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

cara susanna

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So I actually became a champion of something at my facility and you wouldn't BELIEVE the number of meetings they have, all of which conflict with my clinical time. How do other providers do this? They must be mostly admin.
 
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Terri Dactyl

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Regarding psychological testing... So the "sense" among psychologists who have time allocated for psych/neuropsych testing is that they (i.e., administration/leadership, supervisors) are trying to eliminate psych testing from our profiles/duties because they "cannot capture workload" and "cannot prove we're actually working" during these times. Several of us have implemented our methods of tracking our work (i.e., spreadsheets).

The attitude is that psychologists are not utilizing this time because our PCUBs don't capture CPTs--- seemingly to forget that all assessment CPT codes are not billed by the day/hour as in therapy and other MH services but after the report is completed (exp: If I begin a testing process first week in January but due to scheduling limitations and limited time each week given to interpret data/write report, the report may not be ready until March so CPT workload isn't captured until the later months); and there is pressure among supervisors/leadership that we need more therapists so the discussion is to eliminate psych testing because it's underutilized, not essential/necessary for treatment (been told that directly), neuropsychology really isn't necessary at the VA (been told that directly too), and "we need more therapy slots.... you could be seeing therapy patients instead..."

So my question is... for those who conduct psych testing, how is your workload captured? Leadership cannot tell us what the SOP is for capturing specifically psych assessment CPT/workload or any information how other VAs maintain psych testing within their facilities.

I mean... we can't all be lazy SOBs trying to get away with not doing work (that's the attitude towards psychologists, unfortunately).
 

WisNeuro

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Regarding psychological testing... So the "sense" among psychologists who have time allocated for psych/neuropsych testing is that they (i.e., administration/leadership, supervisors) are trying to eliminate psych testing from our profiles/duties because they "cannot capture workload" and "cannot prove we're actually working" during these times. Several of us have implemented our methods of tracking our work (i.e., spreadsheets).

The attitude is that psychologists are not utilizing this time because our PCUBs don't capture CPTs--- seemingly to forget that all assessment CPT codes are not billed by the day/hour as in therapy and other MH services but after the report is completed (exp: If I begin a testing process first week in January but due to scheduling limitations and limited time each week given to interpret data/write report, the report may not be ready until March so CPT workload isn't captured until the later months); and there is pressure among supervisors/leadership that we need more therapists so the discussion is to eliminate psych testing because it's underutilized, not essential/necessary for treatment (been told that directly), neuropsychology really isn't necessary at the VA (been told that directly too), and "we need more therapy slots.... you could be seeing therapy patients instead..."

So my question is... for those who conduct psych testing, how is your workload captured? Leadership cannot tell us what the SOP is for capturing specifically psych assessment CPT/workload or any information how other VAs maintain psych testing within their facilities.

I mean... we can't all be lazy SOBs trying to get away with not doing work (that's the attitude towards psychologists, unfortunately).
I'm not sure I understand, testing codes, both neuro and psych, are time based, so there is really no problem with capturing that time as one would with therapy. It would seem that the real issue here is a grossly unacceptable time frame from the testing until the report is written and billing dropped. In most settings, you'd get about two weeks from the testing date to drop the billing, in some, just a week. In my VA time, we had two weeks for reports for the most part.

It sounds like there is no real assessment leadership to advocate for it at your location. Plenty of literature regarding the utility and potential cost savings with the utilization of testing. So, sounds like there needs to be someone to step up to the plate to go to bat for testing, you all just take what they tell you, or you vote with your feet.
 

cara susanna

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Regarding psychological testing... So the "sense" among psychologists who have time allocated for psych/neuropsych testing is that they (i.e., administration/leadership, supervisors) are trying to eliminate psych testing from our profiles/duties because they "cannot capture workload" and "cannot prove we're actually working" during these times. Several of us have implemented our methods of tracking our work (i.e., spreadsheets).

The attitude is that psychologists are not utilizing this time because our PCUBs don't capture CPTs--- seemingly to forget that all assessment CPT codes are not billed by the day/hour as in therapy and other MH services but after the report is completed (exp: If I begin a testing process first week in January but due to scheduling limitations and limited time each week given to interpret data/write report, the report may not be ready until March so CPT workload isn't captured until the later months); and there is pressure among supervisors/leadership that we need more therapists so the discussion is to eliminate psych testing because it's underutilized, not essential/necessary for treatment (been told that directly), neuropsychology really isn't necessary at the VA (been told that directly too), and "we need more therapy slots.... you could be seeing therapy patients instead..."

