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VA Mental Health Provider Venting / Problem-solving / Peer Support Thread
Started by Fan_of_Meehl
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Not sure what to say other than, damn, that sucks! Is your leadership at least aware of the situation / supportive?
Sanman
O.G.
We just made them aware when a few us noticed jacked up encounters while gathering up notes for quarterly peer review. So they are now aware. Supportive, no just trying to not look like they have egg on their faces. It is not as if anyone in the psychology dept has control over this stuff.
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This happened to a few of us as well, and there didn't seem to be any rhyme or reason to it. Your best bet may be setting up a meeting between you and other affected providers, your service chief, and the head of billing. But As we know, good luck getting all those people to reply.
Sanman
O.G.
Thanks for the advice. Good luck is right. At the moment, local leadership is trying to address new RVU expectations for several psychology specialty areas in the middle of the pandemic while things are being down-coded and visits are anything but normal. Several battles to fight at the moment and I need a drink.
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Ugh what a mess, sorry you're having to deal with this and having all the important stuff out of your hands! And I hope this provides a brief respite from RVU talk as they sort things out.
I've always wondered what the worst case scenario was for providers who are below admin expectations. There were some long-tenured providers at my last VA who consistently didn't sign notes for 7+ days and as far as I can tell, nothing of consequence ever happened. Is it mainly admin wielding the threat of consequence but knowing they don't actually have the authority to do much of consequence?
I've always wondered what the worst case scenario was for providers who are below admin expectations. There were some long-tenured providers at my last VA who consistently didn't sign notes for 7+ days and as far as I can tell, nothing of consequence ever happened. Is it mainly admin wielding the threat of consequence but knowing they don't actually have the authority to do much of consequence?
Sanman
O.G.
Well, worse come to worse, I am willing to find out while building my PP on side. Always have a backup plan folks.
My guess would be they could place you on an FPPE. If you aren't meeting the requirements of that FPPE, then they could probably move toward termination.
A lot of that depends on how motivated they are, how much paperwork they want to complete, and how much they want to deal with the union. I suspect you'd have a pretty good argument for yourself if you could say the billing people are downcoding your appts, so your RVUs are X but should be Y.
I heard that they send in a short guy from HR dressed up in full Hamburglar regalia to burst into your office at lunchtime and scream, 'Robble Robble Robble!!!' at you full tilt for a good 20 mins while wagging his finger at you. Then you only get the remaining 10 mins to finish your hamburger.
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You know the Gen Zers have no idea who that is. You have to include an analogy of Logan Paul or someone shattering their spine on milk crates for that generation to understand.
For what it's worth, I was below my RVU target one year and still got "Meets Expectations." I just didn't get a bonus. I talked to my supervisor about my concerns regarding my lower RVUs beforehand though, so they knew that I was working on it.
I've always wondered about this. So how--even in principle--is an outpatient provider supposed to increase rvus's when our clinic grids are chosen for us and we simply see everyone who shows up (since someone else does the scheduling?).
Sanman
O.G.
There are only two ways:
Upcode your visits (45 min visit becomes a 55 min visit) or cold call/harass no shows until they answer and see you. I am having a similar issue.
They are trying to set individualized productivity expectations for all the specialty folks because the previous leadership never did. They are doing this by picking random theoretical numbers (there is no data on non-COVID times as the dashboard only goes back one year) and asking us to meet them. This started with asking HBPC and Neuropsychology to see 7 patients a day if that gives you any idea of how well this is going. Meanwhile, admissions are down and we are admitting more severe dementia folks from long term care that have no psychology needs. What do they want me to do, prop the guy up, declare him cognitively intact, and chat about how he is waiting for the bus to see his young children?
In my particular case, I was undercoding. But, yeah, that bothers me too. A lot of my caseload is BPD and PTSD, so you can imagine the no shows. Plus is it my fault that I'm efficient and don't always need a full session?
I read from the National EBP people that we aren't supposed to be going the full 60 min session and, if we do bill for that, we need to justify why in the note.
Sanman
O.G.
There is a lot push back against the 90837 from insurance companies unless you are doing specific therapies (exposure therapy for anxiety was one if I recall). However, I have not had any issues with billing it since joining the VA and will continue to bill it until I am yelled at by somebody.
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Ugh I feel the pain. One of the main reasons why I moved from my previous inpatient position is that I had the same RVU expectations as BHIP providers (due to inertia and laziness since nobody was checking) and when RVUs became a more focal point nationally earlier this year, instead of working to make some adjustments, the solution was to pick up clinical work for understaffed outpatient clinics. Yea, that didn't go over great with me.
