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Suggested Citation:"Summary." 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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Summary

The wars in Afghanistan and Iraq are among the longest sustained U.S. military operations in history. Operation Enduring Freedom (OEF)1 is the name for the war in Afghanistan that began on October 7, 2001, and ended on December 31, 2014; and Operation Iraqi Freedom (OIF) is the name of the war in Iraq that began on March 20, 2003. On September 1, 2010, operations in Iraq continued under the name Operation New Dawn (OND).

In response to concerns about the health care experience of the approximately 4 million U.S. veterans who supported the wars in Iraq and Afghanistan and who may have mental health conditions, Congress passed Section 726 of the National Defense Authorization Act for fiscal year 2013; Section 726 required that the Department of Veterans Affairs (VA) enter into an agreement with the National Academies of Sciences, Engineering, and Medicine for a study that would assess veterans’ ability to access mental health services at the VA and the quality of mental health services within the VA and would provide recommendations to improve problems with access and quality of services. The National Academies appointed the Committee to Evaluate the Department of Veterans Affairs Mental Health Services and assigned to it the following task:

A National Academies committee will comprehensively assess the quality, capacity, and access to mental health care services for veterans who served in the Armed Forces in OEF/OIF/OND. The committee will assess the spectrum of mental health services available across the entire VA. The scope of this assessment will include analysis not only of the quality and capacity of mental health care services within the VA, but also barriers faced by patients in utilizing those services. Types of evidence to be considered by the committee in its assessment include relevant scientific literature and other documents, interviews with VA mental health professionals, survey data to be provided by

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1 Operation Enduring Freedom officially refers to several operations around the world that were part of the global war on terror; however, in the context of this report, the focus is the operation in Afghanistan.

Suggested Citation:"Summary." 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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the VA, and results from surveys of veterans to be conducted independently by the committee. Site visits will be conducted to at least one VA medical center in each of 21 Veterans Integrated Service Networks (VISNs) across the country. In addition, the committee will hold an open meeting of experts to discuss the Secretary’s plan for the development and implementation of performance metrics and staffing guidance. The committee will provide a final report with recommendations to the Secretary of the VA regarding overcoming barriers and improving access to mental health care in the VA, as well as increasing effectiveness and efficiency.

COMMITTEE’S APPROACH TO ITS CHARGE

The National Academies appointed a committee of 18 experts with extensive knowledge in a variety of relevant fields to carry out the study. The committee’s approach to gathering information was threefold: reviewing the relevant published literature, conducting site visits, and developing and fielding a survey of OEF/OIF/OND veterans.2 The committee sought input on the use of VA mental health services directly from veterans, veterans’ families and caregivers, providers, and others at each of the 21 VISNs across the United States.3 The committee developed a survey that was administered to veterans to gather information on access to and the quality of VA mental health services and to determine why some veterans choose not to use VA mental health services. The major mental health conditions addressed in this report are posttraumatic stress disorder (PTSD), major depressive disorder, substance use disorder (SUD), and suicidal thoughts or behaviors.

To accomplish the part of the task that requires discussion of “the Secretary’s plan for the development and implementation of performance metrics and staffing guidance,” the committee held a public meeting on November 22, 2013, in Washington, D.C. During this meeting, VA officials presented their work related to the Secretary’s plan, and the committee engaged in a discussion with them about it.

KEY FINDINGS

The committee’s findings, derived from its survey of OEF/OIF/OND veterans, its site visits, and the literature, about the mental health needs of the OEF/OIF/OND population and the accessibility and quality of VA’s mental health services are summarized below.

There is a substantial unmet need for mental health services in the OEF/OIF/OND population as identified using standard screeners of mental health conditions or veteran-reported diagnoses. Approximately half of OEF/OIF/OND veterans surveyed by the committee who may have a need for mental health care services do not use VA or non-VA mental health care services. These results are consistent with several other studies of VA mental health care and demonstrate that a large proportion of veterans do not receive any treatment following diagnosis of PTSD, SUDs, or depression. Additionally, over half of veterans who have a mental health need do not perceive a need for mental health services, which suggests that some veterans do not seek care because they do not perceive that they personally have a need.

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2 See Appendix A for details on the survey methods.