So my question is... for those who conduct psych testing, how is your workload captured? Leadership cannot tell us what the SOP is for capturing specifically psych assessment CPT/workload or any information how other VAs maintain psych testing within their facilities.

I mean... we can't all be lazy SOBs trying to get away with not doing work (that's the attitude towards psychologists, unfortunately).
Holy cow, that's ridiculous. Do you know where your Chief of Psychology stands on this?
 
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I'm not sure I understand, testing codes, both neuro and psych, are time based, so there is really no problem with capturing that time as one would with therapy. It would seem that the real issue here is a grossly unacceptable time frame from the testing until the report is written and billing dropped. In most settings, you'd get about two weeks from the testing date to drop the billing, in some, just a week. In my VA time, we had two weeks for reports for the most part.

It sounds like there is no real assessment leadership to advocate for it at your location. Plenty of literature regarding the utility and potential cost savings with the utilization of testing. So, sounds like there needs to be someone to step up to the plate to go to bat for testing, you all just take what they tell you, or you vote with your feet.
I am going to second this, why are you not given enough time to report write and get paperwork done in a timely manner? Two weeks seems appropriate and is the general standard I have seen at all my former training sites. It sounds like no one is organizing the testing schedule appropriately. Regarding workload, department leadership is allowed (supposed to) setup alternative metrics for those of us that do not fit neatly into the grid validation scheme to establish appropriate workload. It sounds like someone in your local leadership dropped the ball and now wants to get rid of testing rather than setting guidelines and following them. My VA has a busy neuropsych clinic and it is not going anywhere that I have heard.
 
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erg923

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(exp: If I begin a testing process first week in January but due to scheduling limitations and limited time each week given to interpret data/write report, the report may not be ready until March
I agree that this is a completely unacceptable practice. Don't your patients (or their families) and referral sources complain?
 
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cara susanna

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I am going to second this, why are you not given enough time to report write and get paperwork done in a timely manner? Two weeks seems appropriate and is the general standard I have seen at all my former training sites. It sounds like no one is organizing the testing schedule appropriately. Regarding workload, department leadership is allowed (supposed to) setup alternative metrics for those of us that do not fit neatly into the grid validation scheme to establish appropriate workload. It sounds like someone in your local leadership dropped the ball and now wants to get rid of testing rather than setting guidelines and following them. My VA has a busy neuropsych clinic and it is not going anywhere that I have heard.
Here neuropsych does placeholder notes, so they can still bill for the encounter in time.
 

WisNeuro

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Here neuropsych does placeholder notes, so they can still bill for the encounter in time.
That was what we did as well at the sites I worked at. Though, that was much easier with only having a couple codes billed. At this point I leave the initial encounter open, in case they do not show for feedback (which is very rare). After feedback I bill everything on the feedback note, which includes the full report, and write a quick no charge note for the initial encounter.
 
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That was what we did as well at the sites I worked at. Though, that was much easier with only having a couple codes billed. At this point I leave the initial encounter open, in case they do not show for feedback (which is very rare). After feedback I bill everything on the feedback note, which includes the full report, and write a quick no charge note for the initial encounter.
This, I believe, is how we're "supposed" to do it. Unfortunately, many/most VAs would balk at leaving an encounter open for a couple weeks, so the use of placeholder notes with actual + anticipated CPT codes is one possible compromise, which you can then go back and edit later. The difficulty is that you can't include the feedback code on the initial note, since you'll need it to close the encounter for the feedback appointment.
 

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Fresh vent about the VA:

Dept Chief: Sanman you need to do RQI BLS, it is overdue in your TMS

Me: There is no RQI dummy at our CBOC, we were told not to start RQI is this correct or do I need to start RQI now?

Dept Chief: No Answer

Me: Following up since i got no answer, do you have any guidance about what to do?

Dept Chief: Do RQI (Not answering my original question at all)

Me: Bangs head against wall, finds out name of facility BLS coordinator, and then emails facility BLS coordinator for actual guidance.
 