Interesting, I hadn't ever heard of that. I'm a talker and not especially efficient so I find myself hitting the top of the hour quite often.
Yeah, you'll definitely get a lot of scrutiny and possibly denials if you use this regularly.
Sanman
O.G.
Medicare used to be more liberal, but started cracking down in 2017-18 with auditing from outside companies. The private insurers have been denying it since 2014. At least in my experience.
Yeah, some are automatic denials. some need some sort of prior auth to "justify" the session length. If you read through their guidelines, some are easier than others to get that approval if you know how to word things.
I've been hearing of a lot of Medicare and private insurance audits of late per my state's listserv. For the former, it does definitely sound like it's related to the specific company managing Medicare here.
Sanman
O.G.
This is exactly what is happening with us. They are "trying" to fix it, but I just got hit up with helping out in the outpatient clinic yesterday. It is not sitting particularly well with me either.
I can definitively say supervisors and local leadership are supposed to work with providers, especially specialty providers, to individualize RVU goals. To the best of my knowledge, all they have nationally are the data for psychologists as a whole.
Now, the odds of that happening? Mixed.
Now, the odds of that happening? Mixed.
Sanman
O.G.
Absolutely, they are. The issues is there is no data for individualized productivity because they had all of us help out in other clinics during the pandemic. So, they are making up random numbers rather than working with us to set up reasonable expectations based on caseload. HBPC work is often consultative and not easily billable by nature, so RVU expectations are not the best measure.
Yep, and because many of the first-line supervisors are just as overworked as frontline clinicians, they don't necessarily have the time or energy to sit down and meet with every provider to do the math on a reasonable goal. Easier just to have a single guideline (e.g,. "reduce by 15%") and apply broadly.
Not to mention the fact that full 50 to 55 min sessions is the norm in psychotherapy and they keep adding mandated components to cover in the sessions.
I saw a recent breakdown of average RVUs of psychologists employed by each VISN but it was not differentiated by position type.
Exactly. In my previous gig, daily rounding would take between 75-120 mins depending on the census and the attending. So a solution that was thrown out was to only attend rounds every other day in order to create consistent outpatient slots where RVUs can be generated. I threw out some stall tactics to attempt prolong these changes and in the meantime, doubled down on my job search. I was also fairly unconfident that my particular leadership would be responsive to other solutions, unfortunately.
Sanman
O.G.
Many of the central office folks for specialty programs have done surveys of provider productivity and have some numbers, but they are not all in one place. I know I have seen HBPC numbers from the national folks that run the program.
That’s frustrating and feels like a fairly simple thing for the national program directors to collect and disseminate to local facilities.
I reached out to VA inpt colleagues around the country about how their productivity was tracked and it was all over the place, ranging from having never talked about it with admin, to adjusted RVUs, to internal encounter tracking systems that bypass RVUs all together so there wasn’t any consistency which leads to situations like these where local program managers and chiefs pull stuff out of thin air (or intentionally use these opportunities to fill gaps elsewhere).
Sanman
O.G.
Same for HBPC on a national level. It is the most frustrating thing about specialty care in the VA.
How is it possible to see 7 patients in HBPC? All VVC visits maybe?
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How is it possible to see 7 patients in neuropsychology in a day? That was essentially a busy week for me in fellowship (4 outpatients, ~3 inpatients). This was doing all my own testing.
Sanman
O.G.
It isn't. Local leadership decided that everyone needed a grid and 7 patient blocks because they have no idea what we do. I do wonder if they are telling the surgeons to see any many patients as the primary care docs as well. Makes about as much sense.
I have exactly 2 veterans on my roster that are capable of using VVC independently and own their own computer/smartphone/tablet. Not sure what I would do with the other 33 slots.
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Sorry WisNeuro, I left you out. My apologies. That is an insane expectation.
No worries, just pointing out that that expectation would be absurd for both HBPC and Neuropsych, despite Sanman saying that that was the message sent down by admin who obviously does not know what either service line actually does. It's almost as bad as maintaining % grid appointments filled for providers with lengthy sessions, and giving then no ability to reschedule into non-grid slots. But, who am I to question the omnipotence of higher ups in the VA? 🙂
I mean, I guess if you have a gaggle of psychometrists and a whole lot of testing space, and you don't mind doing 6-8 hours' worth of interviewing each day...
...but if you're doing that much work on a VA salary, they're making a killing off of you. Heck, like you've said, even at 7 patients a week, they're riding your work to the bank.
But yes, both HBPC and neuropsych are notoriously and widely misunderstood by facility leadership (and sometimes even MH leadership) pretty much nationwide.
