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Evaluation of the Department of Veterans Affairs Mental Health Services (2018)

Chapter: 8 Mental Health Workforce and Facilities Infrastructure

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Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
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8

Mental Health Workforce and Facilities Infrastructure

The Department of Veterans Affairs (VA) employs mental health providers of many different disciplines including psychiatrists, psychologists, licensed clinical social workers, marriage and family therapists, peer specialists, substance use counselors, care navigators, and advanced practice psychiatric nurses (including psychiatric clinical nurse specialists and psychiatric nurse practitioners). However, difficulty recruiting, problems with retention, and lengthy hiring procedures contribute to high vacancy rates throughout the system, and these vacancy rates can be a barrier to service. Furthermore, some locations lack the physical space needed to fill some vacancies or adequately accommodate the size of their clientele.

A fully staffed facility will be able to schedule more appointments, operate more efficiently, and, ultimately, serve more veterans than an otherwise identical understaffed facility. The Government Accountability Office (GAO) reported that while the VA has met recent hiring initiatives designed to increase the number of inpatient and outpatient mental health providers, the VA continues to face challenges in hiring mental health staff to meet the demand for services (GAO, 2015). The GAO cites pay disparities with the private sector, competition between VA medical centers (VAMCs) to fill positions, lengthy hiring processes, a lack of space for new hires, a lack of sufficient support staff, and a nationwide shortage of mental health professionals as reasons why the vacancies are going unfilled. This chapter will describe the current state of the VA mental health workforce as well as promising practices, initiatives, and activities the VA and mental health community at large are undertaking to address mental health workforce issues. The discussion includes details about the VA’s program to train VA providers and enhance the VA’s capacity to provide evidence-based care and also highlights findings from the committee’s site visit and survey research about providers’ and patients’ perspectives on the experience of care at the Veterans Health Administration (VHA). The chapter also will discuss the physical infrastructure of VA facilities and their proximity to where veterans live and how those factors affect patient access.

MENTAL HEALTH WORKFORCE

VA-provided data indicate that in fiscal year (FY) 2017 (as of May 31, 2017) there were 9,986.5 full-time equivalent (FTE) mental health providers working in the system (psychologists, psychiatrists,

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
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licensed professional mental health counselors, marriage and family therapists, and peer support). This count does not include nurses or social workers working in mental health who are undoubtedly mental health providers but are not counted as such in the VA data (see the Workforce Tracking and Efficiency section of Chapter 12 for an expanded discussion on VA-collected workforce data). This is a slight decline from FY 2016 when there were 10,008.2, but an increase from FY 2013 when there were 8,473 (VA, 2017h). More than half of these providers are psychologists. Different data provided by the VA indicate that, as of May 31, 2017, there were 8,577.84 FTE nurses (these data do not including psychiatric mental health nurse practitioners) and 4,695.9 social workers working in mental health (VA, 2017h). The organization and types of mental health providers staffing VA health care facilities can be variable across the VA health care system.

In Assessment G of the 12 independent assessments of the VA, as directed by the Veterans Access, Choice, and Accountability Act of 2014, Grant Thornton LLP examined VA provider staffing and productivity (Grant Thornton LLP, 2015). While the Grant Thornton assessment found the staffing ratios of provider per patient population for most specialties in the VA to be lower than industry standards, for psychiatry VA provider ratios per patient population were actually higher than industry standards (Grant Thornton LLP, 2015). However, a recent GAO report cited incomplete and inaccurate provider staffing level data as a major deficiency in the VA’s metrics and models that affects the completeness and accuracy of information on clinical productivity and efficiency at VAMCs (GAO, 2017). Provider staffing and productivity at the VA is discussed further in Chapter 12, which examines efficiency of care delivery.

Hiring and Vacancies

The Grant Thornton assessment found that the VA is struggling to fill provider vacancies. As of January 6, 2015, the VA had 16,995 vacancies for providers and clinical support staff (of all disciplines) that had been open for at least 180 days (Grant Thornton LLP, 2015). The vacancy rates are generally higher in the VA than in the private sector. There is, however, great variability within the VA as some of the Veterans Integrated Service Networks (VISNs) have fewer than 300 vacancies and others have over 1,000 (Grant Thornton LLP, 2015). Table 8-1 below shows data from the VA Office of Mental Health and Suicide Prevention (formerly the VA Office of Mental Health Operations) on vacancy rates by mental health profession from June 1 to June 30, 2016. The gap in mental health staffing has broad effects on the system’s ability to deliver patient-centered care (see Chapter 10) and effective care (see Chapter 11).

Provider vacancies in the VA, particularly for mental health providers, are in part a reflection of a mental health provider shortage nationwide (Annapolis Coalition on the Behavioral Health Workforce, 2007). The Health Resources and Services Administration (HRSA) reports that as of January 1, 2016, there were 4,362 designated health professional shortage areas in the country, defined as having a short-

TABLE 8-1 VHA Mental Health Position Vacancy Rates

Profession National Average (%) Range Across VISNs (%)
Psychiatrist 18.4 6.3–30.9
Psychologist 14.2 6.3–23.1
Social worker 11.6 4.9–18.3
Nurses 12.3 5.4–19.6
Peer Specialist 13 2.5–24.2
Licensed professional counselor 19.3 0–60
Marriage and family therapist 16.9 0–50

SOURCE: VA Office of Mental Health Operations, 2017.

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
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age of providers in a given geographic area1 (HRSA Data Warehouse, 2016). Furthermore, the Substance Abuse and Mental Health Services Administration reported to Congress in 2013 that 55 percent of all U.S. counties (all of which were rural) have no practicing psychiatrists, psychologists, or social workers. A study from 2009 revealed that 77 percent of counties had a severe shortage of prescribing and non-prescribing mental health providers, and 96 percent had at least some unmet need for mental health (Thomas et al., 2009).

A combination of factors is behind to the shortage of psychiatrists both in the VA and in the health care industry overall. One factor is that the current psychiatry workforce is aging. The majority of practicing psychiatrists—nearly 60 percent (12,486)—were 55 or older in 2015 (Staff Care, 2015). Many of them may be retiring in the coming years, while projections show that fewer medical students will go into psychiatry as a specialty. Between 2014 and 2017, 6,032 students will complete graduate medical education programs for general psychiatry (Staff Care, 2015). This is expected to set up a greater shortfall as more psychiatrists will retire in the coming years than enter the workforce. VA data reflect this finding—21.7 percent of psychiatrists and 12.0 percent of psychologists in the VHA workforce will be retirement eligible by September 30, 2017 (VA, 2017b).

The Grant Thornton LLP assessment of VA staffing (Grant Thornton LLP, 2015) found that the lengthy hiring process at the VA may also contribute to high vacancy rates and provider shortages. While there are no hiring-time data available (the VA does not track hiring times), the assessment reported consistent complaints from VAMC leaders that it takes too long to hire VA staff (both providers and clerical staff). It can take up to 4–8 months for a candidate to begin working after he or she is selected to be hired. In the private sector, it is typical for employees to begin work within 2 months or less of being hired (Grant Thornton LLP, 2015). The certification of applicants’ credentials and the VetPro2 background check were cited as major contributors to the lengthy hiring process. The VA has acknowledged that lengthy hiring practices are a barrier to recruitment for mental health professionals (VA, 2016d).

