This chapter provides an overview of the Veterans Health Administration (VHA) and how it fits into the broader U.S. health care landscape. The VHA is the sub-cabinet level agency within the Department of Veterans Affairs (VA) that provides health care, including mental health care, to millions of veterans. The chapter begins with an explanation of how veterans enter the VHA health care system. It next describes the general organizational structure of the VA and the VHA. Specific mental health services offered at the VHA are detailed in Chapter 3. The chapter concludes with a brief discussion of other health care sectors and how they generally compare to VHA mental health care services.
If active-duty service members wish to receive health care services after they leave the military, they must seek private health coverage or non-VHA public health coverage (for example, through Medicaid or community health centers) or else enroll in the VA health care system. Transitioning to the VA system requires successfully completing several critical steps or “handoffs” from Department of Defense (DoD) based providers and facilities to VA providers and facilities: enrollment in the VA system, identification of and enrollment in programs, and the successful transfer of medical records. Additionally, some reserve members might receive care from both DoD and the VHA. Unfortunately, although both DoD and the VHA use electronic health records, the two systems are not yet fully interoperable.
In general, transition points pose risks to both access to and the quality of care, including the disruption of relationships with care providers and treatment interruptions. Furthermore, the VA requires consent for medical records to be transferred from DoD to the VHA for Reserve members, creating another potentially problematic transition point. The Institute of Medicine (IOM, 2014) found that moving from DoD to VHA systems may affect access to services by disrupting the continuity of care. Common problems that may occur during the transition from DoD to the VHA include treatment interruptions and switching to new providers who may take time to become familiar with a patient’s history.
DoD and the VA have both developed programs designed to bridge gaps in care and to decrease lack of coordination between the two systems. The joint DoD and VA in Transition program serves service members receiving mental health care who are transitioning from active duty to veteran status. In this program, transition support coaches provide patient education, answer technical mental health questions, and help connect patients with appropriate providers (IOM, 2014). The Federal Recovery Coordination Program (FRCP) was jointly developed by DoD and the VA to coordinate care for severely wounded service members and veterans. It was designed to complement existing programs such as DoD’s Recovery Coordination Program, the Wounded Warrior Program operated by the individual military services,1 Army warrior transition units, the VA’s Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Care Management Program, the VA’s Spinal Cord Injury Disorders Program, and the VA Polytrauma System of Care. FRCP coordinators are assigned to link multiple case managers, oversee service members’ enrollment in programs, and serve as the single point of contact for injured service members and their families (CBO, 2011; Yano et al., 2003).
A major limitation and concern of the FRCP is the inability to share information across DoD and the VA and, more broadly, the general incompatibility among systems used by different programs. Service members are typically enrolled in multiple programs—in September 2010, 84 percent of FRCP enrollees were also enrolled in a military service wounded warrior program. This limits the coordination of services, increases the duplications of services, and may result in enrollee confusion. Accordingly, FRCP is making efforts to address those limitations and improve information sharing; however, as noted by the Government Accountability Office (GAO, 2011), it appears that increased efforts to improve data exchange between the two systems and interdepartmental coordination are needed.
Furthermore, to help ease the transition from DoD to the VA, VHA liaisons from the Office of Care Management and Social Work Services and the Office of Interagency Health Affairs help make appointments and coordinate continued care for transitioning service members. Similarly, OEF, OIF, and Operation New Dawn (OND) Transition and Care Management Teams are present in all VHA facilities to help veterans access and coordinate care. These teams receive lists with the contact information of newly separated veterans in their catchment areas and are encouraged to reach out to them (IOM, 2014).
Not all veterans are eligible for health care through the VA. Veterans may be eligible for health care services if they
- Served in the active military service and were separated under any condition other than dishonorable.
- Served in the Reserves or National Guard, or are currently serving, and were called to active duty by a federal order and completed the full period for which they were called or ordered to active duty (VA, 2015).
There are minimum duty requirements for eligibility, but a number of exceptions to these requirements exist. Therefore, veterans must apply for health care services to determine their eligibility (VA, 2015). Chapter 6 includes detailed information on which veterans are eligible to use VA health services.
1 The Wounded Warrior Program includes the Army Wounded Warrior Program, the Marine Wounded Warrior Regiment, Navy Safe Harbor, the Air Force Warrior and Survivors Care Program, and the Special Operations Command’s Care Coalition.
