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Tuesday, August 08, 2006


Department of Veterans Affairs

Fact Sheet for Veterans Health Administration

Actions on Recommendations of the Special Committee on Post-Traumatic Stress Disorder---Fiscal Year 2004 Report

Purpose: To report on the Department of Veterans Affairs' (VA) progress in implementing the recommendations made by the Under Secretary for Health's Special Committee on Post-Traumatic Stress Disorder (PTSD) in its fiscal year (FY) 2004 Annual Report. The GAO February 1, 2005 report (GAO-05-287, Recommendations to Improve VA PTSD Service) acknowledged 12 of the recommendations made by the Special Committee on PTSD as being met or closed by the Special Committee on PTSD (and by VA). These 12 recommendations remain implemented by VA under the Mental Health Strategic Plan (MHSP).

Special Committee on PTSD Recommendations:

1. Recognize specialized PTSD programs as an important component of care. VA should recognize specialized PTSD programs as a critically important component of VA expertise and service. In addition to meeting a core need of VA (provision of mental health services for veterans suffering from PTSD, which is the single most prevalent mental disorder rising from combat), these programs maintain America's readiness to deal with survivors of future wars, disasters, and acts of terrorism and mass destruction.

Status: The Special Committee on PTSD closed this recommendation; however, work continues. Veterans Health Administration (VHA) has provided increased Mental Health Initiative funding in anticipation of an increased need for services. As a result, specialized PTSD programs are available in all VA medical centers, and the capacity of other services has been increased.

2. Develop and implement procedures to prevent closure of PTSD programs without authorization from VA headquarters. VA needs to develop, announce, apply clear and prompt consequences when VA network leaders close PTSD programs without VA headquarters authorization.

Status: The Special Committee on PTSD closed this recommendation. Under Directive 2005-033, "Authority for Mental Health Program Changes," dated August 8, 2005, changes in the capacity of mental health programs must be approved by the Office of Mental Health Services in VA's Central Office.

3. Reinvest resources from closed PTSD programs into other PTSD programs. VA should establish system-wide administrative mechanisms to ensure that when PTSD programs are closed, the resources freed up by the closure are reinvested in other PTSD programs. This will ensure that VA does not reduce its capacity to treat PTSD.

Status: The Special Committee on PTSD closed this recommendation; however work and monitoring continue. Under directive 2005-033, and with support from VHA's leadership, there is a firm commitment to ongoing support of PTSD programs. In implementing Directive 2005-033, the Office of Mentl Health Services will ensure that PTSD programs are not closed without reinvestment.

4. Implement a VA network director performance measure on PTSD capacity. The Special Committee on PTSD will work with VA headquarter officials to develop a network director's performance measure aimed at maintaining capacity to treat PTSD within each network and ensuring that PTSD resources, when reassigned, remain within the PTSD continuum of care.

Status: The Special Committee on PTSD closed this recommendation; however, work and monitoring continue. Current performance measures for PTSD screening will be expanded and supplemented with measures for follow-up in FY 2007. In addition, there is close scrutiny of the PTSD services provided and the number of veterans served by specialized and general mental health programs through the ongoing PTSD program evaluation, "Long Journey Home," the annual report of the Northeast Program Evaluation center (NEPEC), and VA's assessment of needs and services for veterans returning from the Global War on Terror (GWOT).

5. Develop and implement a national standardized set of tools for assessment of PTSD. VA should develop and implement a national standardized set of tools for assessment of PTSD.

Status: The Special Committee on PTSD closed this recommendation; however, work and monitoring continue. There is system-wide use of the standard 4-question screen for PTSD found in the Joint VA/DoD PTSD Clinical Practice Guideline. This is identical to the Post Deployment Health Assessment (PDHA) and Post Deployment Health Reassessment (PDHRA) screening tools used by Department of Defense (DoD).

6. Establish a PTSD screening and referral mechanism in every VA community-based clinic. Every VA community-based clinic should have a PTSD screening mechanism in place and should define how veterans who screen positive for PTSD will gain access to PTSD services.

Status: The Special Committee on PTSD closed this recommendation; however, work and monitoring continue. The system-wide screening process for PTSD is automated through a clinical reminder that facilitates its use for all veterans receiving services, including those new to the system, as well as those receiving ongoing care.

7. Establish electronic clinical records that follow veterans across VA's system of care. The clinical database derived from the standardized assessment tools and the medical record of the veterans with PTSD must follow the veteran across the VA system. The Special Committee on PTSD should work with VA medical record specialists and computer experts to develop a system for sharing pertinent clinical data across the entire PTSD continuum of care, including Vet Centers.