3 The VISNs were undergoing reorganization during the study period. The reorganization process is expected to be completed in 2018. Therefore, the VISN geographic coverage and numbers in this report may not correspond directly to the current VISN geographic coverage and numbers.

Suggested Citation:"Summary." 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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A number of VA health system factors may facilitate or be barriers to veterans’ willingness to seek care.

  • A lack of awareness about how to connect to the VA for mental health care is pervasive among OEF/OIF/OND veterans. Among OEF/OIF/OND veterans who have a mental health need and who have not sought VA mental health services, their main reasons for not doing so are that they do not know how to apply for VA mental health care benefits, they are unsure whether they are eligible, or they are unaware that the VA offers mental health care benefits.
  • The process of accessing VA mental health services has been burdensome and unsatisfying for many OEF/OIF/OND veterans. The changes that OEF/OIF/OND veterans would like to see at the VA include, for example, making the process for scheduling appointments easier and improving customer service.
  • From a systems perspective, the VA can facilitate access by ensuring VA leadership and management acumen are focused on aligning resources to veteran needs. Chronic workforce problems exist that have a significant impact on the care veterans receive. Complex eligibility criteria and confusing procedures to transition between the Department of Defense (DoD) and the VA are examples of policy-related barriers veterans encounter when seeking VA health care.

Many veterans’ personal factors may facilitate or be barriers to veterans’ willingness to seek care.

  • OEF/OIF/OND veterans who have significant others (for example, family members and friends) who support their seeking treatment are much more likely to use VA health care services than veterans without such support.
  • The use of the Internet or the phone to receive mental health care is acceptable to nearly half of OEF/OIF/OND veterans. Younger veterans tended to be more open to obtaining mental health care using the Internet.
  • Transportation to and the convenience of VA medical facilities may pose challenges for many OEF/OIF/OND veterans who live far from VA facilities or who have chronic health conditions that make traveling long distances difficult.
  • Additional barriers to seeking mental health care include employment concerns (spending time off from work, harm to their careers, denial of security clearance, and receiving less confidence and respect from co-workers and supervisors) and fears that discrimination could affect their ability to own guns, lead to a loss of contact with or custody their children, or lead to a loss of medical or disability benefits.

A majority of OEF/OIF/OND veterans who use the VA report positive aspects of and experiences with VA mental health services. These aspects of care include the availability of needed services, the privacy and confidentiality of medical records, the ease of using VA mental health care, the mental health care staff’s skill and expertise, and the staff’s courtesy and respect toward patients.

Many OEF/OIF/OND veterans receive high-quality mental health care from the VA; however, the VA’s ability to deliver high-quality mental health care consistently to all veterans across facilities and subpopulations is an ongoing challenge. While evidence-based mental health services are available to veterans and are mostly concordant with clinical standards and policy mandates, there are significant gaps in care delivery. Problems with adequate staffing, physical infrastructure, and providing timely care appear to contribute to the variability in the VA’s delivery of evidence-based mental health services. Burnout and job-related stress among VA mental health providers may contribute to high turnover.

Suggested Citation:"Summary." 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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The VA dedicates resources to and has a history of implementing innovative practices in the areas of patient care, health information technology, and quality monitoring.

  • The VA has implemented innovative and evidence-based models of collaborative and integrated care to improve the delivery of mental health treatment.
  • The VA has long-standing experience and expertise with electronic health records (EHRs), telehealth, virtual care technologies, and tele-mental health research and app development.
  • The VA has many data systems tracking patient care; however, it has not yet operationalized a comprehensive system for collecting health outcome data with standardized patient-reported outcome measures.
  • The VA is using some community-based mental health resources to serve veterans—for example, through the Choice Program and partnerships with organizations specializing in veterans’ services—to help alleviate the VA’s workforce and infrastructure problems. However, the VA does not collect adequate information about the approaches that it uses to ensure care coordination and quality monitoring for services the VA offers through contracts with community providers.