Complaints about the lengthy hiring process were frequently heard on the committee’s site visits. One VA staff member stated, “We have such an archaic hiring system. Even if we could get the good employee that applied, by the time we get back to them, they’ve moved on and been hired someplace else.” [El Paso, Texas]

Recent attrition among VA human resources staff has further compounded hiring problems by limiting the office’s ability to recruit clinical staff in a timely manner (GAO, 2016). According to a recent GAO report, in FY 2015 attrition among VA human resources staff was 12 percent. The report also states that VA’s current internal oversight and control practices limits its ability to monitor and improve human resources (HR) processes, make data-driven decisions, and determine appropriate HR training needs. However, in 2017 VA announced it will establish a “manpower management office” with the ultimate goal of establishing a position management system to help improve the hiring process (VA, 2017g).

A recent VA report citing Bureau of Labor Statistics data concluded that while VA salaries are below the industry standard for most health provider specialties, VA mental health care providers are actually paid higher salaries than their private-sector counterparts (VA, 2016d). The VA report found that psychiatrist salaries are, on average, 7 percent higher than in the private sector; psychologist salaries are 23 percent higher; VA marriage and family therapists salaries are 18 percent higher; mental health counselor salaries are 29 percent higher; and peer support staff salaries are 11 percent higher. Salaries for nurses, social workers, and other mental health professionals were not reported (VA, 2016d). This finding, however, contradicts previous reporting by the GAO (2015).

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1 Health professional shortage areas are geographic areas made up of a county, a county subdivision, a census tract, or a combination of any of the above.

2 VetPro is the VA’s Web-based credentialing system that all VA hires must complete before they begin employment.

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
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On the committee’s site visits, VA interviewees described a high rate of staff turnover due in part to a high-stress work environment where the clinical demand exceeds the supply (“We had a psychiatrist here through Primary Care Mental Health Initiative. He was here, I think, six to seven months. Because of the workload over in this area, he decided he didn’t want to continue here” [East Orange, New Jersey]). In addition, in some of the locations perceived by staff as “less desirable” places to live (for example, Temple and El Paso, Texas, and outlying community-based outpatient centers in many areas), interviewees said that they believed clinicians were taking jobs at the local VA in order to “get their foot in the door” so they could move to a more desirable location when a position became available (“It’s harder to recruit the professionals to go out to these small towns to live out there or to drive out there” [Cleveland, Ohio]).

Because these clinicians reportedly were remaining with the VA, the system as a whole was not losing intellectual capital in these cases. At the local level, however, the turnover was reportedly having an adverse effect on the remaining staff and, more importantly, the veterans regularly had to adjust to a new therapist.

Job Stress, Burnout, and Space Constraints

Burnout and job-related stress at the VA may contribute to the high turnover among health care providers. While research on the topic is scant, one recent study (Garcia et al., 2014) found that, among a sample of 138 (non-prescribing) VHA mental health clinicians who provide evidence-based posttraumatic stress disorder (PTSD) care, 50.0 percent reported feeling exhausted and 47.1 percent reported feeling cynical on the job. Having more clinical work than could be accomplished predicted both exhaustion and cynicism. Organizational bureaucracy politics was a predictor of cynicism. Demographic variables were not predictors of either exhaustion or cynicism. A number of factors were significantly correlated with “mental health days” taken by providers (work absenteeism). Feeling that there is more clinical work than can be done, feeling that the clinic is understaffed, and feeling that organizational bureaucracy is negatively affecting work were associated with increased absenteeism. Feeling that you are part of a coherent team, feeling that co-workers are supportive, and feeling that good work is acknowledged by superiors was associated with decreased absenteeism. The authors also asked participants about their intent to leave the VA within the next 2 years. While the majority of the sample (58 percent) reported it was “not likely” or “not very likely” that they would leave in the next 2 years, 32 percent reported it was somewhat or very likely that they would leave. Not surprisingly, those who reported that they were likely to leave in the next 2 years were more likely to report feeling cynicism and exhaustion (Garcia et al., 2014).

In another study by the same lead author (Garcia et al., 2015), the researchers measured burnout among 125 VA psychiatrists using the Maslach Burnout Inventory-General Survey delivered via the Internet. The survey was sent out to 500 randomly selected VA psychiatrists. The survey measured cynicism, exhaustion, professional efficacy, and intent to leave the VHA. Among the 125 psychiatrists who completed the survey, 90 percent reported high cynicism, 86 percent reported high exhaustion, and 74 percent reported high professional efficacy. Cynicism and exhaustion were far higher in this sample of prescribing psychiatrists than in a similar study, cited above of non-prescribing clinicians (Garcia et al., 2014). High cynicism predicted intent to leave the VA and not feeling like part of a team predicted cynicism. Complaints about workplace conditions, such as unfair treatment by supervisors and insufficient resources, predicted exhaustion (Garcia et al., 2015).

In a recent report, the VA concluded that there is a system-wide problem with providing adequate clinical support staff or “medical support assistants” (MSAs) to mental health providers. The report states

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

that the VA “currently has no way of tracking data on clerks and other program support staff working in mental health clinics, and thus it is difficult to identify and address local gaps in staffing for these positions” (VA, 2016d, p. 35). Since then, the VA has been working to improve the MSA staffing model although final recommendations to improve the consistency of MSA staffing for mental health programs have not been announced (VA, 2017e).

The committee’s site visit interviews revealed how this puts a strain on the workforce. Many VA clinical staff interviewees described having too few clinical staff to accommodate the demand for services. In several locations, supply limitations were described as resulting from clinicians having to perform administrative activities that would normally be performed by support staff:

Twenty-five percent of my time is spent actually doing clinical services as the team lead. The other 75 percent, I’m doing administrative stuff. [Charleston, South Carolina]

Finally, even if vacancies are filled, staff in many locations indicated that there is a lack of sufficient space in which to house staff and provide clinical services.

If we hire all of the individuals that we are being expected to hire . . . we cannot place them. We have many creative options where folks were sharing space, particularly in mental health, working alternate hours, doing clinical visits. [Nashville, Tennessee]

In several of the VISNs, new mental health outpatient clinics are currently under construction. Once these facilities are open, many of the space issues described by staff may be alleviated. However, turnover and hiring are likely to remain issues because of the challenges previously noted.

Through interviews with over 700 VA providers, the Grant Thornton staffing assessment (Grant Thornton LLP, 2015) identified several provider and leadership-reported barriers that providers face when delivering care. Nearly half of the providers interviewed reported insufficient exam rooms. More than 40 percent reported insufficient clinical staff and nearly 30 percent reported insufficient non-clinical staff. Nearly 30 percent reported that the electronic health record was slow to use and nearly 25 percent reported that they were not working to the top of their licensure. The assessment points out that many of the barriers are interconnected. For example, if a physician needs more exam room space and more support staff it will not necessarily increase productivity to hire more support staff but not provide additional rooms for the additional staff to use. While the additional support staff could prepare patients before a physician sees them, without additional exam room space there may be nowhere for that to happen, and productivity would not increase (Grant Thornton LLP, 2015).

