots on the ground state of affairs)
- Primary care panels are 1200 currently

Can you not post such things until later in the day? It is very difficult to get IT to give me a new laptop if I spit coffee all over mine.

 

[summerbabe]

Can you not post such things until later in the day? It is very difficult to get IT to give me a new laptop if I spit coffee all over mine.

Don't worry, we've got plenty of money for new laptops - just see more patients and more quickly.

I wonder if the 'protected therapy hour' might be getting chipped away at (e.g., 30 min scheduled intake/access appointments) so that those people will count as being seen by VA.

 

[Sanman]

Don't worry, we've got plenty of money for new laptops - just see more patients and more quickly.

I wonder if the 'protected therapy hour' might be getting chipped away at (e.g., 30 min scheduled intake/access appointments) so that those people will count as being seen by VA.

This must be why the VA switched mobile providers from Verizon to T-Mobile and I can't go one day without a dropped call on my VA cell phone.

 

[Fan_of_Meehl]

A couple of things that I learned in an email that I received regarding what they are terming "Access Sprint":

- This is coming from Congress/interpretation of what Congress wants (duh) and in particular, to show that recent VA hiring expansion is being put to good use
- VISN leadership are currently sharing best practices on how they have improved Primary Care access with the idea of adopting some of these best practices for MH, with a focus on speeding up access for new patients (I'm sure there will be very nuanced and realistic discussions regarding differences between PC and MH by people who have a genuine grasp of the boots on the ground state of affairs)
- Primary care panels are 1200 currently

Psychotherapy is delivered in COURSES (say, 12 - 20 weekly sessions over a time frame of 3 to four months) and not as single sessions or monthly check ins.

I hope to God someone who is involved in this 'sprint' comprehends this basic principle.

"episodes of care...episodes of care...episodes of care..."

Meanwhile, we're losing providers left and right these days.

 

[Fan_of_Meehl]

A couple of things that I learned in an email that I received regarding what they are terming "Access Sprint":

- This is coming from Congress/interpretation of what Congress wants (duh) and in particular, to show that recent VA hiring expansion is being put to good use
- VISN leadership are currently sharing best practices on how they have improved Primary Care access with the idea of adopting some of these best practices for MH, with a focus on speeding up access for new patients (I'm sure there will be very nuanced and realistic discussions regarding differences between PC and MH by people who have a genuine grasp of the boots on the ground state of affairs)
- Primary care panels are 1200 currently

- primary care panels are at 1200 currently

Hell...at least it's a number/cap.

I never have been able to get anyone in MH leadership to even state a number, even off the record, even hypothetically, that would represent a max feasible caseload number for a full time therapist.

To me, the max caseload would be approximately the number of weekly slots you have for therapy in your grid (for most folks between 20 and 25 weekly slots) at any one point in time.

 

[summerbabe]

I never have been able to get anyone in MH leadership to even state a number, even off the record, even hypothetically, that would represent a max feasible caseload number for a full time therapist.

To me, the max caseload would be approximately the number of weekly slots you have for therapy in your grid (for most folks between 20 and 25 weekly slots) at any one point in time.

I know multiple people at different facilities who have been well over 100 in the past (and they couldn’t really do 12 session EBP episodes of care even when the veterans wanted that)

 

[cara susanna]

Primary Care is also really swamped, which is why they put in the most half-assed (honestly, half is an overstatement) MH consults imaginable

 

[deleted1038433]

I know multiple people at different facilities who have been well over 100 in the past (and they couldn’t really do 12 session EBP episodes of care even when the veterans wanted that)

I'm at over 70 "active" currently. I mostly pray my new referrals don't come and don't pop up later down the road. There's a lot of kicking the can down the road because you don't really get to decline new referrals where I am.

I hear in Atlanta, you inherent panels of 200+ patients as a new therapist there.

 

[Sanman]

I'm at over 70 "active" currently. I mostly pray my new referrals don't come and don't pop up later down the road. There's a lot of kicking the can down the road because you don't really get to decline new referrals where I am.

I hear in Atlanta, you inherent panels of 200+ patients as a new therapist there.

