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VA Health Care: Efforts Needed to Ensure Effective Use and Appropriate Staffing of Suicide Prevention Teams

GAO-21-326 Published: Apr 05, 2021. Publicly Released: Apr 05, 2021.
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Fast Facts

An average of 18 veterans died by suicide each day in 2018. As a result, suicide prevention is the top clinical priority for the Department of Veterans Affairs for FY 2018-24.

Local VA medical facilities use suicide prevention teams to evaluate at-risk veterans and connect them to treatment. But VA doesn't have a good idea of how the program's growth is affecting its staff and caseloads. Some staff reported burnout, high turnover, large caseloads, and insufficient guidance for new initiatives.

We recommended, among other things, that VA evaluate its local suicide prevention teams, including the effects of program growth on staff.

Stethoscope and military identification tags placed on an American flag.

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What GAO Found

The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) uses suicide prevention teams at local facilities to implement its Suicide Prevention Program, which was mandated by law in 2007. As VHA has added new initiatives to the program since its inception—such as Risk ID, a standardized suicide risk identification process that it initiated in 2018—local teams' activities have increased, in particular as more veterans at risk of suicide are identified. This has created challenges, according to the selected teams in GAO's review. For example, team staff at one facility said they have experienced burnout and turnover due to new initiatives and a large caseload of veterans at high risk for suicide. Staff from a team at another facility said they typically manage a caseload of about 150-200 veterans identified as being high risk for suicide. According to VHA guidance, teams are expected to engage in a number of activities related to these veterans, including regular interactions. Team staff at one facility noted the importance of these interactions in building relationships with veterans at risk of suicide, so veterans know they can reach out to their local teams when they need help.

VHA's Office of Mental Health and Suicide Prevention (OMHSP) determines policy for and monitors the program. OMHSP officials said that they have made changes to their guidance and technical assistance, which may help address some of the challenges reported by teams. For example, in January 2021 OMHSP issued new guidance that consolidates information on teams' activities, including those related to recent initiatives. In addition, in June 2020, OMHSP initiated monthly “office hours” calls for teams to answer questions and provide technical assistance beyond what is covered during other regular calls.

However, VHA has not conducted a comprehensive evaluation of local suicide prevention teams, including an assessment of any challenges teams face in implementing VHA policies and the effects of program growth on workload. Without such an evaluation, VHA does not have a good understanding of how its various activities and initiatives are affecting teams, including any effects on the care teams provide veterans who may be at risk for suicide. Such an evaluation would allow OMHSP to refine the guidance and other support it provides to local teams to potentially reduce challenges they face.

OMHSP uses a benchmark to help determine facilities' suicide prevention staffing needs. Although facilities are responsible for making their own staffing decisions, according to the benchmark, each facility should aim to have at least one coordinator or case manager for every 10,000 unique patients the facility serves. However, the benchmark may not accurately reflect facilities' staffing needs because it was not developed according to the key practices for staffing model design previously identified by GAO. For example, the benchmark does not account for the increasing workload of teams, such as the addition of activities related to new initiatives over time. Additionally, it does not account for risk factors, like suicide rates, that may vary among facilities. Because the benchmark was not developed following key practices, VHA may not be able to help facilities to appropriately determine their staffing needs. As a result, suicide prevention teams may be vulnerable to understaffing, which may leave facilities unable to meet veteran needs related to suicide prevention.

Why GAO Did This Study

Compared to the general population, veterans suffer a disproportionately higher rate of suicide. VA has stated that suicide prevention is the agency's top clinical priority. At its local medical facilities, VHA employs suicide prevention teams, which include coordinators—staff with a full-time commitment to suicide prevention activities—and case managers.

The Support for Suicide Prevention Coordinators Act included a provision for GAO to review, among other issues, the responsibilities and workload of suicide prevention coordinators. This report examines how VHA (1) uses local suicide prevention teams, and (2) helps determine facilities' suicide prevention staffing needs. To do this work, GAO analyzed team staffing data, reviewed VHA policies, and interviewed OMHSP officials and team staff from five medical facilities. The facilities were selected for variation in composition of suicide prevention teams, geographic location, and total number of patients, among other factors.


GAO is making three recommendations, including that VHA (1) conduct an evaluation of local suicide prevention teams that includes an identification of the effects of program growth on workload, and (2) incorporate key practices for staffing model design into its determination of facilities' suicide prevention staffing needs. VA concurred with GAO's recommendations and identified actions it is taking to address them.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Veterans Affairs The Under Secretary for Health should ensure that OMHSP conducts a comprehensive evaluation of local suicide prevention teams (including suicide prevention coordinators and case managers and others). Such an evaluation should seek to (a) obtain a full understanding of how facilities are using these teams, (b) identify challenges teams may experience in implementing VHA policies, and (c) identify the effects of program growth on teams' workload. (Recommendation 1)
Closed – Implemented
In response to Section 506 of the Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019, VA's Office of Mental Health and Suicide Prevention (OMHSP) completed a study examining the feasibility and advisability of realignment and reorganization of suicide prevention coordinators. OMHSP submitted the final version of the study to Congress in January 2022. In addition to addressing congressional requirements, the study also incorporated qualitative and quantitative data that resulted in additional information about local suicide prevention teams that met the intent of GAO's recommendation. Specifically, the study provided detailed information on local facilities' use of suicide prevention teams, the challenges teams face in implementing policy, and the effects of program growth on teams' workload.
Department of Veterans Affairs The Under Secretary for Health should ensure that OMHSP uses information obtained through the comprehensive evaluation of local suicide prevention teams to inform the support it provides--e.g., direction, guidance, and technical assistance. (Recommendation 2)
Closed – Implemented
OMHSP incorporated information obtained from the completed study described in Recommendation 1 to inform support for local suicide prevention program implementation. Specifically, OMHSP has continued to provide technical assistance and training resources to assist teams on an ad hoc basis, and have refined these processes using data such as that obtained through the study. In addition, OMHSP designed a suicide prevention regional network site visit pilot process to provide a more in-depth monitoring of suicide prevention policy implementation, allow for increased communication to OMHSP by local teams related to challenges faced in program implementation, and increase opportunities for sharing of best practices. The first site visit was completed in October 2021, and a second site visit was scheduled for January 2022. OMHSP developed tools for summarizing regional suicide prevention metrics, site visit agendas, and training using site specific data. OMHSP officials said they are collecting feedback from all key stakeholders involved in the process, and they plan to make improvements to the site visit process on a continual basis.
Department of Veterans Affairs The Under Secretary for Health should ensure that OMHSP incorporates key practices for staffing model design into its determination of facilities' suicide prevention staffing needs: (a) involving key stakeholders; (b) incorporating work activities, their frequency, and the time required to complete them; (c) ensuring the quality of data used in the model; and (d) incorporating risk factors. (Recommendation 3)
Closed – Implemented
In August 2021, VA reported that the agency had taken steps to address this recommendation, such as ensuring the accuracy of existing staffing data and revising its existing staffing model for suicide prevention teams. Since November 2021, officials from VA's OMHSP have provided GAO with documentation related to the new staffing model, which provided evidence that the design of the model incorporated the key practices we previously identified. Specifically, OMHSP engaged key stakeholders; identified duties and tasks completed by suicide prevention coordinators and defined core workload factors; used validated data; and ensured that the model could also reflect other factors such as local workload variations.

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