Veterans Health Care: Staffing Challenges Persist for Fully Integrating Mental Health and Primary Care Services
With the growing demand for mental health services, Veterans Health Administration facilities must make providers—like psychologists and psychiatrists—available within primary care settings to assess and treat veterans with mild-to-moderate symptoms and conditions, like anxiety or depression.
But persistent staffing issues at some VHA facilities have negatively affected efforts to integrate these services into primary care settings. To address this, some facilities have offered flexible work schedules and provided more technology to reduce workloads. We recommended that VHA evaluate these and other mitigation strategies.
What GAO Found
The Veterans Health Administration (VHA) requires its medical facilities serving at least 5,000 veterans annually to integrate mental health services into the primary care services they provide. Specifically, facilities are required to have mental health providers, such as psychologists, psychiatrists, and social workers, available within primary care settings to work collaboratively and share responsibility with primary care providers to (1) assess and treat veterans with mental health symptoms and conditions, such as anxiety or depression; and (2) follow up with those veterans to monitor symptoms and adherence to medications, and provide education and referral services.
VHA data show that as of February 2022, about 79 percent of 455 VHA facilities reported they met both requirements, with the remainder meeting one or none of the requirements. VHA officials said that regional networks are responsible for monitoring their facilities' adherence to the requirements and developing corrective action plans. However, VHA does not monitor implementation of corrective action plans. Doing so would ensure facilities are taking appropriate actions to comply. Veterans at those facilities would then have better access to mental health care services in primary care settings, as VHA intends.
VHA facilities reported that persistent staffing challenges have adversely affected their efforts to integrate mental health services into primary care settings from 2016 through February 2022 (see figure).
Percentage of VHA Facilities That Reported Staffing As Their Most Significant Challenge, 2016 through 2022
Note: Data were reported in VHA annual surveys. According to VHA officials they did not administer a 2020 annual survey due to the COVID-19 pandemic.
To address staffing challenges, officials from the selected facilities in GAO's review reported taking steps such as offering more flexible work schedules and providing additional technology to reduce workloads. Regional network officials identified several additional strategies that VHA could consider, such as providing additional guidance on recruiting and retaining staff and increasing funding for certain positions. Evaluating and implementing these strategies, and any others as appropriate, may help facilities mitigate staffing challenges. Doing so would help ensure that veterans receive the most appropriate and timely mental health care services available.
Why GAO Did This Study
VHA has seen a significant increase in demand for mental health services and expects that demand to continue to grow. One way VHA meets such demand is by integrating certain mental health services within primary care settings.
The Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019 included a provision for GAO to review VHA's integration of primary and mental health services. Among other objectives, this report examines the extent to which facilities have met VHA requirements to integrate mental health care into primary care. It also discusses challenges that have affected such integration and steps VHA has taken to mitigate them.
GAO reviewed VHA documentation and policies on integration efforts and annual survey data from 2011 to 2022. GAO also interviewed VHA officials and providers from nine VHA facilities. These facilities were selected based on geographic location and other factors, such as the percentage of veterans receiving integrated mental health services in fiscal year 2020.
GAO is recommending that VHA (1) monitor the development and implementation of corrective action plans and (2) evaluate and implement strategies to help mitigate staffing challenges affecting the integration of mental health and primary care services. VA concurred with GAO's recommendations and described steps it has or plans to take to implement them.
Recommendations for Executive Action
|Veterans Health Administration||The Under Secretary for Health should ensure that the Office of Mental Health and Suicide Prevention monitors VISNs' development and implementation of corrective action plans for any VHA facilities that do not fully adhere to VHA's Primary Care Mental Health Integration program requirements. (Recommendation 1)||
In May 2023, VA stated that cognizant VHA offices are exploring next steps for addressing this recommendation. VA anticipates addressing the recommendation by December 2023.
|Veterans Health Administration||The Under Secretary for Health should ensure that the Office of Mental Health and Suicide Prevention comprehensively evaluate and implement strategies to help mitigate staffing challenges that affect VHA facilities' abilities to integrate mental health care within primary care settings. (Recommendation 2)||
VA has taken some steps but has not yet fully implemented our recommendation. In May 2023, VA stated that the Office of Mental Health and Suicide Prevention evaluated its current strategies to help mitigate staffing challenges that affect VHA facilities' abilities to integrate mental health care within primary care settings and established an action plan to consider further implementation of those strategies. In its plan, VHA assessed ten factors based on a review of the Office of Mental Health and Suicide Prevention's current strategies, the strategies documented in our December 2022 report, and other sources. VHA then assessed those factors to determine whether further action should be taken. Of the ten factors in its plan, VHA stated that it had completed an assessment of eight factors and identified a number of strategies with further actions to implement. VHA noted that it is making progress on meeting the plan's objectives and anticipates completing remaining actions outlined in its plan by December 2024.