Many of these same issues were identified in the VA’s National Mental Health Providers Survey in 2015. (See Chapter 15 for details about VA’s mental health provider survey.) Between December 2015 and January 2016, 8,700 mental health providers completed the survey administered by the VA. Based on the responses, the VA identified space limitations and lack of clerical support as “areas for improvement.” Filling vacancies, the inability to schedule evidence-based treatments due to full provider schedules, lack of discussion about VA mental health service requirements, and tele-mental health equipment shortages and technical performance issues were also identified as areas for improvement, based on how these items were rated by survey respondents. The VA also identified a number of strengths based on survey respondents’ agreement with some survey items. Overall, most of these strengths were related to the respondents’ beliefs that they were providing valuable, effective services to veterans and improving access to care (VA, 2016c).

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
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Strengthening the Mental Health Workforce

The VA has employed a number of strategies to help bolster the recruiting and retention of and compensation for its workforce. It has also expanded its mental health workforce to include professionals with a wider variety of credentials, which has expanded its applicant pool. This section will discuss some of these efforts.

The VA has affiliation agreements with nearly every medical school in the United States. In 2014, the VA trained over 40,000 medical residents, over 20,000 medical students, and several hundred advanced medical fellows (VA, 2017d). In 2016, the VA offered over 1,000 psychiatry residency positions, over 1,000 psychology residency or internship positions, and over 1,000 social work internships (Jones et al., 2015). Title 38 U.S.C. mandates that the VA train health professionals to address its own needs and those of the nation. It is the largest training program of health professionals in the United States (VA, 2017d), and about 70 percent of psychologists employed by the VA received some of their academic or residency training at the VA. Nationally, 50 percent of psychologists received at least some VA training (Jones et al., 2015). In 2017, the VA announced it was “pursuing legislation to expand graduate medical education training opportunities to help with staff shortages” (VA, 2017g, p. 3).

The Veterans Access, Choice and Accountability Act of 2014 authorized an additional 1,500 training positions for primary care and mental health. These were originally required to be created within 5 years of the law passing, but that has since been extended to 10 years (VA, 2017e). Thus far, 136.4 residency training slots have been added under mental health.

Separately, beginning in 2012, the VA began a 5-year mental health education expansion (MHEE) program to strengthen the pipeline of well-trained mental health professionals with the goal of recruiting and hiring an additional 1,600 VA-trained mental health providers (VA, 2015). Through the MHEE program, four new professions were allotted training opportunities at the VA. These include residencies for psychiatric/mental health nurse practitioners and physician assistants and internships for licensed professional mental health counselors and marriage and family therapists (VA, 2017e). Through May 2017, 764.8 new mental health training positions have been added. See Table 8-2 below for a breakdown of training slots by profession. The VA is currently planning to further expand its training portfolio to include neuropsychology fellows, psychology interns, and master’s level counselors. There are also plans to expand the number of physician assistant residency positions to increase the prescribing capacity in the system (VA, 2017e). It is notable, however, that expanding the number of residencies for psychiatric

TABLE 8-2 VA Mental Health Training Slots by Profession, Expansion Since 2013/2014 and Current Total (as of May 31, 2017)

Profession Expansion Slots Since 2013/14 Current Total Number of Slots
Psychiatry 228.2 1,235.38
Psychology 334 1,149
Social work 112 1,033
LP mental health counselor 21 21
Marriage and family counselor 8 8
Mental health nursing 32 52
Physician assistant 7 7
Pharmacy 74 74
Occupational therapy 1 1
Clinical pastoral education 41 153

SOURCE: VA, 2017h.

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

mental health nurse practitioners would also expand the prescribing (and diagnosing) capacity of the system.

The VA is permitted to avoid the lengthy hiring process by appointing academic trainees and former trainees to Title 38 and Hybrid Title 38 positions. Under this mechanism, the VA may tentatively offer positions to trainees and former trainees without posting a vacancy announcement and going through the lengthy hiring process. Offers are contingent upon meeting the position’s required qualifications at the time of appointment. During FY 2016, physician, nurse, psychologist, and physician assistant trainees were eligible to be appointed to positions under this rule.

The VA is also permitted to offer incentives for recruitment, relocation, and retention. Up to 25 percent of annual salary may be offered to help fill critical vacancies or to encourage employees to move to less desirable locations. The VA may also offer the 25 percent incentive to retain high-quality or critical employees that may otherwise leave (VA, 2013b).

Student loan debt reduction incentives are also available under the Education Debt Reduction Program to VA employees whose positions providing direct patient care are difficult to recruit and retain. Eligible loans must be for the employee’s professional training directly related to the position held, but only certain positions designated by the VA are eligible for loan repayment incentives. Eligible student loan payments are reimbursed by the VA to the employee. Under the program, employees may receive up to $120,000 over 5 years (VA, 2017a).

Similarly, the Clay Hunt Suicide Prevention for American Veterans Act3 contained a provision for the VA to establish a pilot program to repay up to $30,000 in student loans to psychiatrists practicing in the VA to incentivize recent psychiatrist graduates entering the workplace to consider employment at the VA. A report summarizing the first 2 years of the program is due to Congress in 2017.

In 2012, as a part of a mental health hiring initiative, the VA announced it would begin to include marriage and family therapists (MFTs) and licensed professional counselors (LPCs) in its mental health workforce. According to 2014 data there were over 150,000 MFTs and LPCs in the United States (BLS, 2016), representing a significant share of the overall mental health workforce nation-wide, so the VA’s inclusion of these workers in its hiring significantly expanded the pool of potential VA mental health providers. Additionally, the VA also offers a variety of scholarship, nursing education, and residency incentive programs to help attract health care professionals to the VA (VA, 2017c).

In another step to improve provider efficiency and increase access to care, including prescribing services, in 2016 the VA granted advance practice registered nurses (APRNs) practicing in the VA the authority to practice to the full extent of their education and training regardless of the state in which they are working (VA, 2016a). Previously, VA APRNs practiced under the supervision of a physician if practicing in a state that requires such oversight (Lowes, 2013). The policy change aligns with a recommendation by the Institute of Medicine in 2010 that APRNs should practice to the full extent of their education and training (IOM, 2010). The Institute of Medicine recommendation was not directed at the VA specifically.

Following the recovery model in which people in recovery are employed as part of the provider workforce can also help lessen the supply-versus-demand gap and make care more accessible and easier to navigate. The VA is currently doing this with its peer specialist program. That program employs veterans, who are in recovery for a mental health condition themselves, to serve as peer supports to other veterans receiving mental health care. Peer specialists in the VA can offer tools, resources, and navigational assistance to veterans in VA care. They serve as advocates for effective recovery-based services that will help a veteran readjust to civilian life (VA, 2013a). As mentioned in Chapter 10, peer specialists are an important asset in the delivery of patient-centered care.

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3 Public Law 114-2.