CONCLUSIONS AND RECOMMENDATIONS

As the nation’s largest provider of mental health care services, the VA health care system has tremendous mental health care expertise, many and diverse care delivery assets, and substantial training and research capabilities. It has a unique and unparalleled opportunity to address the mental health care needs of veterans in a truly integrated and strategic manner. Furthermore, the VA is positioned to inform and influence how mental health care services are provided more broadly in the United States. After reviewing extensive evidence, the committee concludes that the VA provides mental health care that is generally of comparable or superior quality to mental health care4 that is provided in the private and non-VA public sectors and that it has multiple centers of excellence in various aspects of mental health care. However, the accessibility and quality of mental health care services across the system varies by facility. For example, the committee found variability in staffing levels, types of providers, infrastructure resources, and veterans’ access, and in the types and consistency of treatments provided. It should be noted that problems with accessibility to and quality of mental health care are not unique to the VA as similar problems also have been reported in the private and non-VA public sectors. Although many OEF/OIF/OND veterans are satisfied with VA’s mental health care, the committee believes that there are multiple opportunities for improving VA mental health care, especially with regard to increasing or facilitating access to care, providing care that is centered on the patient’s needs and expectations (that is, patient-centered care), and ensuring the consistency and predictability of readily accessible high-quality care being provided across the entire system.

To become a high-reliability provider of mental health care services, the VA needs to consistently and predictably provide readily accessible, high-quality mental health care at every facility for every veteran on every occasion.

Recommendation 16-1. The VA should set a goal of becoming a high-reliability provider of high-quality mental health care services throughout the VA health care system within 3 to 5 years. The VA should develop a comprehensive system-wide strategic plan for providing

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4 Health care quality is a multidimensional concept. Chapter 7 of this report describes key concepts used by the committee in its evaluation of the evidence.

Suggested Citation:"Summary." 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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readily accessible, high-quality, integrated mental health care services to improve the overall health and well-being of veterans. This plan should have a 3- to 5-year horizon and its implementation should be regularly monitored, reviewed, and updated, as needed, during that time.

The Veterans Health Administration (VHA), the sub-cabinet level agency within the VA that provides health care, needs to undertake a concerted, system-wide effort to organize and align its care delivery assets and processes of care toward this end, while concomitantly working with the Veterans Benefits Administration (VBA) and other elements of the VA to achieve this goal. To support these efforts, the VA should develop a comprehensive strategic plan or roadmap for reaching this objective. The strategic plan should address at least the following areas:

  1. Ways to enhance and facilitate timely access to patient-centered care and remove barriers to access. Broad input from patients using mental health care, as well as from staff, about service satisfaction and the barriers to providing patient-centered care should be solicited. Evaluate service-improvement programs such as MyVA as well as the many mental health service programs that the VA offers to learn whether these programs are achieving stated goals. Facilities should be identified that have high-service satisfaction, service effectiveness, increased access, and efficiency with the objective of calling out practices that might be adopted by other facilities.
  2. Workforce issues, including the recruitment, hiring, and retention of diverse staff; ensuring that VA health professionals are working at the top of their skills and expertise; and using health professional training programs to address staffing needs.
  3. The integration of the services of non-VA mental health care providers (for example, providers participating in VA community care programs such as the Veterans Choice Program) into the VA health care system. Independent evaluation of the utilization and quality of mental health services specifically provided by community care programs.
  4. Facility and other infrastructure needs, including facility physical plant issues that present barriers to access (for example, a lack of parking) or to the efficient and effective delivery of patient-centered care (for example, insufficient space for clinical evaluations and treatment).
  5. The integration of mental health care with both primary and non-mental health specialty care.
  6. The use of virtual care technologies, including telehealth and Internet-based technologies, to enhance access to and the delivery of mental health care.
  7. Performance management to advance the quality of mental health care.
  8. Incorporation of continuous quality improvement into all aspects of mental health care delivery.
  9. The deployment and use of evidence-based practices (EBPs).
    1. Address barriers to providers’ use of recommended guidelines.
    2. Review existing priority areas in clinical guidance and policy directives to confirm the evidentiary base underlying the practices recommended for these priorities and to identify clinical practices requiring reassessment, inclusion, or removal.
    3. Increase use of EBPs through efficient and scalable clinical training procedures.
  10. The system-wide review, modification, and standardization of policies and processes of care that facilitate and support access and the provision of high-quality mental health care.
  11. Ways to foster and nurture innovation in methods and processes of mental health care.
  12. Identifying and addressing research gaps and priorities.