You can inherit any number of patients. I have had larger active panels than that (multiples). The question is why are they seeing you? As a provider, once I am seeing someone less than 2x/month, I am really just providing care management and engaging in crisis prevention. You can't control the referrals, but you can control patient goals and timeline. Most of these people should be getting a BDI,BAI, C-SSRS, and conversation about meds and groups. Document they are stable and gauge interest is seeing you when an opening shows up. If someone complains, tell them to cap your intakes, so you can see more treatment or invent more hours in the day.

 

[Fan_of_Meehl]

I know multiple people at different facilities who have been well over 100 in the past (and they couldn’t really do 12 session EBP episodes of care even when the veterans wanted that)

Which is just--plain and simple--admin talking out of both sides of their mouths. IMHO, they need to make up their minds whether they want to staff (a) actual/weekly courses in effective psychotherapy, (b) MH case management services, or both and just honestly and appropriately staff said services.

 

[Fan_of_Meehl]

I'm at over 70 "active" currently. I mostly pray my new referrals don't come and don't pop up later down the road. There's a lot of kicking the can down the road because you don't really get to decline new referrals where I am.

I hear in Atlanta, you inherent panels of 200+ patients as a new therapist there.

If you are only working 40 hrs/week and have a caseload of 200+ "psychotherapy patients," while you have my sympathy, you are just being expected to commit out and out fraud. There ain't NO WAY anyone is doing courses of actual psychotherapy on a caseload of that size.

 

[Fan_of_Meehl]

You can inherit any number of patients. I have had larger active panels than that (multiples). The question is why are they seeing you? As a provider, once I am seeing someone less than 2x/month, I am really just providing care management and engaging in crisis prevention. You can't control the referrals, but you can control patient goals and timeline. Most of these people should be getting a BDI,BAI, C-SSRS, and conversation about meds and groups. Document they are stable and gauge interest is seeing you when an opening shows up. If someone complains, tell them to cap your intakes, so you can see more treatment or invent more hours in the day.

"Dammit, Jim...I'm a DOCTOR, not a TIME LORD!"

 

[summerbabe]

If you are only working 40 hrs/week and have a caseload of 200+ "psychotherapy patients," while you have my sympathy, you are just being expected to commit out and out fraud. There ain't NO WAY anyone is doing courses of actual psychotherapy on a caseload of that size.

Actual ‘practices’ I’ve seen or heard recently at different VAs which are experiencing access issues (and possibly coming to a VA near you):
- opening up more intake clinics within the mandated scheduling window, which then pushes follow-up further out
- assigning a clinician to complete a single time sensitive appointment (such as after a non-MH established pt calls the VCL or somebody discharges from the hospital for MH reasons) that checks off some SAIL metrics regarding access and then putting them into the overall wait cue
- strongly encouraging community care
- putting caps on how many RTC orders that you can schedule in a row (like 6 consecutive apts and the then veteran has to be triaged to see if more therapy is clinically indicated, which means an automatic wait of another couples of months if they want another episode of care)

I’ve heard some talk about using more 30 min appointments like social work but for BHIP therapy but I don’t know if those have been implemented anywhere.

 

[Fan_of_Meehl]

Actual ‘practices’ I’ve seen or heard recently at different VAs which are experiencing access issues (and possibly coming to a VA near you):
- opening up more intake clinics within the mandated scheduling window, which then pushes follow-up further out
- assigning a clinician to complete a single time sensitive appointment (such as after a non-MH established pt calls the VCL or somebody discharges from the hospital for MH reasons) that checks off some SAIL metrics regarding access and then putting them into the overall wait cue
- strongly encouraging community care
- putting caps on how many RTC orders that you can schedule in a row (like 6 consecutive apts and the then veteran has to be triaged to see if more therapy is clinically indicated, which means an automatic wait of another couples of months if they want another episode of care)

I’ve heard some talk about using more 30 min appointments like social work but for BHIP therapy but I don’t know if those have been implemented anywhere.

Thanks for the interesting 'heads up.' None of these are surprising. Nor are the 'top-down' iron-handed one-size-fits-all rules/procedures/'thou shalt's.'

None of these will work.

The organization needs to make the critical distinction between evidence-based psychotherapy (the APA definition, which is broader than just protocols) vs. mental health case management and staff both services. They also need to do some serious training of their MH clinicians (and supervisors) to identify and address barriers to client engagement in care and to deal with the realities of clinical practice in the system.