Status: Ongoing. The electronic medical record system is shared between VA medical centers (VAMCs) and Community-based Outpatient Clinics (CBOCs). Currently, over 60% of Vet Center patients are also served by VAMCs or clinics. Sharing of patient clinical information between settings for these individuals is accomplished for individuals seen in both settings through contact facilities and/or providers at the local level, depending upon clinical needs. However, it is important to recognize that a sizeable minority of Vet Center patients do not receive care in medical centers or clinics. While there is a need to know more about this group of veterans, it is at present, reasonable to assume that it includes individuals who are concerned about the stigma of a diagnosis of mental illness and the confidentiality of issues that are discussed during care. Given the distinct clinical approaches of the Vet Centers and mental health services within the medical centers, developing a specific system for sharing pertinent clinical data between them will require balancing the values of privacy and confidentiality, and maintenance of the seperate missions of the two systems, versus the value of increased coordination of care between the two systems. The barriers to developing a system for information sharing are certainly amenable to problem solving. However, this process will be best accomplished within the context of ongoing discussions about approaches to increase interactions and coordination between these systems, rather than as a narrowly defined issue for medical record specialists and computer experts.

8. Designate a PTSD coordinator in each VA Network. VA should designate a PTSD coordinator in each VA network to ensure implementation of the PTSD continuum of care in each network.

Status: Evolving. There are ongoing interactions between the Office of Mental Health Services (OMHS) and the Veterans Integrated Service Networks (VISNs) to facilitate regional approaches to program planning and coordination of mental health services. At present, to ensure that issues related to PTSD are addressed within the context of these overall initiatives, the Network Mental Health Liaison, the individual designated by each VSN Director as the coordinator of mental health services and the bridge between the Network and OMHS, has been designated to also serve as the PTSD coordinator. As these efforts mature, OMHS will consider designation of a seperate PTSD coordinator in each Network, who will be responsible for the implementation of the continuum of care for this specific disorder, including availability of guideline-based care, evidence-based psychotherapies, adequate capacity for both returning veterans and established patients, and equitable access to these programs across the system.

9. Improve the continuum of care for PTSD. The present continuum of care established to treat PTSD in VA needs better coordination and further refinement, which should include early identification and intervention; assessment, triage, and referral; acute stabilization and intervention (including option for hospitalization in a general psychiatric unit or a specialty PTSD unit as clinically appropriate); treatment and rehabilitation, involving short-or longer-term care on an outpatient or residential basis; and other outpatient care, encompassing continuing care, monitoring, and relapse prevention for those who also have substance use disorders.

Status: Ongoing. A number of Mental Health Strategic Plan (MHSP) initiatives addressing improved integration and access to care are in place and underway. The continuum of care for PTSD ranges from outreach to returning veterans in the community, to non-medical approaches to counseling in Vet Centers, to increased attention to PTSD and other stress-related conditions in primary care in medical centers and clinics, and to an array of specialty mental health services.

Funding of Returning Veteran Outreach, Education, and Care (RVOEC) coordinators is expanding the presence of PTSD programs in the community. In parallel, the presence of specialty PTSD diagnostic and treatment services have been increased in primary care settings, including CBOCs, through augmented staffing and increasing use of tele-health services.

Ther have also been increases in PTSD specialty services. By the end of 2006, VA will have 152 PTSD Clinical Teams or specialist programs, and 57 other specialized PTSD programs. These include: Residential Rehabilitation Programs (14); Day Hospitals (11); Domiciliaries (8); Women's PTSD Teams (7); Outpatient PTSD/Substance Abuse Teams (6); Specialized Inpatient Units (5); Evaluation and Brief Treatment Units (4); and Women's Trauma Recovery Programs (2). The funding for these specialized programs is planned to increase by $5,590,000 from $163,844,000 in 2006 to $169,434,000 in FY 2007.

10. Provide sustained treatment settings for PTSD and coexisting psychiatric and medical condition. Because PTSD is a chronic condition with frequent coexisting psychiatric amd medical conditions, sustained treatment settings of varying intensities are required.

Status: Ongoing. As addressed in response to Recommendation 9, the number of specialized treatment programs for PTSD includes inpatient, outpatient, and residential care services. For PTSD, as for other chronic conditions, sustained treatment is best delivered in an outpatient, ambulatory care setting. For those with levels of acuity or impairment that go beyond those that can be managed within clinic settings, Mental Health Intensive Case Management (MHICM) and psychosocial rehabilitation programs are available.