The development of this strategic plan should be informed by the numerous studies and evaluations that have been conducted of VA health care in recent years. The VA should examine those reports to

Suggested Citation:"Summary." 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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determine the reasons why some recommendations contained in them were judged to be appropriate but were not implemented. As appropriate, those recommendations, along with the recommendations contained in this report, should be collated and incorporated into or otherwise addressed in the mental health care strategic plan (see Recommendation 16-1).

Below, the committee makes additional recommendations that expand on some of the strategic plan areas listed above in Recommendation 16-1.

Access to Mental Health Care

The committee identified a number of ways OEF/OIF/OND veterans were having problems accessing mental health care from the VA. On the basis of those findings, the committee believes that the VA needs to do more to bring veterans who have unmet mental health care needs into the VA health care system. The lack of awareness about how to connect to the VA for mental health care demonstrates the need for awareness campaigns and effective dissemination of the mental health care opportunities, eligibility criteria, and services to help veterans understand how and where to access mental health care. The VA’s recent initiative to offer emergency mental health care to veterans with other-than-honorable discharge status is an important step to improving access for veterans who may be in need of immediate help.

It may be particularly challenging to support veterans who are not ready to seek mental health services but who may want to obtain services at a later time. The VA should consider strategies for following up with veterans at regular intervals (for example, every 3 to 6 months for 2 to 3 years) following discharge from the military.

Recommendation 16-2. Via policy changes and other approaches, the VA should eliminate barriers to accessing mental health care experienced by OEF/OIF/OND veterans. The VA should adopt additional strategies to engage veterans, expand outreach efforts beyond the initial postdeployment period, and improve its transitional services as well as VHA and VBA processes with the goal of enhancing and facilitating access to mental health care.

Specific actions to be undertaken include the following:

  1. The VA, along with DoD, should re-examine the processes for transitioning services from DoD to the VA with the objective of enhancing the coordination and integration of services (including the determination of benefits and disability ratings and the transfer of health care records) and with the continuation of health care services. Possible improvements could include setting up initial VA health appointments as part of the Transition Assistance Program and providing liaisons who can be contacted to assist throughout the transition process and for a period of time afterward.
  2. The VA should examine the VHA and VBA interfaces with the goal of creating standard protocols (for example, for VBA compensation exams) to facilitate veteran access to services for physical and mental health conditions. The VA should view VBA compensation and pension examinations as an opportunity to engage veterans in ongoing care.
  3. The VA should use assertive outreach to bring veterans who have mental health care needs into the system. The U.S. Department of Housing and Urban Development–VA Supportive Housing program to address veteran homelessness is an example of how assertive outreach already has been effective for the VA.
Suggested Citation:"Summary." 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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  1. The VA should assess the availability and effectiveness of its peer specialist program and other support programs (for example, patient care navigators) at its facilities and develop appropriate implementation strategies if the assessment determines that these resources should be augmented.

Mental health care services in the private and non-VA public sectors are not adequate to meet the current demand for such services in many communities across the United States. There are, however, communities where resources are sufficient to do more and where these resources could be used to meet veterans’ needs. These resources generally provide ancillary and complementary services to support mental health treatment obtained from VA providers and from community care providers such as Veterans Choice Program providers.

Recommendation 16-3. The VA should examine how its facilities interface with community resources and compile an inventory of VA–community collaborations with the objective of identifying exemplary or model collaborations and best practices for forging community partnerships.

Equitable Care

Demographic data show that the OEF/OIF/OND veteran population is more racially and ethnically diverse and has more women than other veteran cohorts. Differences exist in mental health diagnosis and treatment patterns across races and ethnicities among veterans receiving care at the VA. The reasons are not clear, but some researchers posit that the difference in diagnosis patterns may be related to provider characteristics, doctor–patient communication, patient participation, or the lack of cultural sensitivity in diagnostic criteria for mental health conditions. The rates of using mental health care services also differ across different demographic groups. Women veterans who served in OEF/OIF have a higher need for mental health care compared to women veterans from previous conflicts, but also are significantly more likely to believe that they are not entitled or eligible for VA mental health services compared to men veterans who served in OEF/OIF/OND. The committee heard from women veterans during the site visits that VA staff at health care facilities sometimes assume that they are wives accompanying their husbands and not themselves veterans. They also are at times uncomfortable in VA clinic waiting rooms because they get unwanted sexual attention, which can be particularly unsettling for women veterans who have experienced military sexual trauma. Research on homeless veterans shows that they are more likely to defer or delay mental health care than housed veterans even though they have a greater need for services. Although the research is still emerging, lesbian, gay, and bisexual veterans may use mental health services at a lower rate than veterans who are not lesbian, gay, or bisexual. Transgendered veterans may be more likely to have a mental health diagnosis than non-transgendered veterans. While interventions to reduce mental health stigma are emerging, stigma remains a barrier to seeking mental health care among veterans.

