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

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cara susanna said:
Our PCPs are refusing to do cognitive screeners and apparently it's now reached OIG levels. Never a dull moment, lol
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Do PCPs lose these kinds of battles? I feel like the compromise always seems to land in PCMHI's lap.
 
Shiori said:
Do PCPs lose these kinds of battles? I feel like the compromise always seems to land in PCMHI's lap.
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PCPs lose plenty of battles. It depends on who is doing the bargaining though. That said, if I don't pick up my phone, ignorance is not a defense for liability if you are an independent provider.
 
Shiori said:
Do PCPs lose these kinds of battles? I feel like the compromise always seems to land in PCMHI's lap.
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Yes, in the past that is what happened - they would always send them to PCMHI. But, since we don't currently have PCMHI, that's not an option and OPMH has put our foot down on taking all of the referrals.
 
cara susanna said:
Yes, in the past that is what happened - they would always send them to PCMHI. But, since we don't currently have PCMHI, that's not an option and OPMH has put our foot down on taking all of the referrals.
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They're sending referrals just for cognitive screening (e.g., MMSE or MoCA)?

If so, I'd say a multidisciplinary cognitive screening clinic like a half-day or one day per week might be able to knock out a bunch of those patients.
 
AcronymAllergy said:
They're sending referrals just for cognitive screening (e.g., MMSE or MoCA)?

If so, I'd say a multidisciplinary cognitive screening clinic like a half-day or one day per week might be able to knock out a bunch of those patients.
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LOL.

This would be the most "VA" solution ever...

An entire clinic solely devoted to doing 'cognitive screeners' for everyone, one after the next...line out the door for blocks and blocks. Maybe they could get one of those luggage conveyor belts that airports use...
 
Fan_of_Meehl said:
LOL.

This would be the most "VA" solution ever...

An entire clinic solely devoted to doing 'cognitive screeners' for everyone, one after the next...line out the door for blocks and blocks. Maybe they could get one of those luggage conveyor belts that airports use...
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I'd sign up for one day a week of just doing SLUMS. But yes what a VA solution when the PCPs need to do these.
 
Fan_of_Meehl said:
LOL.

This would be the most "VA" solution ever...

An entire clinic solely devoted to doing 'cognitive screeners' for everyone, one after the next...line out the door for blocks and blocks. Maybe they could get one of those luggage conveyor belts that airports use...
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It's easy to ace these tests, just say "person, woman, man, camera, TV" over and over and your providers will label you an extremely stable genius who is the most healthy person that ever lived.
 
WisNeuro said:
It's easy to ace these tests, just say "person, woman, man, camera, TV" over and over and your providers will label you an extremely stable genius who is the most healthy person that ever lived.
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WisNeuro said:
It's easy to ace these tests, just say "person, woman, man, camera, TV" over and over and your providers will label you an extremely stable genius who is the most healthy person that ever lived.
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40 out of 30 no notes
 
AcronymAllergy said:
They're sending referrals just for cognitive screening (e.g., MMSE or MoCA)?

If so, I'd say a multidisciplinary cognitive screening clinic like a half-day or one day per week might be able to knock out a bunch of those patients.
Click to expand...

Yup, just for cognitive screeners. Back in the day, PCMHI would do them (so it'd be like a 30 min appt). I used to work in that dept so I did quite a few of them.

I'm glad we're putting our foot down, personally. We don't have the resources, and for PCPs to view this as a "MH thing" is ridiculous. Community neurologists do them all of the time, I know for a fact.
 
cara susanna said:
Yup, just for cognitive screeners. Back in the day, PCMHI would do them (so it'd be like a 30 min appt). I used to work in that dept so I did quite a few of them.

I'm glad we're putting our foot down, personally. We don't have the resources, and for PCPs to view this as a "MH thing" is ridiculous. Community neurologists do them all of the time, I know for a fact.
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Not for nothing, I know the VA does things like this. However, that is a non-billable event if you are coding properly. What would they like you to code the visit as for that?
 
Fan_of_Meehl said:
LOL.

This would be the most "VA" solution ever...

