Veterans Health Administration: Behavioral Health Services

Veterans Health Administration: Behavioral Health Services

December 3, 2019
Veterans Health Administration: Behavioral Health Services
Introduction
numerous behavioral health conditions, including
The Department of Veterans Affairs (VA) provides health
depression, SUD, and post-traumatic stress disorder
care and health-related services through the Veterans
(PTSD), among others. Depending on the disorder and its
Health Administration (VHA), one of the largest integrated
severity, services can be provided by general practitioners
health care systems in the United States. The VHA is
in a primary care setting or by more specialized providers,
divided into 18 Veterans Integrated Service Networks
such as a psychiatrist or psychologist, in a specialized
(VISNs) that comprise over 1,700 sites of care, including
setting (e.g., residential program that focuses specifically on
VA medical centers (VAMCs), community-based
recovery from SUD). A veteran receiving behavioral health
outpatient clinics (CBOCs), extended care facilities, and
treatment in a specialized setting is assigned a principal
readjustment counseling centers (Vet Centers). Each of
mental health provider. This provider maintains regular
these sites of care offers behavioral health services. The
contact with the patient and coordinates mental health care
term behavioral health comprises mental health and
amongst providers of different specialties.
substance use. Although the VA often refers to mental
health services in its documentation, the VHA also provides
According to the VA, in FY2020, the VHA expects to
substance use disorder (SUD) services. For this In Focus,
provide about 15 million visits in outpatient specialty
the terms mental health and behavioral health are used
behavioral health care settings and expects to pay for over
interchangeably.
600,000 outpatient specialty behavioral health care visits in
non-VHA facilities (i.e., Veteran Community Care Program
VHA Eligibility for Behavioral Health
[VCCP]). The VHA also expects to provide approximately
Services
1 million mental health visits in primary care in FY2020.
Eligibility requirements for accessing behavioral health
services at the VHA are generally the same as for accessing
Outpatient Primary Care Services
all other health care services at the VHA, with certain
Generally, mild and/or moderate behavioral health
exceptions. Some veterans experiencing an emergent
symptoms and conditions (e.g., depressive, anxious
behavioral health crisis may not meet all eligibility
symptoms) are treated in an outpatient primary care setting.
requirements for VHA care. However, certain former
servicemembers with other than honorable (OTH)
Compared to some private providers, the VHA is unique in
discharges are eligible for an initial assessment and
its delivery of mental health services in a primary care
subsequent care for an emergent behavioral health need as
setting (i.e., primary care-mental health integration [PC-
long as the need persists (38 U.S.C. §1720I). OTH former
MHI]). The VHA initiated PC-MHI in 2007. In this model,
servicemembers do not need to meet minimum active duty
a PC-MHI care manager coordinates care with primary care
requirements to be eligible under this authority and do not
providers, as well as other PC-MHI mental health experts
need to be enrolled in VHA care to receive services.
(e.g., psychiatrists, psychologists, and clinical social
Veterans who are not eligible under this authority (e.g.,
workers). In 2010, the VHA started implementing Patient
dishonorable discharge) may still be able to receive care
Aligned Care Teams (PACTs), in which PC-MHI providers
under humanitarian care authorities (38 U.S.C. §1784), but
work in a team with primary care providers, registered
in this case, a veteran would be billed for care received.
nurses, and other staff to ensure patient-centered care.
For more information about VHA eligibility, care provided
Outpatient Specialty Behavioral Health Care
under 38 U.S.C. §1720I, and conditions of discharge (e.g.,
Services
OTH discharge), see CRS Report R42747, Health Care for
Generally, moderate severity behavioral health symptoms
Veterans: Answers to Frequently Asked Questions.
and conditions are treated in outpatient specialty behavioral
health care settings. These settings include general mental
VHA Behavioral Health Services
health clinics or outpatient specialized programs.
The VHA is one of the largest behavioral health care
service providers in the United States. Based on the
A general mental health clinic provides outpatient
President’s requested funding, the VA expects FY2020
behavioral health services beyond those offered in primary
mental health care obligations to be approximately $9.4
care, but are used by veterans who do not need outpatient
billion. In comparison, FY2015 mental health care
specialized programs. In 2014, the VHA introduced the
obligations were $6.9 billion, an approximate $2.5 billion
Behavioral Health Interdisciplinary Program (BHIP) in
increase over five years.
some of its general mental health clinics. The BHIP—
similar to PACTs—assigns patients to an interdisciplinary
Behavioral health care at the VHA comprises a continuum
team to coordinate and deliver behavioral health care. The
of outpatient, residential, and inpatient services for
VHA has also implemented outpatient specialized programs