Once a veteran is determined to be eligible for VHA health care, the veteran is assigned an enrollment priority group (see Chapter 6 for a list of priority groups). Priority groups are used because Congress annually allocates funds for the VA and the agency needs a way to prioritize, given the allotted funds, who should receive health care services. More than 9 million veterans of all eras are enrolled to receive health care through the VHA and are assigned to a priority group.2
Veterans who served in a combat theater after November 11, 1998, and were discharged from active duty on or after January 28, 2003, are eligible for comprehensive VHA health care services for 5 years following their discharge. Veterans in this group would include veterans serving in combat theaters in support of OEF/OIF/OND (unless they discharged before January 28, 2003). After 5 years, these veterans are assigned to a priority group based on their income and the degree of disability due to their service-related condition at that time (IOM, 2014). Combat veterans who did not enroll within the 5-year window of eligibility and were discharged from service between January 1, 2009, and January 1, 2011, were granted 1 additional year of eligibility under the Clay Hunt Suicide Prevention for American Veterans Act.3
The VA is the second largest U.S. federal agency on the basis of the number of employees, following the Department of Defense. The VA has three administrations—the VHA, the Veterans Benefits Administration, and the National Cemetery Administration. The VHA is responsible for providing health care services to the eligible veteran population (see above for eligibility requirements). The VHA has many components that provide centralized policy direction and operational support to the field facilities. It provides routine and specialized clinical services, conducts health research, and offers one of the largest professional health training programs in the world (VA, 2010a).
The VA’s Office of Mental Health and Suicide Prevention, part of the VA’s central office, is responsible for providing clinical policies and national guidance for best practices in mental health and suicide prevention programs. It also supports implementation of the policies and best practices.4 Other VA divisions, such as Health Informatics, Nursing, and Homelessness, also address mental health issues. The VHA has divided the United States and its territories into 21 regional units, or Veterans Integrated Service Networks (VISNs), to manage VHA health service delivery within defined geographic service areas. The VHA is currently in the process of realigning its VISNs. In consultation with the VA’s central office, VISN leadership provides guidance and oversight to VHA health care facilities on capital asset management, clinical quality management, assessment and reviews strategy, safety and health, and environmental and engineering programs (VA Office of Inspector General, 2012). Each VISN has a mental health lead who is responsible for overseeing mental health programs across that VISN.
The VA health care system, which is managed by the VHA, includes more than 150 VA medical centers (VAMCs), 780 community-based outpatient centers (CBOCs), and 130 nursing homes (Watkins et al., 2011). A VAMC is defined as a VA-owned point of service that offers two or more of the following types of care: inpatient, outpatient, residential, and institutional extended care (VA, 2013). VAMCs are the largest medical facilities with the highest capacity and widest range of medical services in the VA system. A CBOC is a VA-owned, VA-leased, mobile, contract, or shared clinic that provides a range of outpatient services and is located separate from a VAMC (VA, 2013). VAMCs and very large CBOCs (serving more than 10,000 unique veterans per year) must have integrated mental health systems that
2 Personal communication, Stacy Gavin, Department of Veterans Affairs, May 25, 2017.
3 Public Law 114-2.
4 Personal communication, Stacy Gavin, Department of Veterans Affairs, October 3, 2017.
are capable of providing a range of mental health services within the primary care setting (VA, 2008). Large CBOCs (serving 5,000–10,000 unique veterans per year) must have on-site integrated care clinics and mid-sized CBOCs (serving 1,500–5,000 unique veterans per year) are required to have an on-site presence of mental health service available in the primary care setting (VA, 2008). Additional information on the VHA’s mental health services can be found in Chapter 3.
Vet Centers, established by Congress in 1979, offer readjustment counseling to veterans who served in theater during any conflict, including OEF/OIF/OND. Their services are available to former active duty, National Guard, and Reserve service members. The Vet Center Program offers services that specifically address the psychological and social consequences of combat-related problems (VA, 2010b). There are about 300 Vet Centers in the United States and its territories and about 70 mobile Vet Centers which are used for outreach and to reach veterans who live in rural areas (VA, 2016). In fiscal year (FY) 2015, almost 220,000 veterans and their families received services at a Vet Center for a total of 1,663,011 visits (VA, 2016) and in FY 2013, the Vet Center Combat Call Center received almost 44,000 calls (Fisher, 2014).
MENTAL HEALTH SERVICES IN THE BROADER U.S. HEALTH CARE SECTOR COMPARED TO THE VETERANS HEALTH ADMINISTRATION
The VA administers the largest integrated health care system in the country, with a FY 2017 operating budget of more than $65 billion for medical care (VA, 2017a). More than 9 million veterans are enrolled in the VA health care system (VA, 2017a). In general, the VHA health care system serves as a safety net, providing care to veterans who are older, economically disadvantaged, and burdened by disease (Phillips et al., 2015). Not all veterans, however, are eligible to use VHA health care or want to use it. Many veterans have private health insurance or qualify for Medicare or Medicaid, and they obtain their health care, including mental health care, from private providers. The focus of this report is access to and the quality of mental health services for veterans through the VHA. For the purpose of general context, information on the non-VA health care sector and on mental illness in the general population is discussed below. The committee, however, did not conduct a comprehensive comparative study of VA versus non-VA mental health services or of mental illness in the veteran population versus the general population.
