Veterans Health Administration: Behavioral Health Services

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