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WisNeuro

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This, I believe, is how we're "supposed" to do it. Unfortunately, many/most VAs would balk at leaving an encounter open for a couple weeks, so the use of placeholder notes with actual + anticipated CPT codes is one possible compromise, which you can then go back and edit later. The difficulty is that you can't include the feedback code on the initial note, since you'll need it to close the encounter for the feedback appointment.
Ah, we can't include the billing right away, as the billing dept will submit that sucker right away, and, since we haven't done some of that work yet, would technically be billing fraud once submitted. Also, feedback should be rolled into the overall evaluation from a billing standpoint, so shouldn't be a huge issue. Are you billing FB separately?
 

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Ah, we can't include the billing right away, as the billing dept will submit that sucker right away, and, since we haven't done some of that work yet, would technically be billing fraud once submitted. Also, feedback should be rolled into the overall evaluation from a billing standpoint, so shouldn't be a huge issue. Are you billing FB separately?
Our billing folks haven't been the clearest in what they'd like us to do. Technically, like you've said, FB should be included with the billing for all the other stuff (since 96133 isn't really a stand-alone code). Realistically, CPRS isn't setup well to allow that to happen.
 

erg923

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Fresh vent about the VA:

Dept Chief: Sanman you need to do RQI BLS, it is overdue in your TMS

Me: There is no RQI dummy at our CBOC, we were told not to start RQI is this correct or do I need to start RQI now?

Dept Chief: No Answer

Me: Following up since i got no answer, do you have any guidance about what to do?

Dept Chief: Do RQI (Not answering my original question at all)

Me: Bangs head against wall, finds out name of facility BLS coordinator, and then emails facility BLS coordinator for actual guidance.
When I was at the VA, I got along very well with our "chief"..... on a personal level. I think we really liked each other. Shot some pool, knew the husband well, kids were at same Catholic school early on. However, we never really did agree/get on "professionally" (I guess you could say).

Think the Psychology Internship duties/responsibility/ownership spoiled it to some degree? I could go on and on. Funny how that works out.
 
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Sanman

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When I was at the VA, I got along very well with our "chief"..... on a personal level. I think we really liked each other...shot some pool, knew the husband well, kids were at same Catholic school early on. However, we did not really agree/get on "professionally" (I guess you could say). Think the Psychology Internship duties/responsibility/ownership spoiled it??? I could go on and on. Funny how that works out.
Was it because you didn't do your TPS reports? Did you get the memo about the new cover sheets?
 

erg923

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Was it because you didn't do your TPS reports? Did you get the memo about the new cover sheets?
Nuts to that. What else ya got?

She was already "less enamored with myself than some" (so to speak) by late 2016.

During late 2017, we had a pretty formidable row about some VA policy nonsense...but by that time I was already on my way out.
 
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psychRA

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I gave a didactic to interns at my local VA recently (my buddy wont let me give it up even though I haven't worked there in 3 years), and one of the interns told me his assigned MHC supervisor quit 3 months after he started, saying: "This is not a good place to work right now." Apparently, they have all the MH staff in a Bullpen type thing and are using medical/physical exam rooms on a rotating basis for therapy and MH work at that particular CBOC. It's not a temporary set-up either. I cant imagine being treated like that (both as a patient and a psychologist)...especially when working in an area of VA care that is so highly utilized. How bizarre is that???
Those are the new buildings based on the lean model. They sound absolutely miserable. Who could have predicted that a business approach adopted from the manufacturing industry wouldn't translate well to patient care?
 

erg923

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Is this some kind of widespread business plan for the VA? I have one good buddy left there, and we just drink and smoke and **** . He's IOP and SUDS IP, He doesn't know ****. Its a very divorced system there,....[/QUOTE]
 
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WisNeuro

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I just got assigned lean training in CMS. My wife did this at her corporate job 6 yrs ago. VA behind the curve? Checks out to me.
They've been doing it for a while, at least at some leadership levels. One of my postdoc supervisors was doing a lean project way back when.
 
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Fresh vent about the VA:

Dept Chief: Sanman you need to do RQI BLS, it is overdue in your TMS

Me: There is no RQI dummy at our CBOC, we were told not to start RQI is this correct or do I need to start RQI now?

Dept Chief: No Answer

Me: Following up since i got no answer, do you have any guidance about what to do?