Recommendation 16-4. The VA should take steps to ensure that its diverse patient population receives readily accessible, high-quality, integrated mental health care services. Areas to focus on are service delivery, workforce issues, and resource allocation (including the logistics of care delivery and the structure of clinical space).

Specific actions should include the following:

  1. Ensuring that clinical environments are supportive of quality care for racial and ethnic minorities by ensuring that the racial and ethnic diversity among clinical and administrative staff reflects
Suggested Citation:"Summary." 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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  1. the diversity of the patient population, identifying and addressing discrimination, and monitoring and addressing health care disparities.

  2. Ensuring that clinical environments are supportive of quality care for women veterans, efforts that should include the provision of gender-appropriate providers and intolerance of harassment of women veterans by either staff or fellow patients.
  3. Assessing the needs of lesbian, gay, bisexual, and transgender veterans and providing an appropriately welcoming and supportive environment.
  4. Assessing the needs and barriers to care for rural-dwelling veterans and ensuring that the demand for care in rural locations is met.
  5. Identifying the homeless veterans who are being served and adjusting clinical services to provide them quality care and facilitate domiciliary services when appropriate.
  6. Ensuring that both VA and community care providers understand military culture.

Human Resources and Capital Assets

Some VA facilities are understaffed and have inadequate clinical and office space to support the efficient delivery of care or patient-centered care. As a result of these infrastructure problems, VA mental health providers sometimes cannot meet the demand for mental health care services and providers “burn out,” which can interfere with the quality of the relationship between the veteran and provider. Primary care–mental health integration is one strategy that the VA has employed to realign its human resources to reduce service fragmentation and improve patient care. While the VA needs to ensure that its existing mental health care resources are allocated in a manner that optimizes the likelihood that they are effectively and efficiently used, additional staff and clinical space are needed at some facilities. The committee recognizes that increasing the VA’s mental health workforce is particularly challenging, given the nationwide shortage of mental health care providers, and, consequently, it believes that the VA should explore ways it can use its educational and training infrastructure to address its workforce needs. Space shortages appear to be more of a concern at VA medical centers (VAMCs) and VA community-based outpatient clinics (CBOCs) than at Vet Centers. The lack of adequate space and workforce appears to be a prominent reason that staff at some VA facilities sometimes cannot provide EBPs.

Veterans sometimes experience a lack of continuity in their mental health care because of the turnover of providers and, especially, providers in training. The training of mental health care providers at VA facilities is highly desirable, but VA should make an effort to better bridge the transition from one trainee therapist to another. The VA should raise provider awareness of the issues of continuity of care from the veteran’s perspective.

The VA has a variety of incentive programs to help bolster recruiting and retention. Title 38 U.S.C. positions, for example, can be filled by appointing a former or current VA trainee without formally posting the position and going through the full recruitment process. At present, the only types of mental health care providers included under Title 38 are physicians, psychologists, nurses, and physician assistants. Reclassifying all types of mental health care workers, including substance use counselors, under Title 38 might help in addressing some of the mental health care workforce problems.

The committee heard repeatedly during its site visits that the VA’s human resources management process is cumbersome and onerous. There was broad support for improving the human resource management process, specifically with regard to the recruitment, onboarding, and retention of both care provider and support staff.

