Published: December 1, 2011
Despite adding billions of dollars for mental health care to Department of Veterans Affairs budgets the last four years, and the hiring of 7000 more mental health professionals at VA clinics and hospitals, many veterans with severe combat-related stress still face long waits to get the care they need.
And some VA facilities might be “gaming” appointment dates so they appear to comply with a rule that veterans with post-traumatic stress disorder, or PTSD, begin treatment within 14 days of seeking care.
Those were just two of many complaints leveled at VA officials who oversee the department’s burgeoning mental health care program during a hearing Wednesday of the Senate Veterans Affairs Committee.
The most disturbing testimony came from Michelle Washington, coordinator of PTSD services and evidence-based psychotherapy at the VA medical center in Wilmington, Del. She said staff shortages are impacting patient care as needed therapy for severe PTSD cases gets delayed by weeks or months, and scheduled appointments are sacrificed to management’s higher goal of boosting new patient enrollment figures.
“Due to chronic short staffing at my facility, and the inability to manage my patient appointments based on their individual needs, I am frequently frustrated in my ability to provide that care,” Washington said.
The evidence-based psychotherapy she uses for severe or complex PTSD cases, said Washington, involves 10 to 12 consecutive weekly sessions during which patients “re-experience” the trauma and address “erroneous beliefs” about the event so they “better process” trauma memory.
But scheduling patients for a series of weekly appointments “is very difficult at my facility,” Washington said. Patients wait as long as six weeks for their first appointment. While waiting, some patients lose their motivation for treatment while others see their PTSD worsen.
“Also, because scheduling clerks are under great pressure to bring new veterans in within 14 days, they may take one of my PTSD patient’s regular appointments for a new patient appointment, which hurts the effectiveness of my patient’s treatment,” said Washington.
The Wilmington center appears on paper to schedule appointments for PTSD patients within the mandated 14 days. But the first visit often will involve paperwork and patient history and no therapy, allowing statistical records to indicate treatment has begun.
“As long as scheduling continues to be driven by clerks pressured by management to make the numbers look good, and as long as mental health providers have little or no say about where and when to best serve their patients,” Washington said, “this will keep happening.”
She also described a “pervasive shortage of primary care providers” that results in patients being referred erroneously to mental health care for lack of an initial comprehensive care assessment to diagnosis properly conditions that require medical care and not a mental health provider.
John Roberts, executive vice president for mental health at the Wounded Warrior Project, said many veterans still can’t get timely mental health appointments because staff hires aren’t keeping pace with the needs of veterans, particularly those returning from Iraq and Afghanistan.
“Why, after 10 years, do warriors have to struggle to get effective care for the signature wound in this war,” Roberts asked. “Why isn’t the under secretary for health…moving beyond measuring baseline access to initial mental health evaluations to systematically tracking access to sustained follow up care? If leaders spent more time speaking with the veterans, and their own clinicians, they would realize that the problems with VA mental health system run far deeper than even their data suggests.”
VA mental health care staffs have increased by 48 percent since 2006 while the number of veterans using mental health service has climbed 34 percent to reach 1.2 million in fiscal 2010.
Roberts urged VA to enhance mental health by using its authority to refer patients to civilian providers when VA resources don’t allow timely care, and by expanding peer support programs so that PTSD patients get mentoring and encouragement from veterans successfully treated.
The veterans affairs committee held its last hearing on mental health staff shortages in July with testimony of two veterans with PTSD who had attempted suicide and still couldn’t get denied timely appointments.
At the time Sen. Patty Murray (D-Wash.), committee chairman, directed VA to survey some frontline mental health care providers to determine whether they had sufficient resources to give timely care. At Wednesday’s hearing Murray announced that the results “were not good.”
Forty percent of providers said they could not schedule an appointment in their clinic within the VA-mandated 14-day window and 70 percent said they did not have adequate staff or space to deliver timely care.
Yet VA officials in July told Congress that 95 percent of veterans were getting appointments within the 14-day window. Murray asked Mary Schohn, director of VA mental health operations, to explain the “disconnect.”
Schohn conceded that Dr. Washington from Wilmington might have hit on the reason “that patients are not having access to the evidenced-based therapies in the way that we expect they should be.”
The query of VA mental health care providers did indicate, Schohn said, that “there’s access to the system but not necessarily access to the specific therapies in the time they should occur. And we are working on ensuring that that happens.” Schohn said clarifying guidance on the 14-day rule has gone out to hospitals and clinics, and site visits are planned “to find ways to solve the issues that Dr. Washington presented here today.”
Sen. Richard Burr (N.C.), the committee’s ranking Republican, noted that VA’s mental health budget jumped by 25 percent in 2011 to $5.7 billion. He demanded that Schohn provide a full accounting of how that was spent.
Schohn conceded some “variability” in access to care across the VA system. But overall VA leads the private sector, and any other health system in the world, in delivering quality mental health care.
“I am personally concerned when I hear these stories about that not happening,” she said.