VA Mental Health:

Clearer Guidance on Access Policies and Wait-Time Data Needed

GAO-16-24: Published: Oct 28, 2015. Publicly Released: Oct 28, 2015.

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Debra Draper
(202) 512-7114
draperd@gao.gov

 

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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.

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 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.

For more information, contact Debra Draper at (202) 512-7114 or draperd@gao.gov.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In October 2015, we recommended that the Secretary of Veterans Affairs direct the Under Secretary for Health to 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. At the time of our report, VHA concurred with our recommendation and stated that they were in the process of revising the relevant policy in the Uniform Handbook to be consistent with the 30-day wait time goal the agency established in response to the Choice Act. In November 2015, VHA published the revised handbook and clarified that the 30 day standard should be used when scheduling new veterans' mental health evaluations.

    Recommendation: 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, the Secretary of Veterans Affairs should direct the Under Secretary for Health to 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.

    Agency Affected: Department of Veterans Affairs

  2. Status: Open

    Comments: When we confirm what actions the agency has taken, we will update.

    Recommendation: 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, the Secretary of Veterans Affairs should direct the Under Secretary for Health to issue guidance on how appointment scheduling for open-access appointments are required to be managed.

    Agency Affected: Department of Veterans Affairs

  3. Status: Open

    Comments: When we confirm what actions the agency has taken, we will update.

    Recommendation: 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, the Secretary of Veterans Affairs should direct the Under Secretary for Health to issue guidance about the definitions used to calculate wait times, such as how a new patient is defined, and communicate any changes in wait-time data definitions within and outside VHA.

    Agency Affected: Department of Veterans Affairs

 

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