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

Research on the peer specialist program is sparse. However, Chinman et al. (2012) surveyed 92 VA local recovery coordinators about their perceptions of the peer specialist program. More than half of those interviewed (62 percent) reported finding it more difficult to hire peer specialists than to hire other VA employees. Support from both clinical and administrative leadership did help facilitate hiring, the respondents reported, but a lack of funding was an often reported barrier (53 percent). Many open-ended responses reported difficulty with the VA’s human resources department regarding hiring a veteran with a mental illness. In some cases, the local recovery coordinators reported the human resources department ultimately chose to hire veterans without the lived experience of mental illness, which undermined the peer specialist role. Just over half of the local recovery coordinators (51 percent) reported that the peer specialist implementation was going well. Nearly all (96 percent) said that peer specialists were having a positive impact on veterans’ care (Chinman et al., 2012).

In another study, Chinman et al. (2015) evaluated patient outcomes in a cluster randomized controlled trial of VA patients receiving care from intensive case management teams. The study compared the outcomes of veterans receiving intensive case management with a peer specialist to those without a peer specialist. The peer specialists developed relationships with their assigned veterans and completed a range of case management duties including medication delivery, accompanying veterans to appointments, developing recovery plans, meeting with veterans individually, leading or co-leading groups, engaging veterans with services, and assisting intensive case management teams. Patient outcomes were measured using a variety of instruments, including the recovery self-assessment, the Mental Health Recovery Measure, the Illness Management Recovery Scale, the Quality of Life Instrument-Brief Version and the Patient Activation Measure (PAM). While most outcomes were not different between the two groups, veterans in the peer specialist group did score marginally (but significantly) higher on the PAM after 1 year of treatment than veterans in the treatment-as-usual group. The PAM measures a patient’s knowledge, skill, and confidence in self-care management. While the improvement among participants in the peer specialist group was slight (approximately 1 point), it was enough to predict improved health care use (Chinman et al., 2015).

Quality of Mental Health Providers in the Veterans Health Administration

Workforce recruitment, retention, and compensation described above affect the VA’s capacity to provide access to specialized clinical knowledge and expertise that meets patients’ expectations. In Donabedian’s paradigm for the evaluation of health care quality, there are two elements in the performance of providers, one of them technical and the other interpersonal (Donabedian, 1988). Technical performance is the knowledge and judgment used in decisions about appropriate strategies of care as well as the skills required to carry out those strategies. The nature of the interpersonal relationship between a provider and patient plays a key role in the success of the technical care provided.

Studies show that training providers in evidence-based practices (EBPs) enhances technical quality through increasing clinical competencies, enhancing self-efficacy, and improving knowledge and attitudes (IOM, 2001; Karlin and Cross, 2014). Studies on the interpersonal aspects of the doctor–patient relationship consistently find that patients value personal care, as characterized by good communication skills, empathy, and caring, when evaluating the care they receive (Cleary and McNeil, 1988). Presented below is an overview of the VA’s provider training in EBPs, followed by a summary of findings from the committee’s site visit and survey research about providers’ and patients’ perspectives on the experience of care at the VA.

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

TABLE 8-3 Psychotherapies in VA Dissemination and Implementation Model

Evidence-Based Psychotherapya Condition
Cognitive processing therapy Posttraumatic stress disorder (PTSD)
Prolonged exposure therapy
Cognitive behavioral conjoint therapy for PTSD
Cognitive behavioral therapy for depression Depression
Interpersonal therapy for depression
Acceptance and commitment therapy for depression
Motivational enhancement therapy Substance use disorders
Cognitive behavioral therapy for substance use disorders
Motivational interviewing Motivation for treatment and adherence
Integrated behavioral couples therapy Relationship distress
Social skills training, behavioral family therapy Serious mental illness
Cognitive behavioral therapy for pain Chronic pain
Cognitive behavioral therapy for insomnia Insomnia
Problem solving training Problem-solving skills

aChapter 4 provides a description of several of the treatments referenced here.

SOURCE: VA, 2017e.

Training in Evidence-Based Practices

The VA’s psychotherapy dissemination and implementation model, launched in 2006, is a leading example of successful postgraduate training in evidence-based practices (IOM, 2015). The VA has 15 different EBP training programs4 in psychotherapy, which are helping to increase the availability of these treatments for veterans. Table 8-3 shows these therapies and the conditions they address. As of FY 2012, the VA had provided training in one or more evidence-based psychotherapies to more than 6,400 VA providers (Karlin and Cross, 2014). As of June 2017, this number had grown to over 11,900 unique clinicians trained in one or more of these therapies (VA, 2017e). In addition to these training programs in psychotherapy, a training pilot program is under way to train clinicians at 20 VHA sites across the country in the use of repetitive transcranial magnetic stimulation for major depressive disorder (VA, 2017e).

The VA’s training programs in evidence-based psychotherapies are generally targeted at licensed independent providers: psychologists, psychiatrists, social workers, and mental health nurses as well as licensed professional mental health counselors and marriage and family therapists. To receive training, providers have to formally apply to a training program and meet eligibility criteria, such as having spent a significant amount of time treating the condition. Regional mental health directors coordinate the nomination and selection process with local medical centers and clinics and with national training program staff. Each VISN, or region, is provided with a specific number of training slots for which the VISN may nominate staff.

The training consists of formal instruction on the various psychotherapies and on-the-job guidance in the clinical setting. VA’s transition to innovative training models began in FY 2015 in order to meet the increased need for improved access to training. This transition has included a move to regional and blended learning models, which has increased access to competency-based training, which involves either attending in-person VISN-level or virtual didactic and experientially based training and ongoing telephone-based consultation (VA, 2017e).

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4 Factors in the selection of specific therapies for dissemination across the VA include the efficacy and effectiveness of the therapy, its recommendation in clinical practice guidelines, its clinical utility in the veteran population, and the feasibility of its implementation in the VHA (Karlin and Cross, 2014).

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

VA’s use of expert consultants in its training program is consistent with research on training methods. Interactive participation and feedback enhance the effectiveness of training workshops, and the impact of a program is increased when the training is supplemented by on-the-job coaching and consultation (Ruzek and Rosen, 2009). The passive dissemination of clinical guidelines or treatment manuals through traditional workshops or lectures does not have a significant impact on clinical practices (BootsMiller et al., 2004; Rosen et al., 2004; Ruzek and Rosen, 2009).

Assessments of Provider Training in Evidence-Based Practices

A few studies have examined whether the VA’s training initiative enabled clinicians to effectively deliver two evidence-based psychotherapies for PTSD—cognitive processing therapy (CPT) and prolonged exposure (PE) therapy. A study of the VA PE training program involving 1,931 veterans treated by 804 trainee clinicians showed, in a pre- and post-treatment analysis of symptoms, that trainees could effectively use PE to reduce PTSD and co-occurring depression symptoms in male and female veterans (Eftekhari et al., 2013). A similar analysis among veterans who received CPT from newly trained therapists also showed a reduction in PTSD symptoms (Chard et al., 2012). In addition, a study of 3,000 PE training cases in the VA demonstrated that positive patient outcomes were achieved by providers of every profession, theoretical orientation, level of clinical experience in treating PTSD, and prior PE training experience (Eftekhari et al., 2015).