As detailed in other chapters of this report, problems have been identified in the provision of mental health care that is accessible and of high quality to veterans at VHA facilities. Problems regarding access to and the quality of mental health care are not unique to the VHA, however; they have been documented in the private health care sector as well (AHA, 2016; The Commonwealth Fund, 2013; Merritt Hawkins, 2014; Sundararaman, 2009). In fact, for some measures—including measures related to the overall quality of care, mental health care, chronic disease management, preventive care, and mortality—research has found that VHA health care performs as well as or better than private health care (Asch et al., 2004; Jha et al., 2003; Kerr et al., 2004; Nuti et al., 2016; O’Hanlon et al., 2017; Trivedi et al., 2011; Watkins and Pincus, 2011; Watkins et al., 2016). An example specifically related to mental health care is the finding that VHA performance on medication management for mental disorders (antipsychotics, mood stabilizers, and antidepressants) is superior to the private sector’s performance (Watkins and Pincus, 2011; Watkins et al., 2016). In 2017, in an effort to increase transparency about access to and the quality of VHA health care, the VA created a website, www.accesstocare.va.gov, containing information on measures such as wait times and patient satisfaction. This website also uses Hospital Compare data from the Centers for Medicare & Medicaid Services to show how VHA facilities compare with private-sector hospitals within geographic regions, although the measures are not specific to mental health care.
In 2016, about 45 million people in the United States aged 18 or older had a mental illness (excluding substance use disorders) and about 20 million people in the United States aged 12 or older had a substance use disorder. Among those with mental illness (excluding substance use disorders) about 1 in 4 (23 percent) had a serious mental illness that interfered with major life activities. Just over 8 million adults aged 18 or older had both a mental illness and substance use disorder (SAMHSA, 2017). Many people with mental health problems do not get the services they need. In 2016, 43.1 percent of adults with mental illness (excluding substance use disorders) had received mental health services in the past year (19.2 million). Among adults aged 18 or older needing substance use treatment, 10.8 percent received specialty treatment (2.1 million), while an estimated 17.7 million adults needed substance use treatment but did not receive specialty treatment (SAMHSA, 2017). Legislative initiatives that expand access to mental health care include the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Patient Protection and Affordable Care Act (Mental Health and Substance Use Disorder Parity Task Force, 2016).5 Lack of appropriate treatment for those with mental illness can have serious consequences. For example, adults with serious psychological distress sometimes do not get needed health care, or there is a delay in obtaining health care services (Weissman et al., 2017). Also, Department of Justice surveys conducted in 2002 and 2004 found that 64.2 percent of inmates in local jails, 56.2 percent of inmates in state prisons, and 44.8 percent of inmates in federal prisons had a mental illness but that fewer than half had ever received mental health care services (NIMH, 2004). A substantial portion of inmates have substance use disorder. For example, an estimated 20 percent of inmates have a history of injection drug use (Rich et al., 2005). Furthermore, one-third or fewer of inmates who have mental illness received mental health care services after incarceration. Another example relates to the U.S. homeless population. In January 2014 about 20 percent of homeless persons were identified as having a severe mental illness, and a similar percentage had a chronic substance use disorder (SAMHSA, 2016). Although the number of veterans experiencing homelessness has been decreasing in recent years, at least half of homeless veterans have a severe mental illness or chronic substance use disorder (SAMHSA, 2016).
People do not seek mental health care for a variety of reasons, including the lack of accessibility (for example, a scarcity of providers near home, a lack of available appointments due to high demand for mental health services, a lack of health insurance, a lack of mental health providers who accept health insurance, and the choice to avoid treatment because of concerns about stigma); the lack of coordination of care among primary care providers, mental health providers, and others, such as social service providers; and the lack of availability of high-quality care (for example, inadequate availability of evidence-based practices, a lack of training among primary care providers in mental health, and an inability to deliver treatments in a culturally appropriate way). Later chapters of the report explore further why people sometimes do not obtain needed mental health care services.
During the past 20 years, public and private health sectors have been undergoing a transformation toward providing care that is more patient centered, of higher quality, better integrated, and more efficiently delivered (ECRI Institute, 2013; Greenfield and Kaplan, 2004; Gresen, 2012; Hartmann et al., 2009; Hogan, 2003; IOM, 2001; Unutzer et al., 2006; Weeks and Bagian, 2000; Young, 2000). In the VA, for example, MyVA is a recent initiative for service excellence and organizational performance (see Chapter 7 for details). Health services transformation in both the public and private health care sectors is making improvements in care, but many challenges remain. For example, access to and the quality of mental health care services in both sectors is adversely affected by a shortage of mental health providers, especially in rural areas (AHA, 2016; Burnam et al., 2009; Merritt Hawkins, 2015). In later chapters of this report the committee explores many of the challenges facing the evolving VHA health
5 Public Law 110-343, Public Law 111-148.
care system (for example, the shortage of mental health providers in the VHA health care system, the VA’s hiring process for providers, the training of providers in the use of evidence-based therapies, and reducing barriers to mental health care encountered by some veterans) and makes recommendations for addressing these challenges.
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