The issue pf psychiatric-medical comorbidity is an important one. The VHA Office of Patient Care Services will be issuing a Request for Proposal (RFP) from VISNs and medical centers to implement programs that integrate mental health services into the primary care setting. This strategy is likely to be applicable for patients with stable, lower levels of symptomology from PTSD. Those with more severe symptoms or impairments may benefit from delivery of primary general medical care within the mental health care setting. Such an approach is currently in place in a number of medical centers, and strategies for broader implementations are under discussion.

Based on the MHSP, significant FY 06 PTSD funding enhancements were targeted at ensuring that there is PTSD specialty capability in every VA medical center. Expanding residential programs was an additional target between the FY 05 and FY 06 funding cycles. One additional PTSD Domiciliary Unit and one Women's Residential Trauma Recovery Program were also established. An assessment of additional needs for residential PTSD treatment is underway.

11. Utilize Vet Center appointments to satisfy VA performance standards for PTSD follow-up care. Vet Center appointments should satisfy VA performance standards for follow-up care.

Status: Not adopted. The relevant performance standards for PTSD follow-up care refer to the time between discharge from a psychiatric unit to the first outpatient follow-up appointment. Given that it is only those patients with the most severe PTSD, in terms of symptoms, impairments, and dangerousness who are admitted to an inpatient setting, it is highly likely that follow-up care will require evaluations of the continuation and outcomes of pharmacological treatment implemented in the hospital, and decision-making about the initiation or outcomes of specific evidence-based psychotherapies. For these purposes, VHA follow-up in a medical center or clinic will be necessary. Nevertheless, referrals to Vet Centers at the time of discharge from a psychiatric inpatient unit should occur when veterans have previously been seen in these settings, and when they express a preference for referrals, and when the nature of their problems is such that they would benefit from the resources and programs in a Vet Center, and the most appropriate strategy for these individuals may be to combine care in the two settings.

12. Improve VA medical facility and Vet Center collaboration. VA medical facilities and Vet Centers need to work together to ensure full collaboration in the service of veterans with PTSD. The Special Committee on PTSD recognizes the unique contributions of VA medical facilities and Vet Cebters and the critical importance of maintaining their distict identities. At the same time, we advocate innovations, including (but not limited to) a common PTSD database for each veteran with PTSD, joint access to clinical notes relevant to PTSD treatment across the two systems, and joint assessment of local and national needs within each system that could be addressed by sharing clinical resources through such programs as co-location and telemedicine.

Status: Ongoing. Developing strategies for increasing collaborations between Vet Centers and medical centers or clinics are among the highest priorities for the new leadership within the Office of Mental Health Services. Given the strength of the Vet Centers in approaching readjustment problems not associated with any psychiatric diagnosis, and their ability to treat families as well as veterans themselves, the Vet Centers can address needs that extend beyond those that can readily be addressed in medical centers. Given the stigma and related barriers that prevent veterans from seeking mental health care, these Centers serve as an important safety valve for individuals with diagnosable mental illnesses who would not otherwise enter care. For these veterans, it is important to design an approach for stepped care, in which the Vet Centers and medical centers collaborate in developing a system of assessments, identifying those who do not respond to Vet Center care alone, and facilitating engagement in evidence-based care in the medical center or clinic. Such strategies are being discussed actively by Vet Center and mental health leadership.

13. Develop, disseminate, and implement best practice treatment guidelines for PTSD. VA should disseminate and implement "best practice" PTSD treatment guidelines.

Status: The Special Committee on PTSD closed this recommendation; however, work continues. Initiatives that support this process include the ongoing work of the National Center for PTSD, the establishment of a Mental Illness Research Education and Clinical Center (MIRECC) in VISN 6 that focuses on post-deployment mental health, plans to fund three new congressionally-mandated Centers of Excellence for PTSD and mental health, and the activities of the VA/DoD Mental Health Workgroup that reports to the VA/DoD Health Executive Committee (HEC).

14. Develop PTSD guidelines for aging veterans, various cultural groups, and other special popultions. VA should develop special guidelines for work with aging veterans; for ethnic and cultural groups shown to have different risks and needs with repsect to PTSD; for veterans of peacekeeping missions; for female and male survivors of sexual and other non-combat trauma in the military; and for other populations for whom specific needs are identified.

Status: The Special Committee on PTSD closed this recommendation. Please note that the actions supporting this recommendation are similar to those contained in recommendation 13 above.

15. Develop more effective treatment approaches for veterans with PTSD and coexisting substance abuse. More effective treatment approaches are needed for veterans with PTSD and coexisting substance abuse. These include improved methods of identifying PTSD among substance abusers.