In 2011 the VA Office of Inspector General reviewed documentation of PTSD training among a random sample of 28 Vet Center facilities (VA, 2011). Approximately 85 percent of Vet Center providers had attended PTSD training required by readjustment counseling services, and 53 percent of the providers had attended VA-sponsored PTSD training. In addition, some Vet Center providers received supplemental training in evidence-based therapy.

The VA has trained thousands of providers on EBP to the benefit of veterans, but building and sustaining sufficient numbers of trained providers over time will be a challenge. Training is time-intensive and expensive, which will require VA to explore more efficient and scalable training procedures (e.g., relying on local trainers, online training, Internet-based interactive training) to grow capacity. However, the researchers caution that the adoption of less resource-intensive training models must be preceded by research establishing that alternative training models do not inadvertently dilute the effectiveness of EBPs (Rosen et al., 2016).

Veteran and Provider Perceptions of Provider Quality

As mentioned above, patients in general place a high value on the interpersonal aspects of the doctor–patient relationship when evaluating the care they receive. Results from VA’s Veterans Satisfaction Survey (VSS), the VA’s annual survey of veterans served by the VA, also suggest veteran satisfaction with VA mental health providers. Veterans were asked to rate the statement, “I am satisfied with my mental health team,” using a scale of 1 to 5, where 1 is strongly disagree, 5 is strongly agree, and 3 is neither. For FY 2016,5 the VA reported a mean rating of 3.98 (SD = 1.15) for OEF and OIF respondents (VA, 2016b), which seems to indicate some agreement with this statement. (See Chapter 15 for details about the VSS.) Results from the committee’s site visit and survey research show that this corresponds with reports from the veterans responding to the survey and interviewed.

Data from the committee’s survey show that a large majority of veterans have had a positive experience with VA mental health providers. Among those veterans who used VA mental health services,

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5 The FY 2016 report reviewed by the committee covers survey data collected through June 2016.

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

63 percent indicated that their VA mental health provider helped them either some or a lot, and 61 percent were at least somewhat satisfied with the care they received. These results are discussed in more detail in Chapter 10, which addresses patient-centered care (see Table 10-1).

Both VA users and non-VA users who have mental health needs6 rated their providers positively across the following four questions (see Table 8-4):

  • My mental health provider understands my background and values.
  • I feel welcome at my mental health provider’s office.
  • My mental health provider looks down on me and the way I live my life.
  • I never have a hard time communicating with my mental health provider because of accents or language barriers.

Notably, the responses to each of the questions were similar across the user groups, indicating that user experiences and veterans’ perceptions of providers are similar regardless of where the veteran seeks care.

Tables 8-5 and 8-6 reflect perceptions concerning the availability of mental health services offered by VA providers among veterans who have mental health needs. Among all veterans (all user groups), 38 percent either somewhat or strongly agreed that a VA provider in their area offered all the mental health care services veterans need, although a notable number of veterans were not sure (40 percent). The percentage of those who somewhat or strongly agreed varied across user groups (see Table 8-6); 64 percent of VA users somewhat or strongly agreed that the needed services are available from a VA provider in their area. However, only 20 percent of veterans who used non-VA providers agreed, and only 30 percent of non-users of any services agreed. Notably, large percentages of veterans who used non-VA providers (58 percent) and non-users (51 percent) were not sure if VA providers in their areas offered needed mental health services. This suggests that perhaps one reason that users of non-VA services and non-users choose to not use the VA for mental health care is simply that they do not know if a provider is offering the services they need in their area.

Table 8-7 shows that among VA users, 74 percent strongly or somewhat agreed that one can see the same mental health care provider on most visits to the VA. Veterans with a need for mental health services who used non-VA providers had the lowest level of agreement with this statement (8 percent), although a vast majority of these veterans were not sure (79 percent). Most veterans who were not users of any mental health service, either VA or non-VA (75 percent), also were not sure if they could see the same VA provider on most visits.

Among veterans unlikely to use VA mental health services in the future, 19 percent agreed that “VA doctors/staff did not provide good quality treatment.” Slightly fewer would not use VA mental health services in the future (15 percent) because of a bad prior experience using VA; 8 percent cited a lack of improvement after using services in the past as a reason for not using it in the future. The full set of reasons surveyed and veteran responses can be reviewed in Chapter 6, Table 6-31.

Many veterans interviewed on the site visits reported positive experiences with VA providers. While veterans often were unable to identify the specific treatment modalities they had experienced, they credited the actions and attitudes of their therapists as being the reason for their improvement:

[My therapist] has told me call him any time of the day, weekends. . . . No matter what he’s doing, he’ll set time aside. [Altoona, Pennsylvania]

___________________

6 As described in Chapter 6, a veteran was classified as having a need for mental health care if the result on at least one mental health screener was positive or if the veteran reported receiving a mental health diagnosis from a health care provider in the past 24 months.

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

TABLE 8-4 Among OEF/OIF/OND Veterans Who Have Mental Health Need, VA and Non-VA Users’ Experiences of Mental Health Care

Experience of Care All OEF/OIF/OND Veterans VA Users Non-VA Users
Unwgt n Wgt N Wgt % SE % Unwgt n Wgt N Wgt % SE% Unwgt n Wgt N Wgt % SE%
Total 1,105 749,453 849 476,654 256 272,799
My mental health provider understands my background and values
Strongly/somewhat agree 785 535,295 71.4% 1.6% 592 327,702 68.8% 1.8% 193 207,594 76.1% 3.1%
I feel welcome at my mental health provider’s office
Strongly/somewhat agree 887 599,396 80.0% 1.4% 676 375,206 78.7% 1.7% 211 224,190 82.2% 2.6%
My mental health provider looks down on me and the way I live my life
Strongly/somewhat disagree 880 587,951 78.5% 1.7% 670 365,392 76.7% 1.9% 210 222,559 81.6% 3.1%
I had a hard time communicating with my mental health provider because of accent or language barrier
Never 876 602,821 80.4% 1.7% 649 359,523 75.4% 1.9% 227 243,299 89.2% 2.5%

NOTE: SE = standard error of percentage; Unwgt = unweighted; Wgt = weighted.

SOURCE: Committee to Evaluate VA Mental Health Services, Veteran Survey, 2017.

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

TABLE 8-5 Among OEF/OIF/OND Veterans Who Have Mental Health Needs, Perceived Local Availability of Mental Health Services

All OEF/OIF/OND Veterans Who Have Mental Health Need
Unwgt n Wgt N Wgt % SE %
There is a VA provider in my area that offers all of the mental health services Veterans need
Strongly or somewhat disagree 439 346,892 20.4 1.0%
Strongly or somewhat agree 929 650,261 38.3 1.3%
Not sure 619 685,264 40.3 1.1%

NOTE: SE = standard error of percentage; Unwgt = unweighted; Wgt = weighted.

SOURCE: Committee to Evaluate VA Mental Health Services, Veteran Survey, 2017.

The one mental health provider who really cared . . . if it wasn’t for her, I probably wouldn’t be here. [Hampton, Virginia]

It was the interpersonal skills of these therapists that left a positive impression for the veterans. In particular, “respect,” “caring,” and “going the extra mile” were things that stood out for veterans as important to establishing a trusting relationship.