An entire clinic solely devoted to doing 'cognitive screeners' for everyone, one after the next...line out the door for blocks and blocks. Maybe they could get one of those luggage conveyor belts that airports use...
Click to expand...
I've actually seen and heard of versions of it implemented at various VA and non-VA academic medical centers. Basically memory clinics that catch people to perform screenings, provide community and other resources, and determine if further evaluation/care is necessary. So yeah, it wasn't just a line of folks out the door for the MMSE. There were also abbreviated interviews and, if needed, meetings with social workers and such.
 
cara susanna said:
Yup, just for cognitive screeners. Back in the day, PCMHI would do them (so it'd be like a 30 min appt). I used to work in that dept so I did quite a few of them.

I'm glad we're putting our foot down, personally. We don't have the resources, and for PCPs to view this as a "MH thing" is ridiculous. Community neurologists do them all of the time, I know for a fact.
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For sure; we required a cognitive screener prior to accepting neuropsych referrals, so our PCPs routinely gave them. And yeah, it's a rare neurology note that I review that doesn't reference a current or past cognitive screener score. Same with many community PCP notes. As an aside, in my experience, PCPs strongly favor the MMSE (probably due to familiarity) or occasionally SLUMS and neurology strongly favors the MoCA.
 
Sanman said:
Not for nothing, I know the VA does things like this. However, that is a non-billable event if you are coding properly. What would they like you to code the visit as for that?
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I just billed it like I would any PCMHI brief assessment. The appt also consisted of a brief functional interview.
 
cara susanna said:
I just billed it like I would any PCMHI brief assessment. The appt also consisted of a brief functional interview.
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Got it, it was the "just a cog screener" that caught my eye. I get referrals for that all the time. The issue being that this alone is not enough for a billable visit. Particularly is the person is a poor historian. The referral really needs to be better.
 
Fan_of_Meehl said:
I don't think that anyone who is a front-line mental health psychotherapist is happy right now, especially in the current climate of, "Just do more with less" while we are seeing more patients with fewer therapists.
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Agreed. Some have it worse than others. That said, this is a good time if you are looking for a transfer.
 
We have a social worker on our team who keeps pushing longer term therapeutic relationships and citing that leaders in the field acknowledge change takes years. It irks me. Anyone else struggling with their social work colleagues?
 
Behaviorismiscool said:
We have a social worker on our team who keeps pushing longer term therapeutic relationships and citing that leaders in the field acknowledge change takes years. It irks me. Anyone else struggling with their social work colleagues?
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Our social workers here in MHC are great. They definitely stick to the time-limited "dose of care" model. I think the only person dragging their feet is one of the psychologists. They get all the veterans who fire the therapists who don't do long-term supportive therapy. Selfishly, it's kind of nice to have one or two therapists who do it that way because otherwise those patients cycle back onto my caseload every 3-6 months.
 
Behaviorismiscool said:
We have a social worker on our team who keeps pushing longer term therapeutic relationships and citing that leaders in the field acknowledge change takes years. It irks me. Anyone else struggling with their social work colleagues?
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I have run into a few and it is becoming an ongoing battle with the hire ups pushing access. I have mhc social workers seeing folks for 10 years straight. No idea if it is a conceptual issue or simply bowing down to the almighty grid/rvu recs in the laziest way.
 
For the most part, the social workers in our clinic are FANTASTIC and value evidence-based practice. There are a handful that will fall into some less empirically supported things, including EMDR (which I know isn't fair because TECHNICALLY EMDR is an EBP), but that's the worst of it.
 
Shew we got proponents of IFS and supportive therapy (i.e., case management) where I'm at. My supervisor is a psychologist trained in EMDR, not that they see patients anymore. It's a mess of bad clinical practice here, but hopefully not causing too much patient harm. There's no legitimate clinical oversight as we all know, so it doesn't matter too much what I think about what they are doing with these patients.
 
Shiori said:
I feel like the issues I'm having will follow me to most VAs, unfortunately.
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Classic case of 'it's not me, it's you!", unfortunately.

Recently, I've been trying to lean more heavily into both acceptance and IDGAF (like logging into all staff Teams meetings to be technically in attendance and then muting the audio) so I can better focus on the parts of the job that I do like, of which there is still plenty of.
 
summerbabe said:
Classic case of 'it's not me, it's you!", unfortunately.