They also need to consider some basic common-sense reforms such as requiring a modest sliding-scale co-pay for appointments (no more 'free' therapy for life whether or not the patient ever completes a homework assignment or makes progress toward any goals).

None of these will happen.

They will keep playing 'blame the provider' games and ignoring reality.

Edit: I am going to continue refining/perfecting my approach to treating veteran MH patients on an outpatient basis. My model is based on the realities (not the politics and bureaucratic posturing) of clinical practice with this population. I'll develop my own measures, procedures, heuristics, implementable theoretical approaches...all based on acknowledging truths that the organization cannot (and will not). Maybe in 8 years I'll retire and start my own business accepting all the 'community care' referrals and make a fortune training my own masters-level folks to implement the model.

Does anyone know if private practice providers seeing veterans have to 'eat' the costs of no-shows or last minute cancellations? I can't imagine that they would accept these clients if this were the case. Doesn't the VA just 'pay up' whatever 'no show' penalty the private providers impose? If so, why can't the VA impose 'no show' penalties?

 

[deleted1129370]

Last week was my first week being out of my VA job. I was able to wake up at 9AM...watch some episodes, see some patients....all from the comfort of my home in my pajamas. I didn't have to check my VA cell phone, be up early, put the wireless computer mouse on the iRobot to move around so it would appear I was present on TEAMS. Life is good.

 

[AbnormalPsych]

Don't worry, we've got plenty of money for new laptops - just see more patients and more quickly.

I wonder if the 'protected therapy hour' might be getting chipped away at (e.g., 30 min scheduled intake/access appointments) so that those people will count as being seen by VA.

This is happening in systems outside of the VA right now. Consider it a matter of time until VA does this.

 

[Fan_of_Meehl]

This is happening in systems outside of the VA right now. Consider it a matter of time until VA does this.

And it will be the death of therapy. At least--as of now--I am actually able to do effective psychotherapy with about 20% of my caseload. This will bring that number, necessarily, to 0%.

 

[Sanman]

Just heard about more national changes related to geriatric care and other specialty medical areas. Increased focus on external peer review process (Read: veteran satisfaction surveys that go to central office). Programs will now have to create action plans if they are a certain percentage below the mean in any of a number of areas compared to similar programs nationally. So, we now have this at the hospital and program level. While this is not affecting me yet, I am certainly mentally preparing for my own exit. At the moment, control of which services I offer is the only thing allowing me to meet metrics.

 

[summerbabe]

Programs will now have to create action plans if they are a certain percentage below the mean in any of a number of areas compared to similar programs nationally.

Ouch. I was previously at a 'failing' facility and this (and other things) that were implemented pushed the facility back into an OK range for SAIL/etc but there were lots of costs to providers across the board, including loss of autonomy and non-sensical action plans (e.g., meets a SAIL metric but doesn't provide good, real-life care).

 

[Sanman]

Ouch. I was previously at a 'failing' facility and this (and other things) that were implemented pushed the facility back into an OK range for SAIL/etc but there were lots of costs to providers across the board, including loss of autonomy and non-sensical action plans (e.g., meets a SAIL metric but doesn't provide good, real-life care).

Meanwhile, there is a national shortage of people willing to take these jobs (CLC and HBPC). I know of jobs that have gone multiple years without anyone filling them. While we are decently staffed and doing well at the moment (always a couple of positions to fill), I am concerned that as areas are targeted, folks will leave and we all know how that goes. No one wants to be the last person standing on a sinking ship.

 

[summerbabe]

Meanwhile, there is a national shortage of people willing to take these jobs (CLC and HBPC). I know of jobs that have gone multiple years without anyone filling them.

Why do you think this is the case? Is it as simple as there being very little emphasis or exposure to gero in grad school and most internships? And that a good chunk of people who do get that exposure go onto full neuro gigs?

I always thought that these can be pretty decent VA gigs, especially if your CLC nurses/staff don’t have rampant axis 2 disorders.

I did an MHICM/ICMRH rotation during postdoc and really enjoyed community based work, team collaboration and chill pace and if I hadn’t been spoiled by my full remote gig benefits, I would certainly consider home based work again.