Veterans who were less sanguine about their experience with VA providers conveyed to the committee their sense that providers are under pressure to keep patients “flowing” through the system. Site visitors heard from numerous interviewees who felt that their treatment had been terminated prematurely because they were not getting better quickly enough. One female veteran, for example, described her reaction to being dropped by her therapist:

Everybody’s on a different pace. Don’t tell me because you’ve been seeing me for a year that you can no longer see me because of your caseload. [Biloxi, Mississippi]

Veterans also frequently described appointments with clinicians that felt too brief to be of any value, either to the clinician (who might want a little more information) or to the veteran (who might want to share a little more). The following quotes are illustrative and indicate that many veterans believe that systemic strains are the reason for the brevity:

[The doctor] she’s like, “I don’t want to hear any of your problems. How are your meds doing?” . . . I don’t blame her for that. I blame the system on it. [Biloxi, Mississippi]

Another thing I find with the VA is like, “OK, I got 30 minutes to deal with you.” Whatever your issue is, if people don’t get it in 30 minutes, “Oh, well. I’ll catch you next time.” [Temple, Texas]

Similarly, VA providers’ also voiced concerns about the high demand for services and its impact on the quality of care they are able to provide and on their choices about which patients to prioritize, as the following quotes illustrate:

I think it’s hard for me to feel like I’m providing good patient care when I can only see someone once a month for therapy. [Topeka, Kansas]

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

TABLE 8-6 Among OEF/OIF/OND Veterans Who Have Mental Health Needs, Perceived Local Availability of Mental Health Services, by User Group

Subgroups of OEF/OIF/OND Veterans Who Have Mental Health Needs
VA Users Non-VA Users Non-Users
Unwgt n Wgt N Wgt % SE % Unwgt n Wgt N Wgt % SE % Unwgt n Wgt N Wgt % SE%
There is a VA provider in my area that offers all of the mental health services Veterans need
Strongly or somewhat disagree 215 124,022 26.0% 1.9% 59 53,743 19.7% 3.4% 162 166,792 17.8% 1.6%
Strongly or somewhat agree 552 306,314 64.3% 2.1% 64 55,787 20.4% 2.8% 309 282,933 30.2% 1.8%
Not sure 78 44,254 9.3% 1.2% 130 159,451 58.4% 4.9% 406 474,909 50.7% 2.1%

NOTE: SE = standard error of percentage; Unwgt = unweighted; Wgt = weighted.

SOURCE: Committee to Evaluate VA Mental Health Services, Veteran Survey, 2017.

TABLE 8-7 Among OEF/OIF/OND Veterans Who Have Mental Health Needs, Reported Ability to See the Same Mental Health Provider, by User Group

Among OEF/OIF/OND Veterans Who Have Mental Health Need by Level of Agreement
Strongly or Somewhat Agree Strongly or Somewhat Disagree Not Sure/Refused
Unwgt n Wgt N Wgt % SE % Unwgt n Wgt N Wgt % SE % Unwgt n Wgt N Wgt % SE %
At the VA, you can see the same mental health provider on most visits
All OEF/OIF/OND veterans who have mental health need 816 509,161 30.0% 1.1% 247 181,931 10.7% 0.8% 889 972,445 57.2% 1.1%
VA users 629 350,699 73.6% 1.7% 123 70,470 14.8% 1.3% 76 44,175 9.3% 1.1%
Non-VA users 33 22,730 8.3% 1.9% 36 28,409 10.4% 1.9% 178 214,754 78.7% 2.3%
Non-users 153 133,697 14.3% 1.1% 88 83,052 8.9% 0.9% 625 703,377 75.1% 1.3%

NOTE: SE = standard error of percentage; Unwgt = unweighted; Wgt = weighted.

SOURCE: Committee to Evaluate VA Mental Health Services, Veteran Survey, 2017.

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

If I saw a new patient, and I want to see them back in 2 or 3 weeks. . . . We couldn’t see them back for like 6 weeks. When [my supervisor and I] were talking about it, he’s like, “That’s not appropriate. You need to see them back sooner.” [Altoona, Pennsylvania]

The committee heard from VA providers who expressed uneasiness about the care that community providers give to veterans through the Veterans Choice program:

I want to say one more thing about the Choice Act . . . and I trained a countless number of mental health providers in our community. They are not equipped. They are clueless about what we see day in and day out. [Cleveland, Ohio]

There are thousands of providers out there . . . it could be some person who has never seen or met a veteran before or knows about PTSD or evidence-based treatment. [San Diego, California]

Chapter 9 presents more details about the Veterans Choice program, including and additional site visit findings about this program.

PHYSICAL INFRASTRUCTURE

As noted in Chapter 2, the VA health care system includes more than 150 VAMCs, 780 community-based outpatient centers (CBOCs), and 130 nursing homes (Watkins et al., 2011). The VA operates out of both VA-owned and VA-leased properties. In Assessment K of the 12 independent assessments of the VA, as directed by the Veterans Access, Choice, and Accountability Act of 2014, McKinsey & Company Inc. examined the VA’s processes for carrying out the construction and maintenance of its medical facilities (McKinsey & Company Inc., 2015). The assessment, which takes into account all VA medical facilities, not only those involved in mental health care services, reports that the VA has a medical facilities budget of about $6 billion per year. Of that amount, major, minor, and nonrecurring maintenance construction cost about $2 billion per year; the annual operation lease obligation budget is about $0.5 billion per year; and reoccurring maintenance, plant operations, and other facility management cost about $3.5 billion year. The major finding from the assessment is that the VA “is expected to face accelerating and likely unfunded capital requirements driven by maintenance to aging infrastructure, projected workload needs to serve the veteran population, and inefficient capital management” (McKinsey & Company Inc., 2015, p. iv). As noted above, Assessment G of the independent assessment of the VA found that some VA facilities had insufficient examination space, which negatively affected provider productivity and, therefore, patient access to timely services (Grant Thornton LLP, 2015). Furthermore, GAO identified clinical space constraints at some VA facilities as an impediment to being able to get new mental health providers in place (GAO, 2015).

VA buildings are, on average, nearly 60 years old and 449 VA buildings are from the Revolutionary and Civil wars (96 of which are vacant). Only half of all facilities have been built since 1920. In all, more than 400 VA buildings are vacant and 735 are underutilized, costing tax payers $25 million per year (VA, 2017g). In 2017, the VA reported that its own assessments had identified critical infrastructure deficiencies in need of remediation totaling more than $18 billion throughout the system. The needed improvements included structural seismic, electrical distribution, and mechanical systems (VA, 2017g). While the VA does have processes in place to identify and address both capital and non-capital solutions to infrastructure needs throughout the system, it acknowledges that the primary challenge is having sufficient funding to address all the capital requirements throughout the system (VA, 2017e).

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

The sections below on VA facilities—specifically relating to veterans’ experiences with obtaining mental health care services—are drawn from the site visit data collected by the committee. The committee did not find a body of existing literature on topics such as ease of parking at VA facilities and veterans’ comfort levels inside VA facilities.