I could see this as feasible (in an absurd sense) if you had a very templated report, had 2 psychometrists, and kept interviews to 31-40 minutes, and only did very basic dementia evals. Do interview, hand off to psychometrist. Do interview hand off to other psychometrist. Testing battery is about an hour. Rinse and repeat, psychometrist enters testing info into your results section, and you dictate the other sections in the small bits of downtime. You'd have to maintain a good amount of efficiency, and you're also losing out on your higher billing codes (96133) if you skimp on report writing and feedback sessions, but hey, you'd be making Mr. Midlevel Manager McSpreadsheets happy up in regional office.
This is going to be a long post here.
To keep myself busy and justify my low HBPC caseload (currently doing 1-2 visits/day; patients live in the range of 15-90 mins travel distance from the VA), I agreed to help out PCMHI. Right now, I only have a VVC clinic for outpatient cases. While the other clinics that can be used for PCMHI are still in the work to be built, some providers heard from the grapevine and started giving me referrals. Referrals are great, but I don't have a phone clinic or a regular clinic to document telephone and F2F encounters.
The primary care providers seem to be very excited about getting extra help. We are a very small VA and there are no BHL techs to do the baseline. No MSA has been designated to me to make scheduling calls. In case I need to do a risk assessment and/or a safety plan over the phone, I don't see a way to document appropriately in CPRS. Due to my concerns, I have not called the new referrals whose risk levels are unclear. My supervisor is very fair, and I don't feel being pressured by her to get on with the referrals right away. She sent a group email out to let the primary providers know that I won't be able to see any referrals unless they are willing and able to be seen via VVC.
I have reached out to one of the referrals who never used VVC before; however, claims VVC capability. Not having a phone clinic for PCMHI, I documented all our initial telephone contacts as addendums to a note entered by the referring provider. Also added comments to the consult note. This patient presented to have a lot of protective factors and doesn't seem to be at high risk at this moment. The likelihood that he would call me for crisis is slim, although that can change. Nonetheless, we were able to schedule a VVC follow-up and I plan to use VVC Now for the upcoming session. Continue to document telephone contacts/encounters as addendums is somewhat problematic, in case VVC doesn't work out in one of the sessions or doesn't work out at all. Things move VERY slow at my VA, and I am not sure how long will it take to have my clinics built.
There is another referral who is supposedly VVC capable and possibly willing to do VVC that I might be able to pick up as a new patient. The most recent C-SSRS was negative, and the patient is referred for depression, anxiety, and "complicated PTSD." This patient is currently a full-time student at an out-of-state university that is about 12 hours driving distance from us. At my last VA, we usually connect veterans to their close CBOC if there isn't a closeby VA hospital. This patient currently lives in a metro area, and there is a Level 1a VA hospital about 20 minutes away from the University that the patient is attending. I wouldn't mind providing transitional care if enrollment and registering with the new VA will take time. However, if the veteran prefers to be treated at my VA, are there any ethical or clinical concerns? My role is limited to providing PCHMI level brief treatment. If the patient needs a greater level of care, then I would refer to MHC. Shouldn't the patient be referred to the Level 1a metro VA instead of my VA? I am hesitant to call the patient and establish treatment without thinking it through. Wonder what your thoughts are.
Thanks a million!
To keep myself busy and justify my low HBPC caseload (currently doing 1-2 visits/day; patients live in the range of 15-90 mins travel distance from the VA), I agreed to help out PCMHI. Right now, I only have a VVC clinic for outpatient cases. While the other clinics that can be used for PCMHI are still in the work to be built, some providers heard from the grapevine and started giving me referrals. Referrals are great, but I don't have a phone clinic or a regular clinic to document telephone and F2F encounters.
The primary care providers seem to be very excited about getting extra help. We are a very small VA and there are no BHL techs to do the baseline. No MSA has been designated to me to make scheduling calls. In case I need to do a risk assessment and/or a safety plan over the phone, I don't see a way to document appropriately in CPRS. Due to my concerns, I have not called the new referrals whose risk levels are unclear. My supervisor is very fair, and I don't feel being pressured by her to get on with the referrals right away. She sent a group email out to let the primary providers know that I won't be able to see any referrals unless they are willing and able to be seen via VVC.
I have reached out to one of the referrals who never used VVC before; however, claims VVC capability. Not having a phone clinic for PCMHI, I documented all our initial telephone contacts as addendums to a note entered by the referring provider. Also added comments to the consult note. This patient presented to have a lot of protective factors and doesn't seem to be at high risk at this moment. The likelihood that he would call me for crisis is slim, although that can change. Nonetheless, we were able to schedule a VVC follow-up and I plan to use VVC Now for the upcoming session. Continue to document telephone contacts/encounters as addendums is somewhat problematic, in case VVC doesn't work out in one of the sessions or doesn't work out at all. Things move VERY slow at my VA, and I am not sure how long will it take to have my clinics built.
