and Vietnam Veterans of America), which are especially active and influential. Perhaps because issues of PTSD and homelessness among veterans have been prominent in recent years, these stakeholders appear to have shown greater interest in mental health issues over the past 15 years, and particularly in the quality and funding of VA mental health care. Congress also established a committee with VHA, the undersecretary for Health’s Special Committee on Treatment of Severely Mentally Ill Veterans (the SMI committee), charged with making recommendations for of improving MH/SA care and monitoring maintenance of MH/SA capacity. The SMI committee is required to submit an annual report to the Congress.

Changes in MH/SA Service Delivery Since 1995

In 1995, Kenneth Kizer, MD MPH, was appointed undersecretary for Health and initiated an extensive reform of VHA. Kizer encouraged a shift to a population-based preventive and primary care focus rather than a hospital, specialty care focus. He vigorously promoted a reduction in inpatient service utilization and championed an expansion of outpatient treatment, in part through the development of community-based outpatient clinics, small satellite clinics located closer to where veterans lived. These goals were reinforced through a capitated system of resource allocation and by placing major emphasis on accountability through the use of performance measures (Kizer, 1999).

Although his focus was not specific to MH/SA, during these years VA mental health underwent a substantial transformation. Between 1995 and 2003, 66% of all general psychiatry inpatient beds and 96% of all inpatient substance abuse beds were closed. The number of long-term psychiatric patients, that is, those hospitalized for more than a year, declined by 81% and the number with psychiatric diagnoses on inpatient medical units declined by 93%. Inpatient length of stay dropped 43%, from an average of 27.8 days to 15.8 days, allowing more patients to use the remaining beds. As a result, the number of episodes of inpatient care declined by only 44%.

With the pressure of a capitated resource allocation system and population-based planning, the total number of mental health outpatients increased by 44.7%, or 5.6% per year, from 545,004 to 788,502. Perhaps to allow time to serve this increasing workload, the average number of annual visits per veteran declined from 15.1 to 12.8 (15%).

Specialized outpatient substance abuse (SA) services initially (FY 1995–FY 1998) followed this general trend, with 3% annual growth in the number of patients treated, but from FY 1998 to FY 2003 the number of veterans who received specialized outpatient substance abuse services declined by 19% (3.7%/year). Since there was no reduction in need of SA services in the

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