Veterans’ Access to Mental Health Care

VHA policy states that veterans are entitled to timely access to mental  health care. Furthermore,  veterans discharged from inpatient mental health stays are to receive  timely access to follow-up outpatient mental health care. Most Veterans in Our Review Received Care within 30 Days of Their Preferred Dates, but VHA’s Method of Calculating Wait Times Does Not Always Reflect Overall Wait Times

		Most Veterans Received Full Mental Health Evaluations within 30 Days of Their Preferred Dates, though VHA’s Access Policies Conflict

Most veterans included in our review received full mental health  evaluations, which provide new veterans with an entry point to access  mental health care, in an average of 4 days of their preferred dates. At  the five VAMCs we visited, the average time in which a veteran received  this full evaluation ranged from 0 to 9 days from the preferred date. By not  clarifying which access policy currently applies to mental health care,  VHA is limited in its ability to effectively manage timely access to mental  health care. 2.) On average, our review of 100 new veteran records found that a veteran’s  preferred date was 26 days after their initial request or referral for mental  health care, though this varied by VAMC. We found this for 50 of the 100 new veterans whose records  we reviewed. VHA Monitors Access to Mental Health Care, but Current Policies Cannot Ensure Reliable Data, Which Precludes Effective Oversight

VHA monitors access to mental health care through on-site reviews of  clinic operations and sharing data, internally and externally, on mental  health access, but the lack of clear policies for reliable data on veteran  wait times and missed opportunities precludes effective oversight. These include: (1) the wait-time  data-entry process has the potential for errors, (2) data may not be  comparable over time, and (3) data may not be comparable across  VAMCs. VHA has changed the  definitions used to calculate various mental health wait-time measures;  thus, these measures may not be comparable over time. VHA has not clearly communicated the definitions used or  changes to the definitions, which limits the reliability and usefulness of the  wait-time data and VHA’s ability to use these measures to determine  progress in meeting stated objectives for veterans’ wait times. Data may not be comparable between VAMCs. blocks of time where veterans may see providers without a scheduled  appointment). Without guidance  on how appointment scheduling for open-access clinics is to be managed,  VAMCs can continue to implement these appointments inconsistently,  and place veterans on lists outside of VHA’s scheduling system,  potentially leading to serious negative health outcomes for veterans that  need mental health care. VHA’s Community Provider Pilot Program Expanded Access to Mental Health Care for a Limited Number of Veterans; VAMCs Reported Successes and Challenges

		VHA’s Community Provider Pilot Program Provided Mental Health Care for a Limited Number of Veterans

In 2013, 10 VAMCs across VHA established partnerships with 23  community mental health clinics (CMHCs), as required by an August  2012 Executive Order in an effort to help VHA meet veterans’ mental  health needs; these CMHCs provided mental health care to a limited  number of veterans. In particular, the way in which VHA calculates the key wait-time  measure for new veterans generally does not account for the full amount  of time it takes veterans to receive their full mental health evaluations,  which we found ranged from 0 days to more than 200 days from their  initial requests or referrals. First, the  existence of two conflicting access policies (14 days versus 30 days) for a  full mental health evaluation, the primary entry point for mental health  care, creates confusion among VAMC officials and providers about which  policy they are expected to meet. Recommendations for Executive Action

To enhance VHA’s oversight of veteran mental health care and, in  particular, improve and ensure the accuracy, reliability, and usefulness of  its mental health data, we recommend that the Secretary of Veterans  Affairs direct the Under Secretary for Health to take the following three  actions:  Issue clarifying guidance on which of its access policies (e.g., 14 day  or 30 day) should be used for scheduling new veterans’ full mental  health evaluations. In its comments, VHA concurred with our three  recommendations and described the agency’s plans to implement each,  but disagreed with certain findings.
Why GAO Did This Study

Between 2005 and 2013, the number of veterans receiving mental health care from VHA increased 63 percent, outpacing overall growth in veterans receiving any VHA health care. In fiscal year 2014, VHA spent more than $3.9 billion providing outpatient specialty mental health care (mental health care) to more than 1.5 million veterans.
GAO was asked to examine VHA's efforts to provide timely access to mental health care for veterans. This report examines, among other things, (1) veterans' access to timely mental health care, and (2) VHA's related oversight. GAO conducted site visits to five VAMCs selected to provide variation in factors such as location and mental health care utilization rates; reviewed a randomly selected, nongeneralizable sample of 100 medical records (20 from each of the five selected VAMCs) for veterans new to mental health care who received treatment between July 1, 2014, and September 30, 2014; and interviewed VHA and VAMC officials on VHA's measures and oversight of access to mental health care. GAO evaluated VHA's oversight of access to mental health care against relevant federal standards for internal control.

What GAO Found

The way in which the Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) calculates veteran mental health wait times may not always reflect the overall amount of time a veteran waits for care. VHA uses a veteran's preferred date (determined when an appointment is scheduled) to calculate the wait time for that patient's full mental health evaluation, the primary entry point for mental health care. Of the 100 veterans whose records GAO reviewed, 86 received full mental health evaluations within 30 days of their preferred dates. On average, this was within 4 days. However, GAO also found
veterans' preferred dates were, on average, 26 days after their initial requests or referrals for mental health care, and ranged from 0 to 279 days. Further, GAO found the average time in which veterans received their first treatment across the five VA medical centers (VAMC) in its review ranged from 1 to 57 days from the full mental health evaluation.
conflicting access policies for allowable wait times for a full mental health evaluation—14 days (according to VHA's mental health handbook) versus 30 days (set in response to recent legislation) from the veteran's preferred date—created confusion among VAMC officials about which policy they are expected to follow. These conflicting policies are inconsistent with federal internal control standards and can hinder officials' ability to ensure veterans are receiving timely access to mental health care.
VHA monitors access to mental health care, but the lack of clear policies on wait-time data precludes effective oversight. GAO found VHA's wait-time data may not be comparable over time and between VAMCs. Specifically
data may not be comparable over time. VHA has not clearly communicated the definitions used, such as how a new patient is identified, or changes made to these definitions. This limits the reliability and usefulness of the data in determining progress in meeting stated objectives for veterans' timely access to mental health care.
data may not be comparable between VAMCs. For example, when open-access appointments are used, data are not comparable between VAMCs. Open-access appointments are typically blocks of time for veterans to see providers without a scheduled appointment. GAO found inconsistencies in the implementation of these appointments, including one VAMC that manually maintained a list of veterans seeking mental health care outside of VHA's scheduling system. Without guidance stating how to manage and track open-access appointments, data comparisons between VAMCs may be misleading. Moreover, VAMCs may lose track of patients referred for mental health care, placing veterans at risk for negative outcomes.

What GAO Recommends

GAO recommends that VHA issue clarifying guidance on (1) access policies; (2) definitions used to calculate wait times; and (3) how open-access appointments are to be managed. VHA concurred with GAO's recommendations but disagreed with certain of its findings, for example, GAO's calculation of overall wait-times. GAO maintains its findings, as discussed in the report, are valid.