 

[Sanman]

Why do you think this is the case? Is it as simple as there being very little emphasis or exposure to gero in grad school and most internships? And that a good chunk of people who do get that exposure go onto full neuro gigs?

I always thought that these can be pretty decent VA gigs, especially if your CLC nurses/staff don’t have rampant axis 2 disorders.

I did an MHICM/ICMRH rotation during postdoc and really enjoyed community based work, team collaboration and chill pace and if I hadn’t been spoiled by my full remote gig benefits, I would certainly consider home based work again.

They can be pretty decent VA gigs and, in truth, I think that they can be one of the better gs-13 jobs out there. That said, the biggest problem with gero has always been that it is extra education and extra work for no/little extra pay. Most everyone I know who does it has a story about an older family member that inspired them into practice. Otherwise, in the real world, you are relying on Medicare for pretty much all of your income. On the assessment side, folks are more interested in the forensic side of things because of the money. Ask @WisNeuro about that. On the therapy side, there is little private pay due to Medicare being ubiquitous. Add in tele-health being more difficult as an additional negative. Both in medicine and psychology, you can do this work as a generalist with no real consequences because there are plenty of old people. In fact many geriatric trained physicians go out of their way to not advertise their specialty and cap their gero practice in the interest of making decent money. Add to that the pandemic really gutted CLCs nationwide and made them miserable places to work. HBPC has always had the issue of traveling to people's homes and, as psychology skews more female, I see less people willing to do this due to the perceived danger (HBPC has a large number of men nationally relative to psychology overall). As someone involved with gero at the national level outside of VA, I see a lot of the older, established folks walking towards retirement and few interested in taking their place. Honestly, I have been doing this for more than a decade and I am still weighing whether to continue to do this work or just move toward a general telehealth practice. I am hoping that more programs push for telehealth geropsychologists, but the move is slow. Some will argue that telehealth is not effective for this population, but the alternative seems to be abandoning them altogether.

 

[AcronymAllergy]

The sad thing is that research consistently supports that behavioral interventions for dementia should generally be the first line intervention (e.g., before medication), can improve quality of life and functioning, and at times delay the need for SNF/assisted living placement. Unfortunately, I don't know that insurance pays enough, if at all, for these services, and there just aren't many providers trained to offer them.

 

[Sanman]

The sad thing is that research consistently supports that behavioral interventions for dementia should generally be the first line intervention (e.g., before medication), can improve quality of life and functioning, and at times delay the need for SNF/assisted living placement. Unfortunately, I don't know that insurance pays enough, if at all, for these services, and there just aren't many providers trained to offer them.

2024 CMS final rule finally allows for a caregiver training CPT code. They are finalizing the rule, but I believe it was proposed as being in group format only. Prior to this, I was well trained in an unbillable service. Fun fact, CMS rules for skilled nursing require behavioral interventions as a first line prior to medication management for dementia and have for decades. They also specifically carved dementia out of health and behavior codes, making this an unbillable service for us. There was also no ability to charge for training staff, so CMS demand for an unbillable service that no nursing home would ever pay for out of their own pocket. We will see if it pays to offer the service or if I will be losing money vs psychotherapy.

 

[WisNeuro]

IIRC correctly, the proposed RVUs do not make these codes attractive to doctoral providers.

 

[cara susanna]

REACH is annoying. That is all.

Like if it's so important that my patient be contacted to be informed that they're in this program, why don't they do it??

 

[Sanman]

REACH is annoying. That is all.

Like if it's so important that my patient be contacted to be informed that they're in this program, why don't they do it??

REACH-VA caregiver support? Why are they bothering you?

 

[cara susanna]

REACH-VA caregiver support? Why are they bothering you?

It's the suicide one, so like identifying veterans that are high risk for suicide (but separate from the HRF)

 

[Pragma]

Last week was my first week being out of my VA job. I was able to wake up at 9AM...watch some episodes, see some patients....all from the comfort of my home in my pajamas. I didn't have to check my VA cell phone, be up early, put the wireless computer mouse on the iRobot to move around so it would appear I was present on TEAMS. Life is good.

Sounds like a crafty mouse juggler

 

[Fan_of_Meehl]

REACH is annoying. That is all.