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Veterans Health Administration: Behavioral Health Services
specific to certain behavioral health conditions, including
patients served) and small CBOCs (<1,500 unique patients
serious mental illness, PTSD, and SUD.
served) are also subject to different requirements.
Inpatient Mental Health Care Services
Vet Centers
Hospital-based inpatient mental health units are primarily
Vet Centers are located in community settings and provide
reserved to treat patients with the most severe behavioral
a range of counseling services to veterans, servicemembers,
health symptoms and conditions that may cause them to be
and their families (38 U.S.C. §1712A). These services
a danger to themselves or others. As a result, hospital-based
address bereavement, PTSD, military sexual trauma, and
inpatient mental health units function mostly as
substance use assessment and referral, among other issues.
stabilization units, with a focus on pharmaceutical
interventions and safety.
Table 1. Examples of VHA Delivery of Behavioral
Health Services
Residential Behavioral Health Care Services
Severity
VHA
Mental Health Residential Rehabilitation Treatment
Clinical
(Mild,
Behavioral
VHA
Programs (MH RRTPs) provide residential rehabilitative
Symptoms
Moderate,
Health
Site(s) of
and clinical treatment for veterans who require additional
or Disorder
Severe)
Services
Care
structure and support to address challenges beyond their
Depressive
Mild/moderate
Outpatient
VAMC,
behavioral health condition(s), such as unemployment or
or anxious
Primary Care
CBOC, Vet
homelessness. There are MH RRTPs specific to different
symptoms
Center,
behavioral health disorders, including SUD and PTSD.
VCL
VHA Behavioral Health Sites of Care
PTSD
Moderate
Outpatient
VAMC,
Behavioral health services offered at the VHA are accessed
Specialty
CBOC, Vet
through different sites of care within a VISN, including
Behavioral
Center,
VAMCs, CBOCs, and Vet Centers. Statute, regulations, and
Health Care
VCL
VHA directives and handbooks require or direct different
Substance use Severe
Residential
VAMC,
care sites to provide behavioral health services based on the
disorder and
Behavioral
VCL
size and capability of the facility.
homelessness
Health Care
Suicide
Severe
Inpatient
VAMC,
In addition, crisis intervention services are offered through
attempt
Mental Health VCL
the Veterans Crisis Line (VCL) as part of the VA’s
Care
comprehensive suicide prevention program (38 U.S.C.
Source: Created by CRS. Veterans Affairs Medical Center = VAMC;
§1720F). The VCL is a confidential toll-free hotline, online
Community-Based Outpatient Clinic = CBOC; Veterans Crisis Line =
chat, and text service that provides 24/7 crisis intervention
VCL; Posttraumatic Stress Disorder = PTSD; Mental Health
services. Some veterans who use the VCL are referred to a
Residential Rehabilitation Treatment Program = MH RRTP. Severity
VA Suicide Prevention Coordinator (SPC), who is tasked
was defined based on VHA Handbooks 1160.06 and 1162.02, as well
with responding to such referrals and coordinating services
as PC-MHI Operations Manual (https://tinyurl.com/s2vet95).
with the veteran in the VHA or in the community.
Notes: Each clinical experience is unique and may be categorized by
VAMCs
a different severity rating and require a different service and/or care
site than suggested in this table.
VAMCs either provide inpatient mental health care or refer
veterans into the community. VAMCs also provide MH
Concluding Observations
RRTPs, outpatient specialty behavioral health care through
general mental health clinics and specialized programs, and
Over the past couple of decades, Congress has taken
PC-MHI in outpatient primary care. Every VAMC provides
significant interest in addressing behavioral health
conditions and suicide among veterans. For example,
same-day mental health services through PC-MHI. Same-
day mental health services means that a primary care and
Congress has consistently provided increased annual
mental health visit can be scheduled in the same day. All
funding for VHA mental health care, and it has enacted
VAMCs must appoint and maintain a SPC.
numerous pieces of legislation to address eligibility and
access to, as well as quality of, VHA behavioral health
CBOCs
services. However, certain challenges remain, including
CBOCs refer veterans in need of inpatient mental health

care to a VAMC or community provider. CBOCs also
reaching veterans with behavioral health conditions
provide outpatient behavioral health care through general
and/or at risk for suicide who do not interface with
mental health clinics and specialized programs, and PC-
VHA;
MHI in outpatient primary care. However, the size of the
 providing consistent, high-quality behavioral health
CBOC dictates the behavioral health services offered. For
services in different care sites across the VHA; and
example, very large CBOCs (>10,000 unique patients
 addressing VHA behavioral health provider staffing
served) are required to offer PC-MHI on a full-time basis
issues, including shortages and burnout.
and appoint and maintain a SPC, while large CBOCs
(5,000-10,000 unique patients served) are required to offer
Victoria R. Green, Analyst in Health Policy
PC-MHI based on clinical need and are not required to
IF11378
maintain a SPC. Mid-sized CBOCs (1,500-5,000 unique
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Veterans Health Administration: Behavioral Health Services

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