Suggested Citation:"Summary." 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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Many veterans reported that they highly valued the care that they received at Vet Centers and that they preferred to go to Vet Centers for their mental health care instead of VAMCs or CBOCs. Some of the reasons that veterans offered for preferring using the Vet Centers were the availability of marital and family therapies, a less formal atmosphere, seemingly enhanced confidentiality, shorter wait times, more flexible hours of operation, and the Vet Center’s emphasis on counseling services rather than the use of medications. Peer support is typically readily available as well. The VA should explore how the Vet Center program could be enhanced or, alternatively, how the characteristics of the Vet Centers that appeal to veterans could be replicated at CBOCs and VAMCs.

Recommendation 16-5. The VA should evaluate whether all types of mental health care workers could be brought under Title 38 U.S.C. and if this might alleviate some workforce shortages. If the assessment indicates that this reclassification would have a salutary effect, then the VA should pursue the necessary solutions.

Recommendation 16-6. The VA should conduct a broad examination of its various types of facilities to assess how it could realign its human resources and capital assets to better meet the demand for mental health care services. Adequate clinical and office space and staffing are necessary to reduce wait times, lessen administrative and clerical burden on clinicians, improve the fidelity of treatment, and increase adherence to clinical practice guidelines.

Health Technology

The VA is using health technology, including telemedicine (the use of electronic information and communication technologies to provide health care) and mHealth (mobile health apps), to increase access to mental health care and to treat and help manage a variety of mental health conditions, including PTSD, depression, and SUD. While telemedicine infrastructure has been widely rolled out, its actual use across the VA is highly variable and seems to be dependent on local champions and use cases, rather than on directed strategic approaches. The VA has been steadily increasing funding for telemedicine and has expanded telemedicine services throughout its health system. A growing body of research supports the use of telemedicine as a way of effectively delivering various health care services and, especially, mental health care. The use of virtual care technologies for mental health care is not yet fully integrated as a part of standard clinical care at the VA. Several barriers to access to care, such as long distances to VA clinics and VA workforce shortages, could be addressed by using tele-mental health for clinical services.

While the growth of tele-mental health indicates the VA’s commitment to using technology to improve access to mental health care, research gaps in the field remain, as do implementation and attitudinal barriers in the VA. Long-term outcome studies are needed on the use of tele-mental health for conditions other than PTSD or depression. Further research also is needed on the use of tele-mental health for evidence-based therapies—for example, therapies delivered in the home or in mobile settings—and for technologies other than video conferencing, such as mHealth smartphone applications. In another use of health technology, research is needed to better understand how to optimize VA information systems for comprehensive surveillance of suicide attempts among VA health service users. To further maximize the benefits of health technology, the VA needs greater buy-in and commitment from national and local VA leaders, providers, and veterans in order to enable telehealth modalities to be a standard part of routine care, when appropriate. Coordinated training efforts at the provider and leadership level could improve buy-in and successful adoption.

Suggested Citation:"Summary." 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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Recommendation 16-7. The VA should leverage its existing health technology infrastructure and internationally recognized expertise in telehealth and virtual care to substantially expand the scale and quality of its tele-mental health and technology-supported mental health services for clinical, research, and educational purposes.

Specific actions should include the following:

  1. Collaborating with partners, such as the DoD and academic medical centers, to increase and support strategic research into the best use of these information technologies to support the mission of the VA and the care of veterans nationally, with a focus on methods used in dissemination and implementation research.
  2. Substantially increasing and scaling the use of clinical information technologies for direct mental health care (for example, video, telephony, e-consults, messaging, apps, virtual reality, and gamification), and integrating them as a routine choice as part of stepped care for veterans across the full range of VA mental health and primary care programs.
  3. Training leadership at all levels throughout the VA on how to promote and incentivize the increasing use of health information technologies in every VA area and on how to capture and copy examples of excellent implementation and innovation found in other VA regions.
  4. Increasingly employing qualified providers as a virtual network of experts to work across the country, rather than primarily in a single region, and substantially increasing the use of such providers for meeting both training and service needs and capacities created by workforce shortages in some VA regions.
  5. Making work conditions more flexible for many clinicians to enable them to increasingly work in a hybrid manner—both in person and online—and to work both within their own work regions and within other VA regions so that mental health care becomes available in a virtual manner, anytime, anywhere, especially direct to veterans in their homes. For workload and cost accounting purposes, providers will need to receive “credit” for work provided outside their own regions or networks.
  6. Ensuring that the current VA EHR system is interoperable with DoD’s EHR and other commercially available EHRs to allow the passage of patient information (both physical health and mental health information) seamlessly and rapidly, thereby making sure that complete information is available to providers when and where it is needed.