Parking

Veterans and VA clinicians both reported during the committee’s site visits that the VA facilities themselves have barriers that prevent veterans from seeking treatment or having a positive experience while doing so. For example, inadequate parking was a complaint at nearly all of the VAMCs that were visited on the site visits conducted for this study, and nearly half of all veterans surveyed did not think parking was readily available (see Table 8-7). Veterans told numerous stories about being late to appointments because they could not find a parking space or of becoming so agitated driving around looking for parking that they simply left and never attended that appointment. Clinicians said that they often have to waste precious appointment time calming a veteran down from his or her parking frustrations before it is even possible to move on to the actual reason for the appointment. As one VA clinician reported:

You spend the first 15 minutes diffusing them from the frustration with the parking situation. You haven’t even started the therapy. The parking is a nightmare. [San Diego, California]

To alleviate the parking issue, some VAMCs have moved to having satellite parking lots and then shuttling patients to the VAMC. However, as VA clinicians noted, this is not an acceptable solution for clients in crisis. Complaints about parking at VAMCs were often followed by praise for CBOCs and Vet Centers, both of which are smaller locations that generally have much more available parking.

Facility Environment

The committee survey explored veteran perceptions of VA mental health facilities. Table 8-8 reports the results for all of the features surveyed among OEF/OIF/OND veterans with mental health needs. Among VA users, a large majority found the cleanliness to be excellent or very good for the reception/waiting area (86 percent), for the restrooms/lavatory (82 percent), and for the building overall (76 percent). This is in contrast to more negative opinions about the facilities that the committee heard on the site visits (described below). However, the survey responses on parking were similar to what the committee heard on its site visits, with only 52 percent of VA users rating the availability of parking as excellent or very good.

In addition to the frustration of inadequate parking, veterans interviewed on the site visits described other aspects of their experiences inside VHA facilities. Veterans reported that being in large, crowded places made them uncomfortable. VHA hospitals are large, crowded areas with aisles and hallways that prevent them from having a clear view of their surroundings. VAMCs also reportedly felt militaristic, adding to veteran stress. Comments related to these issues included:

Part of PTSD is avoiding crowds. Well, this clinic is a crowd. [VHA clinician – Biloxi, Mississippi]

The VA, I feel afraid to go there. I don’t know my safe spots. I don’t know anybody that could help me. I prefer not to even approach it. [Veteran – El Paso, Texas]

As with parking, CBOCs and Vet Centers were generally seen more positively. In particular, they were praised as more comfortable locations to seek treatment because they are smaller, less crowded facilities.

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

TABLE 8-8 Among OEF/OIF/OND Veterans Who Have Mental Health Needs, VA and Non-VA Users’ Perceptions of the VA Facility

Perceptions of the VA Facility All OEF/OIF/OND Veterans VA Users Non-VA Users
Unwgt n Wgt N Wgt % SE % Unwgt n Wgt N Wgt % SE % Unwgt n Wgt N Wgt % SE %
Total 2,007 1,705,168 849 476,654 256 272,799
Cleanliness of reception/waiting area
Excellent/very good 1,107 752,348 44.3% 1.1% 715 407,969 85.6% 1.3% 92 77,073 28.3% 3.5%
Cleanliness of restroom/lavatory
Excellent/very good 1,062 726,223 42.7% 1.2% 676 388,346 81.5% 1.4% 86 73,635 27.0% 3.2%
Cleanliness of restroom/lavatory
Excellent/very good 699 499,163 29.4% 1.0% 420 245,379 51.5% 1.9% 63 56,383 20.7% 3.1%
Building overall (attractiveness, quality of building maintenance and upkeep)
Excellent/very good 1,046 723,364 42.6% 1.0% 642 361,252 75.8% 1.7% 90 77,226 28.3% 2.6%

NOTES: Response options included excellent, very good, good, fair, poor, and don’t know. SE = standard error of percentage; Unwgt = unweighted; Wgt = weighted.

SOURCE: Committee to Evaluate VA Mental Health Services, Veteran Survey, 2017.

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

Some clinicians (both at VAMCs and at CBOCs) commented that even their offices and other treatment rooms were not designed with mental health patients in mind. One clinician described it in this manner,

Sometimes they don’t like their backs to the windows or backs to the doors . . . it looks like design features weren’t considered necessarily. [San Diego, California]

The VA is currently working with mental health field representatives and a consulting group to update its design-guide standards for state-of-the-art mental health facilities. The guide will specify “how to make mental health treatment settings warm, inviting, and patient-centered” (VA, 2017e, p. 15).

GEOGRAPHIC ACCESS

Sufficient geographic access to care requires that users be within reasonable proximity to health facilities that provide needed services, in person or through a telemedicine method that is acceptable to users. Existing barriers to geographic access to care and health disparities between rural and urban communities have been well documented (IOM, 2005). Health care in rural populations poses a variety of challenges, such as limited availability of specialized providers, limited options for assessment and treatment referrals, and a lack of cultural awareness among providers (Richardson et al., 2009). Rural veterans are less likely than urban veterans to access mental health services because they face challenges such as greater distance and travel time and have few (if any) public transportation options. In some cases, a veteran may be located within reasonable proximity to a VA facility, but that facility may not offer the needed service. In such a case, the veteran may have to travel a much farther distance than the distance to the closest facility to receive needed care. The Veterans Choice Program was designed in part to address this issue by offering veterans more convenient options when seeking services. If a VA provider is not within a 40-mile drive of a veterans’ home, the Veterans Choice Program permits the veteran to seek care from an approved non-VA provider. According to the VA’s Office of Rural Health, 2.9 million out of 5.5 million rural veterans are enrolled in the VA health care system. One-third of all veterans enrolled in VA services live in rural locations (VA, 2017f). About 12 percent of VA-enrolled rural veterans served in OEF and OIF.

Studies have shown that VA patients in rural areas have more physical comorbidities and worse health-related quality of life than those residing in suburban or urban settings. In addition, they have reduced access to health services and fewer alternatives to VA care (Weeks et al., 2004; West and Weeks, 2006), and they use services at a lower rate than their urban counterparts (Teich et al., 2016). Compared to urban and suburban veterans, rural veterans live further from private-sector and VA hospitals, have access to fewer mental health and specialty services, and visit their providers less frequently, while at the same time having more physical and mental health problems (Weeks et al., 2004). Among veterans seeking treatment for serious mental illness, travel distance has been found to be the strongest predictor of poor service (McCarthy et al., 2006). Furthermore, as travel distance increases, retention tends to decrease for alcohol abuse treatment, especially among older and younger veterans (but less so among the middle aged) (Fortney et al., 1995).

In a study comparing the use of mental health treatment among veterans with a mental health condition in rural areas versus those living in urban areas, Teich et al. (2016) found that veterans in rural areas were 70 percent less likely to receive any mental health treatment than those in urban areas. Rural veterans were 52 percent less likely to receive outpatient treatment and 64 percent less likely to receive prescription medication than urban-dwelling veterans with mental health conditions (Teich et al., 2016).

