Our past work and other research shows that veterans—especially those living in rural areas—can have trouble getting the mental health care they need.
Veterans Health Administration officials confirmed that veterans living in rural areas face unique barriers to accessing mental health care, such as staff shortages in rural facilities and transportation issues.
VHA assesses its intensive mental health care programs but doesn't specifically monitor rural veterans' access. Our review of VHA's service use data found differences between rural and urban areas.
We recommended ways for VHA to help ensure these programs effectively serve rural veterans.
What GAO Found
The Veterans Health Administration (VHA) provides intensive mental health care for veterans with serious mental illness—disorders resulting in serious function impairment, such as schizophrenia or bipolar disorder. To monitor veterans' access to its inpatient, residential, and outpatient intensive mental health care programs, VHA analyzes the extent to which veterans use these programs. It also analyzes performance data, such as how long veterans wait for residential care and the ratio of patients to program staff. However, VHA does not analyze its data by rurality to compare program utilization and performance for veterans living in rural areas with those living in urban areas. Doing so would help VHA understand the extent to which programs effectively reach rural veterans.
In analyzing VHA's fiscal year 2021 data, GAO found rural veterans used intensive mental health care programs at lower rates than their urban counterparts. For example, the rate at which rural veterans used outpatient care was approximately 21 percent, compared with a utilization rate of 79 percent for urban veterans (see figure). VHA data show 27 percent of veterans with serious mental illness who received VHA care lived in a rural area in the same year. According to VHA officials, there may be various reasons rural veterans use care less than urban veterans, such as other demographic differences.
Proportion of Rural and Urban Veterans Using VHA Intensive Mental Health Care, Fiscal Year 2021
Note: Inpatient programs, such as a hospital stay, are for veterans experiencing acute mental health crisis. Residential programs provide residential and treatment services. Outpatient programs provide treatment services to veterans. GAO uses the term “rural veteran” to include veterans living in rural, highly rural, and insular island areas.
In 2021, VHA updated its guidelines for establishing inpatient and residential intensive mental health care programs to account for projected demand and geographic data, such as the location of where veterans live. However, guidelines for its outpatient intensive mental health care programs do not account for where veterans live. For example, guidelines for establishing rural-focused programs “strongly encourage” establishment in rural areas but do not otherwise identify parameters facilities should use in doing so, such as where veterans live or drive times for reaching a facility. Assessing and updating, as appropriate, its guidelines for establishing outpatient programs to include such parameters would be consistent with the Department of Veterans Affairs' goals of improving access to care for rural veterans and veterans with serious mental illness.
Why GAO Did This Study
Serious mental illness is a persistent and growing concern for our nation's veterans. Research shows veterans with serious mental illness who live in rural areas can face challenges accessing this care, such as long drive times to facilities.
The Sgt. Ketchum Rural Veterans Mental Health Act of 2021 included a provision for GAO to study the intensive mental health care that VHA makes available to rural veterans. Among other objectives, this report examines the information VHA uses to monitor access to such care, what these data show about rural veterans' access, and the guidelines VHA uses to establish programs for rural veterans.
GAO reviewed VHA documentation and policies on its intensive mental health care programs and fiscal year 2021 data (most recent available) on utilization and performance for these programs. GAO also interviewed VHA officials and officials from three health care systems selected for geographic and program variation.
GAO is making four recommendations, including that VHA analyze intensive mental health care utilization and performance data by rurality and assess and update, as appropriate, guidelines for establishing outpatient intensive mental health programs. The Department of Veterans Affairs concurred with the recommendations and identified steps it would take to implement them.
Recommendations for Executive Action
|Veterans Health Administration||The Department of Veterans Affairs Under Secretary of Health should ensure that the Office of Mental Health and Suicide Prevention analyzes, by rurality, the utilization and performance data it uses to monitor access to intensive mental health care and include such analyses in program performance assessments. (Recommendation 1)|
|Veterans Health Administration||The Department of Veterans Affairs Under Secretary of Health should ensure that the Office of Mental Health and Suicide Prevention incorporates into its monitoring efforts, as appropriate, analysis of referral and claims data for intensive mental health care services provided through community care. (Recommendation 2)|
|Veterans Health Administration||The Department of Veterans Affairs Under Secretary of Health should assess and update, as appropriate, its guidelines for establishing outpatient intensive mental health care programs to incorporate parameters to factor in where veterans in need live. (Recommendation 3)|
|Veterans Health Administration||The Department of Veterans Affairs Under Secretary of Health should update its guidelines for providing seed funding to Rural Access Network for Growth Enhancement or Enhanced Rural Access Network for Growth Enhancement programs to include data on the locations of veterans with serious mental illness. (Recommendation 4)|