Like if it's so important that my patient be contacted to be informed that they're in this program, why don't they do it??

Patient has been scheduled for weekly appointments for CPT (for PTSD), medication management appointments, SUDS IOP (multiple days/wk), HUD-VASH (for housing), CWT (for supported employment), has met with the patient advocate who is helping him get hooked up with a VSO to file a claim for service connection and try to get caregiver support, has been offered residential treatment (but declined), OT services (alpha stim and group therapy), consults for ADHD assessment and tobacco cessation, suicide prevention followup (due to HRSF status), has two community care consults (for neurology and a sleep study), has f/u appointments with primary care scheduled and...

The REACH-VET Coordinator puts in a note like...

"I am the REACH-VET Coordinator for the XYZ VACHS and have been informed that John Smith continues to be a veteran who might benefit from enhanced treatment. I have informed the veteran's provider to determine whether any additional steps (e.g., care enhancements, outreach or other services) are clinically indicated at this time."

Well...since medication and/or psychotherapy are the standard of care for treating MH conditions and I think we've got that covered (and then some) I can think of no other indicated "enhancements" at this time.

Unless, of course, the sky is the limit and ya'll are open to paying a PhD $400/hr to provide continuous 24/7 intensive tx and concierge shuttle /food prep/ dining and domicillary services to the tune of $67,200 /wk...

Then we can talk.

This job is so utterly absurd.

 

[summerbabe]

REACH is annoying. That is all.

Like if it's so important that my patient be contacted to be informed that they're in this program, why don't they do it??

I like the idea of REACH & I think it can serve a valuable role.

But tagging a current or previous provider in a chart and expecting them to work some magic is absurd.

Why not hire a social worker or two and have them do all the clinical contacts, provide some brief coping-focused interventions when appropriate, and do case management or care coordination, such as getting them back onto therapy or psychiatry caseloads?

Not only would that be a good use of an FTE but it would help a facility's SAIL metrics either immediately or long-term via engagement/re-engagement metrics.

No wait, that makes too much sense.

 

[Fan_of_Meehl]

I like the idea of REACH & I think it can serve a valuable role.

But tagging a current or previous provider in a chart and expecting them to work some magic is absurd.

Why not hire a social worker or two and have them do all the clinical contacts, provide some brief coping-focused interventions when appropriate, and do case management or care coordination, such as getting them back onto therapy or psychiatry caseloads?

Not only would that be a good use of an FTE but it would help a facility's SAIL metrics either immediately or long-term via engagement/re-engagement metrics.

No wait, that makes too much sense.

If I am remembering my OIG investigative reports correctly (I tend to read the ones pertaining to mental health investigations of 'what went wrong')...I think the REACH VET policy/procedure came as a result of some episode of care in a VA system where a depressed/suicidal veteran slipped through the cracks and failed to get basic followup care/ treatment (after visiting and being released from urgent care, I think).

If people had just been doing the basics, it wouldn't have happened.

So they overreact and create whole new policies/procedures, champions, etc. etc.

And say, 'let's pay someone to put notes in the chart and bug the provider to 'review the record' and go on record saying that there are no further 'enhancements of care' that are clinically indicated' so that if the person does die by suicide we have someone to play 'pin the tail/blame on the provider' with.

 

[Sanman]

It's the suicide one, so like identifying veterans that are high risk for suicide (but separate from the HRF)

Gotcha, my mind jumps to the caregiver support folks as that is where my attention goes.

 

[Sanman]

Patient has been scheduled for weekly appointments for CPT (for PTSD), medication management appointments, SUDS IOP (multiple days/wk), HUD-VASH (for housing), CWT (for supported employment), has met with the patient advocate who is helping him get hooked up with a VSO to file a claim for service connection and try to get caregiver support, has been offered residential treatment (but declined), OT services (alpha stim and group therapy), consults for ADHD assessment and tobacco cessation, suicide prevention followup (due to HRSF status), has two community care consults (for neurology and a sleep study), has f/u appointments with primary care scheduled and...

The REACH-VET Coordinator puts in a note like...