Recently, I've been trying to lean more heavily into both acceptance and IDGAF (like logging into all staff Teams meetings to be technically in attendance and then muting the audio) so I can better focus on the parts of the job that I do like, of which there is still plenty of.
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I always say that this job is a marathon, not a sprint. If you have to half-ass some things in order to make it sustainable, it's still way better than you getting burnt out and quitting (and I don't know about you guys, but it seems like everytime we have a vacancy the pool of candidates gets less and less in terms of quality - especially psychologists)
 
summerbabe said:
Classic case of 'it's not me, it's you!", unfortunately.

Recently, I've been trying to lean more heavily into both acceptance and IDGAF (like logging into all staff Teams meetings to be technically in attendance and then muting the audio) so I can better focus on the parts of the job that I do like, of which there is still plenty of.
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cara susanna said:
I always say that this job is a marathon, not a sprint. If you have to half-ass some things in order to make it sustainable, it's still way better than you getting burnt out and quitting (and I don't know about you guys, but it seems like everytime we have a vacancy the pool of candidates gets less and less in terms of quality - especially psychologists)
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It is a marathon (that's how the pension works after all) and at the end of the day, it is just a job. The one thing I learned from my time in management is that I don't get to set the rules until I own the company/practice. Until that day, the choices are to put a smile on your face and not care or step up and captain the ship. Having captained a ship that was not mine, smiling is easier.
 
Most of the day to day stuff is manageable (mostly). I'm struggling lately because I work with a lot of LGBTQ+ patients and their care, even from a lot of nice, well-meaning providers has been pretty crappy recently. I have had veterans immediately sent for psychotherapy without their permission because they're interested in transitioning, even if it's only socially and not medically transitioning. I am having to do JPRS reports because some staff insist on using birth name even though we're supposed to use preferred names. When corrected, they're almost always very apologetic. They just want to be extra sure they have the right person. I get it. It's just kind of a slog and the veterans are often pretty hurt by the experience.

The VA is notorious for leaning on local sites to roll out these big national initiative with no training. The sexual orientation reminders only make sense if people know how to use them. No one's orientation is "Veteran states he's not having any." It's the wild west.
 
cara susanna said:
I always say that this job is a marathon, not a sprint. If you have to half-ass some things in order to make it sustainable, it's still way better than you getting burnt out and quitting
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Basically what my mentor has told me.
 
Shiori said:
Most of the day to day stuff is manageable (mostly). I'm struggling lately because I work with a lot of LGBTQ+ patients and their care, even from a lot of nice, well-meaning providers has been pretty crappy recently. I have had veterans immediately sent for psychotherapy without their permission because they're interested in transitioning, even if it's only socially and not medically transitioning. I am having to do JPRS reports because some staff insist on using birth name even though we're supposed to use preferred names. When corrected, they're almost always very apologetic. They just want to be extra sure they have the right person. I get it. It's just kind of a slog and the veterans are often pretty hurt by the experience.

The VA is notorious for leaning on local sites to roll out these big national initiative with no training. The sexual orientation reminders only make sense if people know how to use them. No one's orientation is "Veteran states he's not having any." It's the wild west.
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Culture change is a long slow road and takes time. The kind of time that is measured in years and decades, not weeks and months. While it is almost always easier staying within the bubble of people that are aware and supportive, that is not how culture change happens. Someone needs to take the lead in these efforts and champion the long, slow slog. It helps to be an idealist in these situations.
 
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Sanman said:
Culture change is a long slow road and takes time. The kind of time that is measured in years and decades, not weeks and months. While it is almost always easier staying within the bubble of people that are aware and supportive, that is not how culture change happens. Someone needs tp take the lead in these efforts and champion the long, slow slog. It helps to be an idealist in these situations.
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That brings me back to why I consider quitting once a quarter.
 
Shiori said:
That brings me back to why I consider quitting once a quarter.
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How idealistic are you feeling? If stubborn idealism can't carry the day, channel those delayed gratification skills from grad school. If that doesn't work, think about how much work it is to write a resignation letter and find a new job. Procrastination is almost as good as stubborn idealism.

Harold Perrineau Smile GIF by FROM
 
Does anyone have handy any particular references or resources (especially any official literature, articles, books, book chapters, Sharepoint sites, etc.) That actually flesh out the Behavioral Health Interdisciplinary Program (BHIP) model?