Quality Management

The VA has many key initiatives aimed at measuring system performance to improve mental health care access and quality. For example, current efforts by the VA include the collection and use of more mental health care measures, the use of facility-level and system-level performance data to engage VA management in mental health programming and improvement, and programs (such as the Quality Enhancement Research Initiative and the Diffusion of Excellence program) to identify and disseminate best practices. The VA’s programs to train clinicians on evidence-based mental health treatments and to promote the use of those treatments by clinicians are other ways the VA has increased its capacity to provide evidence-based care.

The VA uses a number of quality management strategies, programs, and systems, but questions remain about how well these efforts are driving the system to be more patient centered and value driven while also improving access to care and quality of care. Problems with provision of services suggest

Suggested Citation:"Summary." 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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that the VA does not appear to be adequately generating and using data to improve its mental health care system. More attention is needed to identify sources of variation across VISNs and VAMCs and on using performance data about the various access and quality domains to establish targeted quality improvement efforts.

Given the large numbers of veterans who do not seek mental health care and the significant percentages of veterans who are not receiving mental health treatments that meet recommended dosages, frequency, or follow-up, particular attention should be placed on measuring and monitoring the delivery of evidence-based care, patient engagement in care, and continuity of care. These areas of performance measurement should address veterans who receive care within the VA health system and veterans who receive care through VA community care programs, such as the Veterans Choice Program.

The VA needs a better and a broader array of quality measures to improve the interface between general medicine and mental health. Few indicators have been implemented at the VA or nationally that specifically assess the quality of mental and general health care integration. The quality reported by subgroups (for example, the type of mental health condition and the specific demographics) can support targeted interventions.

None of the VA’s data systems for quality management reviewed by the committee collect and use patient outcome data, which is a significant barrier to quality improvement. Patient outcome data are the necessary standard against which to judge effectiveness of VA facilities’ quality improvement efforts. Another priority area is methods for measuring and improving the delivery of psychosocial interventions. The preponderance of mental health measures focuses on medication management for the treatment of mental health conditions. However, cognitive behavioral therapy is the first-line EBP for depressive and anxiety disorders. The committee found that the VA has started collecting data on the delivery of evidence-based psychotherapy using electronic clinical progress templates incorporated into veterans’ health records.

Finally, to become a high-reliability mental health care system, the VA has to develop a more robust quality management infrastructure that will support the continuous evaluation of access, quality of care, and outcomes, among other things. This requires a much more broadly based portfolio of performance measures than exists today. And while the development and use of mental health performance measures has gained momentum in recent years, and while the VA has been an active participant in this arena, the committee believes that the VA should take a lead role nationally in measuring the quality of mental health care. The VA health care system can serve as a testing ground for measurement innovation that can both benefit veterans and the U.S. population broadly. And since a growing number of veterans are receiving care in the non-VA public and private health care sectors, the VA has a vested interest in establishing standardized performance measures that can be used to assess and improve the quality of care.

Recommendation 16-8. The VA should take a lead role nationally in advancing quality management in mental health care. Toward this end, the VA should take steps to accelerate the development and use of standardized performance measures to assess and improve care for mental health conditions in veterans. It should engage with performance measure development organizations to develop a robust portfolio of mental health care performance measures. As part of its comprehensive mental health care strategic plan, the VA should articulate how performance measures will be rolled out and implemented, maintained, and used for quality improvement and research purposes, and otherwise managed.

Suggested Citation:"Summary." 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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Suggested Citation:"Summary." 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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Suggested Citation:"Summary." 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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Suggested Citation:"Summary." 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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Suggested Citation:"Summary." 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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Suggested Citation:"Summary." 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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Suggested Citation:"Summary." 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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Suggested Citation:"Summary." 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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Suggested Citation:"Summary." 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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Suggested Citation:"Summary." 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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Suggested Citation:"Summary." 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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Suggested Citation:"Summary." 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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Evaluation of the Department of Veterans Affairs Mental Health Services Get This Book
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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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