Status: The Special Committee on PTSD closed this recommendation; however, work and monitroing continue. The number of specifically identified PTSD/Substance Use Disorder (SUD) programs (or tracks) has increased from 4 in 2004 to 10 in 2006. Currently, there is intense ongoing work on the treatment of "dual diagnosis" patients by investigators supported through both the Office of Research and Development and the Office of Mental Health Services. The former includes the work of the Mental Health and Substance Use Disorder QUERIs. The latter includes research and training in the National Center for PTSD, and the MIRECCs in VISNs 2, 4, 6, 16, 20 and 21. Development and implementation of comprehensive services for veterans with substance use disorders and other mental disorders, including PTSD, is a major goal of the Mental Health Strategic Plan.

16. Develop and implement rehabilitation approach to PTSD and coexisting conditions. In addition to aiming at decreasing PTSD severity, treatment efforts should be directed toward decreasing the effects of coexisting conditions, improving function, and improving social support systems. This "rehabilitation" perspective (recovery model) is more appropraite in dealing with a chronic and complex disorder.

Status: The Special Committee on PTSD closed this recommendation; however, work and monitoring continue. The Mental Health Strategic Plan includes core recommendations to transform the focus of VAs Mental Health Services to emphasize recovery and rehabilitation. Developing, validating and disseminating strategies for rehabilitation of PTSD patients who have impairments after evidence-based treatment for symptoms, is a major focus of the planned Center of Excellence in the Central Texas VA Healthcare System at Waco, Texas. To address this more broadly, the Office of Mental Health Services distributed a Request for Proposals (RFP) to expand programs in Psychosocial Rehabilitation. Proposals are currently being evaluated and the initial distribution of funds is anticipated this summer.

17. Develop and implement an integrated clinical approach for assisting aging veterans with PTSD. The medical problems of our aging population of veterans with PTSD require an integrated appraoch of primary care, geriatric, and PTSD experts.

Status: The Special Committee on PTSD closed this recommendation; however, work is ongoing. The integration of services in mental health, primary care, and geriatrics is integral to the Mental Health Strategic Plan. The Office of Patient Care Services distributed a RFP for Models of Integrated mental health and primary care. Responses will be reviewed and funds will be distributed this dummer.

18. Coordinate PTSD care with VA community-based clinic. VA needs to improve coordination of care between specialized PTSD programs and VA clinics, including community-based clinics. The goal is to improve health habits and to identify and manage coexisting medical disorders. This will improve health-related quality of life and lower unnecessary health care costs.

Status: The Special Committee on PTSD closed this recommendation; however, work and monitoring continue. Access to mental health services in CBOCs, including care for patients with PTSD, is a Network Director performance measure. In addition, there is ongoing discussion between the Office of Mental Health Services and the field to identify and support the most effective models for enhancing research in this area. The Office of Research and Development, for example, is supporting a cooperative study designed to test specific smoking cessation interventions in patients with PTSD.

19. Provide increased access to PTSD services. VA needs to create access to PTSD services. This can be facilitated through the continued expansion of Vet Centers, community-based clinics (with specialized PTSD services), and telemedicine services into underserved geographic areas.

Status: Significant progress has been made. Funding in FY 05 and FY 06, allowed for the creation of a new program. Returning Veteran Outreach, Education, and Care (RVOEC). The goal of this program is to increase access of OIF/OEF veterans to services that address their needs. Other program augumentation funds were used to expand treatment capacity for PTSD in medical centers and larger CBOC's. In 2006, 67 new or expanded PTSD programs were funded. This includes 40 new PTSD Clinical Teams, 1 new Day Hospital, and 10 new Military Sexual Trauma programs, as well as the additional residential programs mentioned in response to Recommendation 9. Several programs for veterans with both PTSD and substance use disorders are being established. In addition, support was provided for innovative use of telemental health to support access for PTSD specialty services in CBOCs and rural areas. To ensure that access to specialized programs will remain adequate in the face of increasing demands, funding for these specialized programs will increase by $5,590,000, from $163,844,000 in 2006 to $169,434,000 planned for 2007.

20. Extend efforts to monitor productivity and quality of specialized services across the PTSD continuum of care. VA should extend its efforts to monitor the productivity and quality of specialized PTSD services across the PTSD continuum of care, including measures of funcionality, quality of life, and social support.