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

Brooks et al. (2012) evaluated outpatient service use by rural veterans with PTSD compared with their urban counterparts. Data were obtained for 415,617 veterans with PTSD who received outpatient care at a VA facility. The results indicated that veterans from rural and highly rural areas had, respectively, 19 percent (95% confidence interval [CI] = 0.80–0.82) and 25 percent (95% CI = 0.72–0.79) fewer outpatient visits than those who lived in urban settings. The results are similar for visits to specialized PTSD clinics, with 12 percent fewer visits (mean = 2.17; incidence rate ratio [IRR] = 0.88, 95% CI = 0.87–0.89) for those in rural and 33 percent fewer visits (mean = 1.66; IRR = 0.67, 95% CI = 0.64–0.71) for those in highly rural areas compared to their counterparts in urban areas. Service use was contingent on proximity to services, with a larger effect seen for those veterans requiring specialized mental health care (Brooks et al., 2012).

In a similar comparison, Mott et al. (2014) evaluated the change in psychotherapy use over time in rural and urban veteran populations. The authors evaluated data from the VA National Patient Care Database outpatient treatment files for all veterans who received a new-onset diagnosis for depression, anxiety, or PTSD at a VA outpatient facility between FY 2007 and FY 2010. The authors found that rural veterans were less likely to receive psychotherapy than their urban counterparts. Telepsychotherapy use was low among both groups (less than 1 percent). Over time, however, the use of individual, in-person psychotherapy grew significantly among both rural and urban veterans and the disparity between the two groups slightly decreased. From 2007 to 2010, the proportion of rural veterans receiving any psychotherapy increased from 17 to 22 percent. Among urban veterans it increased from 24 to 28 percent (Mott et al., 2014). Similarly, the proportion of rural veterans receiving eight or more psychotherapy visits increased from 2.4 to 4.3 percent between 2007 and 2010. Among urban veterans it increased from 5.5 to 7.0 percent during the same period. While the rural–urban gaps decreased between 2007 and 2010 for psychotherapy, for other mental health services, such as medication management and case management, the use increased among both rural and urban groups, but the disparity between the two groups persisted.

Aside from affecting the use of mental health care, rural status may also affect the type of mental health treatment given when services are utilized. Pfeiffer et al. (2011) evaluated how driving distance to VA services affected service usage and modes of treatment among a sample of veterans with a depression diagnosis. The authors found that, compared to veterans living within 30 miles of the nearest VA mental health facility, veterans with depression living between 30 and 60 miles from the nearest VA mental health facility were less likely to receive psychotherapy (odds ratio [OR] = 0.71; 95% CI = 0.66–0.76) but more likely to receive pharmacotherapy (OR = 1.27; 95% CI = 1.22–1.33). The authors suggest that this finding may indicate that providers and patients may consider geographic barriers to care when deciding on treatment options.

Buzza et al. (2011) evaluated how geographical distance to care is a barrier to health care services (although not specifically to mental health care) among rural veterans. The authors assessed this barrier through surveys (N = 96 patients, 88 providers/staff), interviews (42 patients, 64 providers/staff), and focus groups (N = 7, consisting of providers and staff) at 15 VA primary care clinics in the Midwest (VISN 23). “Distance to drive” was the most frequently selected barrier by patient and provider; other barriers included travel-related challenges such as time, limited transportation, and cost or expense. Veterans indicated that the same travel distance was more burdensome when they were seeking care for routine services (for example, laboratory, podiatry) as compared to specialty care (for example, cardiology, neurology) (Buzza et al., 2011).

Rural veterans may face disparities when compared to urban-dwelling veterans that are not necessarily related to their physical distance from services. For example, numerous studies have noted an increased risk of suicide for people living in rural areas (Kapusta et al., 2008; Levin and Leyland, 2005; Middleton et al., 2003; Razvodovsky and Stickley, 2009; Singh and Siahpush, 2002). McCarthy et al.

Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

(2012) examined rural–urban differences in suicide rates in a population of veterans receiving services in the VA health system. Suicide mortality was assessed in two periods: FY 2004–2005 and FY 2007–2008; and suicide risks were assessed for two cohorts—those that had VA inpatient encounters in those time periods and those who had VA outpatient encounters. Median distance to the nearest VA mental health provider was greater for patients in rural areas. In the two cohorts, residence in rural areas was associated with an increased rate of suicide and increased suicide risk; however, the distance measures were not necessarily related to suicide risk. This finding suggests that the elevated suicide risks observed among rural populations might have less to do with health system accessibility barriers and more to do with socioeconomic or sociocultural factors.

SUMMARY

This chapter outlined the workforce and facilities-related issues affecting access to mental health care services at the VA. A summary of the committee’s findings on this topic is offered here.

  • The VA is the largest training program for health professionals in the United States.
  • The VA experiences significant shortages of mental health providers due to widespread national shortages of mental health professionals, lengthy and inefficient hiring processes, and high turnover in some areas.
  • Excessive workloads and bureaucratic stressors contribute to mental health staff burnout, which negatively affects both staff retention and the quality of patient–provider relationships.
  • A number of incentive and training programs are in place to help circumvent some of these staffing problems and to streamline the hiring process, although not all provider groups are eligible for all of them. These include the Education Debt Reduction Program, the Mental Health Education Expansion program, and others.
  • The VA is also using a wider variety of types of mental health professionals and paraprofessionals, such as peer advocates, to address staffing needs, and it is implementing efforts to eliminate barriers to their professional staff to work at the top of their licensure.
  • The VA has trained its mental health providers in evidence-based practices as one way to enhance provider quality and expertise.
  • The VA uses effective training methods and has trained a significant percentage of clinicians.
  • In addition to valuing technical expertise, veterans place a high value on the interpersonal relationship they have with their mental health providers.
  • Overall, veterans’ perceptions of providers across both of these domains (technical expertise and interpersonal relationships) were positive.
  • A notable number of non-VA users and non-users of mental health services reported that they did not know if needed services were available in their area.
  • On the site visits, veterans and providers acknowledged the effects of managing high patient load on provider–patient interactions.
  • Physical infrastructure issues such as a lack of office and exam room space, insufficient parking at VAMCs, and aging buildings affect both access to care and the quality of the patient experience.
  • Veterans in rural locations may be less likely to receive mental health services than those who reside in urban locations. Rural veterans who do seek care may be more likely to receive pharmacotherapy and less likely to receive psychotherapy than their urban counterparts.
Suggested Citation:"8 Mental Health Workforce and Facilities Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

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Approximately 4 million U.S. service members took part in the wars in Afghanistan and Iraq. Shortly after troops started returning from their deployments, some active-duty service members and veterans began experiencing mental health problems. Given the stressors associated with war, it is not surprising that some service members developed such mental health conditions as posttraumatic stress disorder, depression, and substance use disorder. Subsequent epidemiologic studies conducted on military and veteran populations that served in the operations in Afghanistan and Iraq provided scientific evidence that those who fought were in fact being diagnosed with mental illnesses and experiencing mental health–related outcomes—in particular, suicide—at a higher rate than the general population.

This report provides a comprehensive assessment of the quality, capacity, and access to mental health care services for veterans who served in the Armed Forces in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn. It includes an analysis of not only the quality and capacity of mental health care services within the Department of Veterans Affairs, but also barriers faced by patients in utilizing those services.

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