There is another referral who is supposedly VVC capable and possibly willing to do VVC that I might be able to pick up as a new patient. The most recent C-SSRS was negative, and the patient is referred for depression, anxiety, and "complicated PTSD." This patient is currently a full-time student at an out-of-state university that is about 12 hours driving distance from us. At my last VA, we usually connect veterans to their close CBOC if there isn't a closeby VA hospital. This patient currently lives in a metro area, and there is a Level 1a VA hospital about 20 minutes away from the University that the patient is attending. I wouldn't mind providing transitional care if enrollment and registering with the new VA will take time. However, if the veteran prefers to be treated at my VA, are there any ethical or clinical concerns? My role is limited to providing PCHMI level brief treatment. If the patient needs a greater level of care, then I would refer to MHC. Shouldn't the patient be referred to the Level 1a metro VA instead of my VA? I am hesitant to call the patient and establish treatment without thinking it through. Wonder what your thoughts are.
Thanks a million!
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1) 'while waiting for my clinics to be built.' I feel ya. I hate it when they use that phrase. I always want to reply, 'You mean...like an actual physical clinic space or something...using bricks, mortar, glass, insulation... Who you gonna get to do the permits?' I mean, they only have to enter some info into a database to 'build' the clinic, as I understand it. Not sure how it could possibly take more than a few minutes of data entry by a clerk or IT person or something. I've seen the task of 'building' such clinics take weeks.
2) I have a problem, generally, with being expected to take on new cases that are hours away geographically (when another clinic/hospital/CBOC is within close driving distance), especially when there isn't even any decent reason for the patient NOT to attend the closer clinic. One reason is that I've noticed that if folks have to drive an hour or more to sessions (many veterans strongly prefer/insist on face to face), the chances of them (empirically) completing an actual course of treatment is dramatically reduced (in my experience). Moreover, I think it adds unnecessary complications/stress to managing crisis situations, especially if they are, God forbid, in another state/jurisdiction where the involuntary hospitalization laws and procedures may differ from your own state's.
Sanman
O.G.
I would definitely get clarification from higher ups regarding tele-mental health treatment across state lines. Not for nothing, but its appears as if your good deed of helping out is getting you referrals no one else wants to deal with and are might be difficult to manage. This is often why I try not to be helpful. Been burned too many times.
Just a question, is your caseload for HBPC "low" due to the census or slow referral process? If it is referrals, the time may be best used to identify all the HBPC folks on your team with dementia and depression, secure referrals, and complete initial evals.
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A lot of suicide prevention coordinators and SWers who do f/u calls to veterans who discharge from community hospitals due to SI do CSREs and safety plans primarily or exclusively over the phone but of course, this is your license and comfort level. I’ve also done my fair share over the phone as part of intakes when it became apparent more substantial risk assessment was needed and when I do, I make sure to note that this was over the phone and visual assessment was not possible.
Yup keep focused on doing PCMHI-type care for all patients as much as possible and rely on interfacility referrals. In this veteran’s case, if their preference is to maintain care with your facility while attending school elsewhere, I don’t think we are allowed to refer to another system. I knew a veteran who would pay out of pocket to fly back to a previous VA to continue their care after moving.
As for ethical concerns, make sure you document consent for telehealth and that you have reviewed benefits and limitations of this modality, their physical location during each appointment and they are aware of resources for acute MH needs (eg., the name and location of their nearest ED, 911, VCL).
As @Sanman brought up, welfare checks and involuntary hospitalization can be dicey because each jurisdiction has their own set of rules and procedures.
Great advice to let your supervisor aware of the out of state aspect. Nationally, there is support for this (e.g., Clinical Resource Hub providers can live anywhere in the US while providing care to veterans belonging to a specific VISN) but you want to make sure admin will have your back just in case things get dicey.
LOL. I jokingly said to my team members out of my frustration that we are waiting for shipment from China to build my clinics.
That is a great point about the legal aspect of involuntary hospitalization. It didn't occur to me until you mentioned it. Thanks, Fan_of_Meehl!
Thank you, Sanman! I will let my supervisor know to get some clarification on Monday. I think you are right about the type of referrals that are sent my way. It makes a lot of sense. The one patient that I was able to schedule was difficult to get a hold of and very picky about appointment date and time. I am fairly new to this VA and am still learning the dynamics. However, I think it is important to establish a healthy and professional boundary from the start.