My quick lit search only turned up ONE article (from 2016, Barry, Abraham, Weaver, & Bowersox, in Psycgological Services) that specifically references BHIP.

Are there better resources?

I mean, I get the basic idea (ideal?) of a 'team-based' approach (in theory) but it seems like implementing that model in our VA culture of "we don't have time for actual scheduled regular team meetings" and the diffusion of responsibility involved in 'bouncing' patients from provider to provider in a game of playing 'tag-you're-it' just seems like it would be REALLY tough to implement in practice.
 
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Fan_of_Meehl said:
Does anyone have handy any particular references or resources (especially any official literature, articles, books, book chapters, Sharepoint sites, etc.) That actually flesh out the Behavioral Health Interdisciplinary Program (BHIP) model?

My quick lit search only turned up ONE article (from 2016, Barry, Abraham, Weaver, & Bowersox, in Psycgological Services) that specifically references BHIP.

Are there better resources?

I mean, I get the basic idea (ideal?) of a 'team-based' approach (in theory) but it seems like implementing that model in our VA culture of "we don't have time for actual scheduled regular team meetings" and the diffusion of responsibility involved in 'bouncing' patients from provider to provider in a game of playing 'tag-you're-it' just seems like it would be REALLY tough to implement in practice.
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This might be what you are looking for
 

Attachments

cara susanna said:
Can there PLEASE be some exception to the NS call policy for HRF patients? Can we please allow SOME ROOM for clinical judgment?

I'm soooooo tired of this cycle of no show, call, r/s, no show, call, r/s, random show up, no show next appt, call, r/s... UGH
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I call it "The Hokey Pokey Pattern of VA Psychotherapy Patient (dis)Engagement."

"You put your left foot in, you take your left foot out, you put your left foot in, and you shake it all about..."

I swear that all of the attempts to top-down manage the provision of psychotherapy are just making everything worse, not better--including 'access issues.'

Relatedly (regarding HRF patients), it's frustrating that VA admins don't appreciate what I consider to be the Fundamental Law of Outpatient Suicide Risk Management: if you determine that the patient does not currently meet medicolegal criteria for involuntary admission, then EVERYTHING after that is VOLUNTARY on the part of the patient and, thus, a matter of NEGOTIATION with the patient rather than waving a magic bureaucratic wand to force the patient to agree to all kinds of things on our suicide prevention wish list per all the policy/procedure bloat from the Church of Suicide Prevention over the last several years.
 
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Fan_of_Meehl said:
I call it "The Hokey Pokey Pattern of VA Psychotherapy Patient (dis)Engagement."

"You put your left foot in, you take your left foot out, you put your left foot in, and you shake it all about..."

I swear that all of the attempts to top-down manage the provision of psychotherapy are just making everything worse, not better--including 'access issues.'

Relatedly (regarding HRF patients), it's frustrating that VA admins don't appreciate what I consider to be the Fundamental Law of Outpatient Suicide Risk Management: if you determine that the patient does not currently meet medicolegal criteria for involuntary admission, then EVERYTHING after that is VOLUNTARY on the part of the patient and, thus, a matter of NEGOTIATION with the patient rather than waving a magic bureaucratic wand to force the patient to agree to all kinds of things on our suicide prevention wish list per all the policy/procedure bloat from the Church of Suicide Prevention over the last several years
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I'm even happy to call them once. But THREE TIMES?

It's not making this patient anymore consistent. It's not helping this patient's care. And it's burning me out.
 
cara susanna said:
I'm even happy to call them once. But THREE TIMES?

It's not making this patient anymore consistent. It's not helping this patient's care. And it's burning me out.
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I completely agree and sympathize with you on this, 100%.

It is unfortunate that a provider can provide care that reasonably satisfies standard of practice/care (e.g., reaching out after a no-show via a single f/u phone call and awaiting a response) yet still potentially be regarded as 'in violation' of the (non-evidence-based) requirement by policy/fiat of 'three no show calls on three separate days plus a letter.'

You can't force motivation/engagement in the psychotherapy process to occur in a client and the more you try the more counterproductive the effort becomes.
 
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