Dept Chief: Do RQI (Not answering my original question at all)

Me: Bangs head against wall, finds out name of facility BLS coordinator, and then emails facility BLS coordinator for actual guidance.
Sadly, this sounds typical.
 

cara susanna

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Our latest initiative is trying to increase our percentage of VVC appts by a certain amount. This seems like a very arbitrary goal to me, but whatever.
 

beginner2011

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Our latest initiative is trying to increase our percentage of VVC appts by a certain amount. This seems like a very arbitrary goal to me, but whatever.
What percentage is OMH at right now? I think my site is very close to 100%. I can't imagine there being much opportunity with a metric like that during a pandemic...
 

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We're only at about 25%, apparently. Still doing a lot of phone I guess.
Yup, my facility is somewhere in that range, probably a bit higher now. We have a lot of older prescribers insistent on phone apts or seeing people in person.

I also think there are some issues with people having VVC appointments but either scheduling them in non-VVC clinics or have requested VVC clinics but MAS has not built them yet so those visit may not be counting. Also, I'm not sure if you have to check the 'synchronous telemedicine service' code in CPRS.
 

beginner2011

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Shows how out of the loop I am as a trainee. I forgot about the "meaningful" difference at the administrative level between phone/VVC. I'm sure my site has similar levels of phone > VVC.
 

Therapist4Chnge

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This, I believe, is how we're "supposed" to do it. Unfortunately, many/most VAs would balk at leaving an encounter open for a couple weeks, so the use of placeholder notes with actual + anticipated CPT codes is one possible compromise, which you can then go back and edit later. The difficulty is that you can't include the feedback code on the initial note, since you'll need it to close the encounter for the feedback appointment.
I'm not shocked to see that little has changed in the VA system in regard to how they do documentation. I was last in the VA system in 2009 and that is how we did it then. My mentor would get notifications for "open" encounters, despite there being a placeholder note. Often we would be waiting on outside records that were needed to complete a report. There are so many backwards and conflicting policies in the VA and it seems to only have gotten worse w. the added levels of useless administrators and downward pressure to see more Veterans, spread out, and not based on any kind of science. Back when I was there there was a huge push to get Veterans into groups, but that was to side-step wait times bc there weren't enough providers. The vast majority needed individual interventions, but then no show rates and lack of progress were an issue, etc.
 
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Yup, my facility is somewhere in that range, probably a bit higher now. We have a lot of older prescribers insistent on phone apts or seeing people in person.

I also think there are some issues with people having VVC appointments but either scheduling them in non-VVC clinics or have requested VVC clinics but MAS has not built them yet so those visit may not be counting. Also, I'm not sure if you have to check the 'synchronous telemedicine service' code in CPRS.
I think you do have to check the synchronous telemedicine service box, at least we do at my VA. Also, checking that box makes me imagine people with headsets doing synchronized swimming.
 

cara susanna

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Oh, if there's a checkbox then my numbers are about to go drastically up. Lol.

Thing is, do we have any evidence that VVC is better than phone? I mean intuitively it would make sense, but VVC is also riddled with tech problems that probably also interfere with therapy quality.
 

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Oh, if there's a checkbox then my numbers are about to go drastically up. Lol.

Thing is, do we have any evidence that VVC is better than phone? I mean intuitively it would make sense, but VVC is also riddled with tech problems that probably also interfere with therapy quality.
There is evidence Zoom and other videoconferencing calls are more draining due to 1 to 2 seconds lag that interfere with how our brain interprets information and body language


 

cara susanna

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There is evidence Zoom and other videoconferencing calls are more draining due to 1 to 2 seconds lag that interfere with how our brain interprets information and body language


I was actually thinking of that possibility, too. I have seen some of those articles and found them validating because I do find VVC more exhausting than phone.
 

LadyHalcyon

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I was actually thinking of that possibility, too. I have seen some of those articles and found them validating because I do find VVC more exhausting than phone.
Same. Except my attention span has seriously declined during the pandemic and I find it becoming more difficult to pay attention during phone sessions. However, I find phone sessions less draining and generally more productive.
 

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In person is definitely easier. I can't imagine seeing a busy therapy caseload over video or phone, between the technical difficulties and the greater challenge of focus (at least for me, but it sounds like a lot of people), anything more than 4 appts a day is a grind for me. Thankfully most of my week is spent doing report writing and record reviews, so I can space out my F/U appts.

Is the VA going to keep videoconferencing long-term? How do you think this will effect the positions they look to fill? I can see this as another way to recruit mid-levels and not back-fill psychology positions.
 