Our current census is low. We only have a little bit more than 100 patients to manage at this moment. No one is really busy at the HBPC. The dietitian is picking up MOVE! patients for one-on-one to have something to do. Comparing to everything else (delayed pay, 2 weeks to get my office key, 4 weeks to get CPRS access...), referrals are moving at a very decent flow. I have only been here for 6 weeks and have 28 patients (24 established and 4 to schedule). On average, we have 1-3 screenings a week with 1-2 potential new admit(s). My team members are great. We have our hour-long lunch together on the days we are not traveling during lunchtime. If I see a new admit with potential mental health needs after chart review, I would ask to join the social worker's initial visit. She usually takes about 30-45 minutes and I take 15-25 minutes during the initial visit. We schedule follow-up appointments individually, and we document accordingly and separately. Other team members usually tell me in person, co-sign me, or let me know during our team meetings. The HBPC work environment is drama-free and almost stress-free, at least for now. Do you have a more systematic referral process that you would like to share or any suggestions about working efficiently?
The communication of PCHMI forks with constant TEAMS messages is somewhat problematic. I hate getting these messages while traveling on the road as I rely on the Goggle map app on the work phone to get to remote areas that regular GPS does not accurately lead me to. Or I get calls when my light turns green as soon as I log in to my computer trying to do some notes after home visits. I guess some people don't get it that HBPC means HOME-based primary care. We deliver care to patients' homes, and we are not photons that exist as light and waves at the same time. Any suggestions?
You can play around with your Teams status including using Do Not Disturb mode (messages will still be received but don’t ping/popup) along with an away status indicating you are commuting for HBPC and when you anticipate being back in the office. Your HBPC team members will have your phone number and probably wouldn’t use Teams to reach you anyways. If you do, just remember to manually change your status off DND when you’re ready.
More broadly, do you have set PCMHI hours or are you in a float-type role where PC can see if you have time for walk-ins or warm hand-offs?
Thanks for sharing your thoughts and tips, summerbabe! I will definitely let my supervisor know. It makes sense that if the veteran wants to continue treatment at an established VA, then we are to support that. I am only provided with a VVC clinic for outpatient. We are in a rural area where we don't have very good internet service. Many veterans do not have internet or very poor internet service. Using VVC is challenging even with their willingness to try. Tech difficulty, such as disconnection is expected. Using the telephone is the most reliable remote communication with our populations here (I know, we in 2021). So far, all my telephone contacts are posted as addendums to primary care providers' notes because I don't see any other ways to document them. Therefore, my work is not credited, which is not a huge concern. Safe Plan and CSRE need to be separate notes that are more visible than addendums. Doing virtual risk assessment and safety planning is not a problem. The issue is there isn't a phone clinic to put these notes under. My concern is how things will develop as the patient becomes more willing to share after we establish treatment and before I have proper clinics for documentations. Eventually, I will have a phone clinic and a regular clinic. Meanwhile, I will do my best to minimus potential risks.
Playing with my Teams status sounds a little devious but I like it. LOL
Blocking hours for PCMHI is a great idea! The initial agreement was that I will be stationed at our PCMHI once a week for hand-offs and consultation. That has not started yet. Not sure how did it translate to that I can be reached at any time. I will definitely make my supervisor aware when I get in touch with her on Monday. She is very supportive and easy to talk to. Thank you, summerbabe! 🙂
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Tbh, I know you want to contribute, but I would not see pcmhi patients until you are set up with clinics and the support you need to follow their procedures. You should definitely be able to access note titles for risk assessments. If at all possible, I would be spending the spare time you have now optimizing yourself for success (cprs templates, familiarizing yourself with resources).
Sanman
O.G.
It depends on how your HBPC team operates and what other RVU pressures you might be facing. However, I generally use IDT meetings to review charts, Identify anyone with dementia, a mental health diagnosis, or a psychotropic medication. If dementia, have they gotten at least a cognitive screening and a FAST? If not, I take the referral. Any dementia behaviors requiring management? caregiver burnout? For MH dx or psychotropic, what is their plan of care and why are they taking the med. If no mental health professional is listed in the chart, I discuss, call, and complete an initial assessment. Then I refer to psychiatry for med management and follow up to ensure stability of symptoms. Many ways to create work for yourself within HBPC if that is what you want. If it is not that is fine as well.
It is indeed. It has taken me several years to develop strategies to smooth out the corners in my own approach.
Sanman
O.G.
Have you considered opening a PP treating former government employees with PTSD related to bureaucratic forms? Every time I get a form in my inbox, I feel my pulse rate quicken slightly.
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