"I am the REACH-VET Coordinator for the XYZ VACHS and have been informed that John Smith continues to be a veteran who might benefit from enhanced treatment. I have informed the veteran's provider to determine whether any additional steps (e.g., care enhancements, outreach or other services) are clinically indicated at this time."

Well...since medication and/or psychotherapy are the standard of care for treating MH conditions and I think we've got that covered (and then some) I can think of no other indicated "enhancements" at this time.

Unless, of course, the sky is the limit and ya'll are open to paying a PhD $400/hr to provide continuous 24/7 intensive tx and concierge shuttle /food prep/ dining and domicillary services to the tune of $67,200 /wk...

Then we can talk.

This job is so utterly absurd.

If the coordinator was a more senior clinician it might make more sense and provide better value. Document chronic and acute suicide risk level, steps being taken by various providers and create some real care coordination by providing a comprehensive note related to treatment planning already being done do that providers don't need to jump around the chart. Then make a suggestion if you have any. That would be work though.

 

[Fan_of_Meehl]

If the coordinator was a more senior clinician it might make more sense and provide better value. Document chronic and acute suicide risk level, steps being taken by various providers and create some real care coordination by providing a comprehensive note related to treatment planning already being done do that providers don't need to jump around the chart. Then make a suggestion if you have any.

Absolutely agree. I don't object to the idea, if properly executed (as you suggest). A higher-level clinical review by a different provider (or small group of providers) might actually, at least in theory, add some value or oversight.

Unfortunately...

The REACH VET 'coordinator' is literally typing a doggone form letter (just a pro forma boilerplate paragraph) that basically says...

"The provider will guarantee that there's nothing else we need to do."

Which is idiotic (and infantilizing).

If the provider thought there was something else we needed to do...he would have already done it in the first place.

 

[cara susanna]

Patient has been scheduled for weekly appointments for CPT (for PTSD), medication management appointments, SUDS IOP (multiple days/wk), HUD-VASH (for housing), CWT (for supported employment), has met with the patient advocate who is helping him get hooked up with a VSO to file a claim for service connection and try to get caregiver support, has been offered residential treatment (but declined), OT services (alpha stim and group therapy), consults for ADHD assessment and tobacco cessation, suicide prevention followup (due to HRSF status), has two community care consults (for neurology and a sleep study), has f/u appointments with primary care scheduled and...

The REACH-VET Coordinator puts in a note like...

"I am the REACH-VET Coordinator for the XYZ VACHS and have been informed that John Smith continues to be a veteran who might benefit from enhanced treatment. I have informed the veteran's provider to determine whether any additional steps (e.g., care enhancements, outreach or other services) are clinically indicated at this time."

Well...since medication and/or psychotherapy are the standard of care for treating MH conditions and I think we've got that covered (and then some) I can think of no other indicated "enhancements" at this time.

Unless, of course, the sky is the limit and ya'll are open to paying a PhD $400/hr to provide continuous 24/7 intensive tx and concierge shuttle /food prep/ dining and domicillary services to the tune of $67,200 /wk...

Then we can talk.

This job is so utterly absurd.

Right?? This patient is already doing weekly therapy (EBP) with me. And then they're like "please contact to notify the patient about this program." What is there to notify them about? Is it really great to tell a patient "hey, this algorithm is showing you're at greater risk of suicide sooooo yeah"?

It feels like they're just second guessing me while also providing ZERO assistance

 

[Fan_of_Meehl]

Right?? This patient is already doing weekly therapy (EBP) with me. And then they're like "please contact to notify the patient about this program." What is there to notify them about? Is it really great to tell a patient "hey, this algorithm is showing you're at greater risk of suicide sooooo yeah"?

It feels like they're just second guessing me while also providing ZERO assistance

The people writing MH policy/procedures in the VA system just make up concepts that don't even exist in the medicolegal or clinical literature. Like, WTF is "enhanced care?" If they are an outpatient, then weekly psychotherapy and/or medication is standard of care. If they're getting that (and are not acute/subacute enough to need inpatient or residential tx) then I'm not sure what "enhanced care" is even referring to in this context.
.
Similarly, WTF is a 'Mental Health Treatment Coordinator' role/responsibility as contrasted with a psychotherapist or a case manager? Psychotherapy roles have boundaries and the psychotherapist-patient relationship can be terminated at some point. MHTC is essentially for life and I probably have 400-500 people for whom I am nominally/technically their MHTC.