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summerbabe

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Is the VA going to keep videoconferencing long-term? How do you think this will effect the positions they look to fill? I can see this as another way to recruit mid-levels and not back-fill psychology positions.
For me, I hope so. I've enjoyed the shift to phone/video and feel like it can definitely increase access to care when implemented properly. I also enjoyed VVC apts pre-COVID and felt like they are generally as or more productive than f2f.

I'm currently actively looking for a fully virtual VA job because I'm sure my ad hoc telework status won't hold up forever and I've enjoyed this shift. But those have been few and far in-between.

At my VA, psychologists are generally valued for therapy positions but we have both PhD and SW/LPC backfill positions as turnover is a major issue.
 

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VA's telehealth and videoconferencing software was in place even before COVID-19, it's just been bolstered since then. I anticipate it persisting going forward, although probably not at a 100% level. I suspect its impact on hiring will vary from site to site. I've heard mention of more fully-virtual positions of late, so that may increase in the future (what VA doesn't have space issues?).
 
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summerbabe

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For those who are ad hoc teleworking, has there been any news/rumors about how long these arrangements might go on at your facility?

At mine, it feels like there's been a push to get some folks back on site more frequently (even if only for 1 day/wk) despite continuing to just do telehealth apts while other clinics/providers have been given permission for permanent telework. .

I think the implication that is if workload is low, they want folks back on station - I'm not sure how that magically manifests new consults but :shrug:
 

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No clue how it'll shake out here, but I'd be surprised if it lasts longer than is required or mandated. It seems like some parties would prefer to have all providers on-site, and to actually never have left, but that was obviously unrealistic. I've been coming in pretty much the whole time, but can understand the utility (and appeal) of telework.
 

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For those who are ad hoc teleworking, has there been any news/rumors about how long these arrangements might go on at your facility?

At mine, it feels like there's been a push to get some folks back on site more frequently (even if only for 1 day/wk) despite continuing to just do telehealth apts while other clinics/providers have been given permission for permanent telework. .

I think the implication that is if workload is low, they want folks back on station - I'm not sure how that magically manifests new consults but :shrug:
It is a mess, but who knows given that so much is dependent on the individual facility directors. For us, I know that PPE has limiting our opening plan and Mental Health is literally last on the list to return to the facility due to tele-health options available. We already had some full-time tele-health positions at the CBOCs, so it will be interesting to see what they do here.
 

beginner2011

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For those who are ad hoc teleworking, has there been any news/rumors about how long these arrangements might go on at your facility?

At mine, it feels like there's been a push to get some folks back on site more frequently (even if only for 1 day/wk) despite continuing to just do telehealth apts while other clinics/providers have been given permission for permanent telework. .

I think the implication that is if workload is low, they want folks back on station - I'm not sure how that magically manifests new consults but :shrug:
My site has been slammed by the increased demand for OMH and the decreased supply of labor (resignations, part-time avilability of staff due to childcare needs, etc.). Is that not the case most places?
 

summerbabe

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My site has been slammed by the increased demand for OMH and the decreased supply of labor (resignations, part-time avilability of staff due to childcare needs, etc.). Is that not the case most places?
I'm not aware of any staff resignations at my site or folks who are now p/t due to childcare. I'm not in GMH but my understanding is that there was a significant dip in April/May and things are getting back to normal but overall demand is still at bit lower compared to pre-COVID, along with an uptick in no-shows/patient cancellations.
 

beginner2011

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I'm not aware of any staff resignations at my site or folks who are now p/t due to childcare. I'm not in GMH but my understanding is that there was a significant dip in April/May and things are getting back to normal but overall demand is still at bit lower compared to pre-COVID, along with an uptick in no-shows/patient cancellations.
What have all the parents of young children been doing to deal with the fact that their children haven't been able to go to daycare/school?
 

summerbabe

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What have all the parents of young children been doing to deal with the fact that their children haven't been able to go to daycare/school?
I live in a state that was slow to shutdown and quick to reopen so there's a whole bunch of in-person education and resumed daycare options currently.

Additionally, the median household income is low in my state. A GS9 or higher job is likely exceeding that median so it's possible that spouses or extended family are picking up the added childcare responsibilities if the VA employee is the high household earner.
 

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What have all the parents of young children been doing to deal with the fact that their children haven't been able to go to daycare/school?
Not sure what they do in other areas, but our state has setup daycare for essential workers. Our daycare never closed, so we've been unaffected. We'll see what happens as schools are starting again this week in a hybrid format for those people.
 
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