Status: Ongoing. In it s annual report, "The Long Journey Home," the North East Program evaluation Center (NEPEC) in its role as a component of the National Center for PTSD reports on the productivity and quality of services for PTSD. On an annual basis they conduct a national overview and performance assessment of PTSD Treatment in VA, which includes utilization date on both specialized and non-specialized programs, a review of patients treated and services delivered by the specialized outpatient PTSD programs, a review of changes in VAs programmatic capacity to provide treatment for PTSD, and outcomes monitoring of specialized intensive PTSD programs. Pateint outcomes are evaluated in five domains: PTSD symptoms, alcohol abuse, drug abuse, violence, and work. Patient-level assessments include questions about satisfaction with care. Although NEPEC, the National Center for PTSD and the Office of Mental Health Services recognize that performance assessment for PTSD clearly requires consideration of multiple outcome domains, the complex results that would be derrived from considering each measure seperately would not allow summary assessment of the performance of each VISN or station. The outcomes variables in the five domains are therefore combined in a single index, analogous to a cumulative grade-point average.

The Committee is clearly correct in pointing out that functionality, quality of life, and social support are critical outcomes variables for PTSD as well as other mental health conditions. Moreover, these domains are aligned with the MHSP's emphasis on recovery and rehabilitation. The Office of Mental Health Services will explore the feasibility of augmenting its assessments and analyses to include them.

21. Expand PTSD treatment to include family assessment and treatment services. VA must expand the focus of PTSD treatment to include family assessment and intervention in order to help veterans and their families deal with the symptoms of PTSD.

Status: Ongoing. Services to families are important parts of care for PTSD and other stress-related conditions. Currently family members can be treated in VA medical centers and clinics as a part of the care for their relative, the veteran "identified patient." However, Vet Centers have a greater flexibility to provide care to family members of their veteran clients independently, in the service of improved family functioning. In these centers, care can address family issues related to readjustment after deployment, as well as those related to the impact of PTSD and related conditions on the family.

Family involvement is especially important when veterans are resistant or undecided about entering treatment, and when symptoms are chronic or persistent. Contact with families to facilitate the newly returned veteran's engagement in treatment is available therough the recently established RVOEC program. Support for families is becoming increasingly available for those with more persistent symptoms as part of the VA's implementation of family psychoeducational activities.

22. Develop a national PTSD education plan for VA. VA should create a national PTSD education plan for VA staff with consistent access across the system.

Status: Significant progress has been made and efforts are ongoing. Collaboration among the Office of Mental Health Services, the Employee Education System, and the VA/DoD Mental Health Workgroup that reports to the VA/DoD Health Executive Committee is centered on comprehensive education initiatives to improve PTSD care in all settings. The National Center for PTSD and the Mental Illness Research, Education, & Clinical Centers are integral parts of the plan for carrying out this recommendation.

23. Develop credentialing standards for VA clinicians specializing in PTSD. VA should develop multidisciplinary credentialing standards for VA clinicians specializing in PTSD.

Status: Under consideration. It is clear that patients with PTSD requires specific knowledge and skills. However, so does the treatment of people with schizophrenia, bipolar disorder, and major depression, and so does the safe and effective use of evidence-based psychopharmacological treatment and of specific forms of psychotherapy. From the perspective of those charged with the care of veterans suffering from a broad range of mental illnesses, it is not entirely clear that there should be a seperate process for credentialing clinicians for each disorder, and, by extension, for each modality of treatment. Nevertheless, specific knowledge and skills regarding the evaluation, diagnosis, treatment, and rehabilitation of those with PTSD are necessary for all clinicians working with mental health services in VA, which include those in specialized PTSD programs. Training and assessment of staff competencies to treat PTSD are ongoing. Examples are the roll-out of the web-based National Center for PTSD's "PTSD 101" curriculum and initiatives for dissemination of evidence-based practices in PTSD.

24. Improve VA collaboration with DOD on PTSD education. VA should improve educational collaboration with DOD.

Status: Significant progress has been made and efforts are ongoing. Examples of recent VA/DoD educational collaborations include the March 2005 Joint VA/DoD Deployment Mental Health Conference; and the satellite broadcast of August 2005 entitled "Health Promotion and Reintegration after Injury During Deployment," which is currently being made into a web-based training program under the working title, "War Injury/Suicide Prevention." In addition, training for staff in the new RVOEC programs will follow the example of training for Counselors in Vet Centers, that include the U.S. Army's "Battlemind" training, a highly innovative program that teaches soldiers to recognize behaviors that are adaptive in the war zone (e.g. erratic driving to avoid roadside bombs) but which are maladaptive in the civilian environment. Vet Center and RVOEC training lets VA staff address issues about war-related stress in a manner that will be familiar to returning veterans from their experiences in active duty; it will move beyond "Battlemind" to help veterans learn adaptive techniques to correct these maladaptive behaviors.