This ambiguity causes massive stress on providers.

 

[Sanman]

Absolutely agree. I don't object to the idea, if properly executed (as you suggest). A higher-level clinical review by a different provider (or small group of providers) might actually, at least in theory, add some value or oversight.

Unfortunately...

The REACH VET 'coordinator' is literally typing a doggone form letter (just a pro forma boilerplate paragraph) that basically says...

"The provider will guarantee that there's nothing else we need to do."

Which is idiotic (and infantilizing).

If the provider thought there was something else we needed to do...he would have already done it in the first place.

Well of course. Why provide value when a form letter will do. This is not about doing better. It is about the appearance of doing better.

 

[Sanman]

The people writing MH policy/procedures in the VA system just make up concepts that don't even exist in the medicolegal or clinical literature. Like, WTF is "enhanced care?" If they are an outpatient, then weekly psychotherapy and/or medication is standard of care. If they're getting that (and are not acute/subacute enough to need inpatient or residential tx) then I'm not sure what "enhanced care" is even referring to in this context.
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Similarly, WTF is a 'Mental Health Treatment Coordinator' role/responsibility as contrasted with a psychotherapist or a case manager? Psychotherapy roles have boundaries and the psychotherapist-patient relationship can be terminated at some point. MHTC is essentially for life and I probably have 400-500 people for whom I am nominally/technically their MHTC.

This ambiguity causes massive stress on providers.

The problem is not the positions. It is that the same person is doing all of the things. The MHTC should be a dedicated case manager, not a clinician with other stuff to do. "Enhanced care" again can be done by a case manager. Hire someone.

Look at me. I am a job creator. #Sanmanforpresident 2024

EDIT: While we are at it. Make all Psychology Chiefs GS-15 and all program managers/ team leaders (anyone managing consult flow) GS-14. Stop being cheap.

 

[Shiori]

A case manager would be amazing. With about 10-20% of my clients, a good chunk of the session is used to follow up on consults and get them connected to appropriate referrals. I have spent hours just trying to get clients connected to PC because they came to us directly from SP. I keep hearing rumblings about practicing "at the top of my license," but that is still a work in progress. I don't mind doing it, but it's definitely not an efficient use of resources.

 

[cara susanna]

The problem is not the positions. It is that the same person is doing all of the things. The MHTC should be a dedicated case manager, not a clinician with other stuff to do. "Enhanced care" again can be done by a case manager. Hire someone.

Look at me. I am a job creator. #Sanmanforpresident 2024

EDIT: While we are at it. Make all Psychology Chiefs GS-15 and all program managers/ team leaders (anyone managing consult flow) GS-14. Stop being cheap.

This actually is going to be a change: MHTC will be a new position (one per BHIP), whose job is to coordinate care.

 

[summerbabe]

A case manager would be amazing. With about 10-20% of my clients, a good chunk of the session is used to follow up on consults and get them connected to appropriate referrals. I have spent hours just trying to get clients connected to PC because they came to us directly from SP. I keep hearing rumblings about practicing "at the top of my license," but that is still a work in progress. I don't mind doing it, but it's definitely not an efficient use of resources.

Sorry but let me introduce you to the new associate administrative officer for mental health (but they will only support our 5 bed RRTP program).

So yes, good case management is a huge need.

The ‘place a new social work consult’ every time that a case management need comes up system is bonkers.

 

[cara susanna]

Our psychotherapy template now he has a section on case management and I'm so bitter that I keep writing "case management is not locally available within (cboc name) OPMH"

 

[deleted1129370]

PSA for switching to private practice from the VA:

 

[Sanman]

PSA for switching to private practice from the VA:

EDIT: With this, I have inadvertently realized that Star Wars was an allegory about modern American healthcare.

Luke Skywalker - Eager intern/resident
Obi wan Kenobi - Wise supervisor that is slightly grizzled
Yoda - Famous VA psychologist that wrote a textbook you once read and remembers when VA staff took two hour daily lunches
Darth Vader - Rich private practice owner
Han Solo - Renegade therapist turned life coach that is all about the money, but still likable
Chewbacca - Therapy Dog