Inside Oversight

Adam Roy
Happy New Year, listeners. This is Adam Roy. Welcome back to another episode of Inside Oversight, a Veteran Affairs Office of Inspector General official podcast that examines in some details some of our more nuanced oversight reporting. To understand the complexities of the topics we report on, we talk with the report authors and experts to gain insight into how the team conducted its work, what it found, and the impact on veterans and the public.
If you're listening today from a podcast platform like Apple or Spotify, I encourage you to subscribe and check back often for new episodes. If you're listening desk-side from our website, www.va.gov/oig, you can find the report we're talking about today as well as other published work, including our most recent semiannual report to Congress, which summarizes VA OIG’s oversight work from April 1 through September 30t, 2022, there as well.

Today I'm going to be talking to Dr. Wanda Hunt, a healthcare system specialist with the VAOIG, about a recent review we completed that assessed element of the Veterans Health Administration’s, or VHA, intensive community mental health recovery programs. These programs provide intensive community-based outpatient care to veterans with serious mental illness.

Wanda, thanks for joining me today, and let's start with you. Share with the listener your role here at the VA OIG and how you came to work within the healthcare space, specifically mental health.

Dr. Wanda Hunt
Well first, Adam, thank you for letting me come on this podcast with you to talk about my team's review. As you said, I work as a health system specialist at the VA OIG, specifically within the Office of Healthcare Inspections, which we call OHI. And within OHI, I specifically work in the mental health group. And so, in this role I take part in various reviews of some of VHA’s mental health programs, conduct inspections. I present our findings to our leadership and to VHA and write reports as well. It's been really rewarding to be here. I love the challenges and the opportunities within OHI, not the job I imagined when I began my career , as you can imagine. As far as how I came to work within healthcare and specifically VHA healthcare, I would say the seeds were planted when I was a kid.

As a kid, I was really aware of what it meant to be a veteran. My father was an Army veteran stationed in Germany in the post-World War II era, and I had multiple other relatives who also served. I had two uncles who served in the Korean War, and one of them sustained a gunshot injury and got care at the VA for many years, really the rest of his life, and he always had such good things to say about the care he received from the VA. Several cousins, family friends, neighbors while I was growing up had served in Vietnam during the Vietnam War. One neighbor in particular really struggled when he got home from Vietnam. For years he resisted the idea of getting help, but he eventually did go to the VA and got great care that really helped him turn his life around. That was a nice thing to see happen.

And then in my generation, my brother served in the Army for 20 years, and I have a number of cousins who have also served. One of my cousins served in Iraq and a nephew served in Afghanistan. One last interesting thing regarding my family's military service, one of my cousins does a lot of family research and genealogy on ancestry.com, and he found a military record of one of my grandfathers of several generations back who served in the Union Army during the Civil War. My cousin found a photo of his military record, a little piece of paper that I guess was the precursor of the discharge paperwork we know today is the DD214.

Adam Roy
Oh, wow.

Dr. Wanda Hunt
Yeah.

Adam Roy
That represents a lot of military lineage, and it's always great to hear the personal connection. How did you end up in healthcare specifically here with us?

Dr. Wanda Hunt
Yeah, so I'll flash forward to the 1990s now. I had finished college, and I was working just in various healthcare settings, and I chose to do a doctorate program in pharmacy. I knew I wanted to be a clinical pharmacist, which is a pharmacist who directly works with patients on their medication management, and my first location for a clinical training was at a VA in the mental health clinic. I loved it. I loved working with the veterans. It was incredibly satisfying to help them achieve improved mental health. So, I was really feeling like that was what I wanted to do. And about three years after I completed my doctorate in pharmacy, that exact dream job came up. For the next 15 years, I worked at the VA in psychiatric medication management and working with veterans with every type of mental health disorder, from schizophrenia to posttraumatic stress disorder to dementia to substance use disorders. The whole spectrum, as you can imagine, the appropriate medications and the proper use of medications is so critical in the care of people with these illnesses. I mean really with any patients, but sometimes mental illnesses can pose particular complications.

Adam Roy
Absolutely.

Dr. Wanda Hunt
Yeah. So, I worked there. I met some—met and worked with some incredible veterans, and I worked with some incredible colleagues. But after 15 years at the same place, I was feeling the need for a change. I wanted to do something different, just feel challenged in new ways. So it was around this time that I became aware of job openings in the VA OIG mental health line and OIG’s oversight goal is to make veterans lives better. And so, I love that mission, and I took a job with the VA OIG in September 2019, and I've been here since then.

Adam Roy
Oh, wow. That's amazing, too. And how lucky we are to have you. You've seen things from on the ground in your professional experience and now you have an opportunity to review these programs from the oversight angle.

Dr. Wanda Hunt
Thank you.

Adam Roy
And that is, I'm sure, very helpful when it comes to looking at reports and doing the oversight work that we do here.

Let's talk about the report now. Give me the title of the report so we can just let the listeners understand what we're talking about.

Dr. Wanda Hunt
Sure. Adam, the name of the report is Improvements Recommended in Visit Frequency and Contingency Planning for Emergencies in Intensive Community Mental Health Recovery Programs. I know that's a mouthful.

Adam Roy
Absolutely. Okay. And to summarize, the report covers mental health care, and for veterans seeking mental health care VHA provides a continuum of treatments and services that include outpatient, inpatient, residential, and community-based care. And according to VHA mental health services provided, I'm quoting here, “timely access to high quality recovery-oriented evidence-based mental health care that anticipates and responds to veteran needs and supports the reintegration of returning service members into their communities.” Given that this report examined the visit frequency for veterans enrolled in the intensive community mental health recovery programs between April 1, 2019 and March 31, 2021, which represents one year prior to and after the onset of the COVID 19 pandemic, help the listener understand what are intensive community mental health recovery programs, and what do they do?

Dr. Wanda Hunt
Absolutely. So intensive community mental health recovery programs, or as we call for short ICMHR, because we love acronyms, there are a set of programs at VHA that provide intense and clinically complex care to veterans with serious mental illnesses. So, the types of illnesses I'm talking about here are schizophrenia, other psychotic disorders and bipolar disorders. These illnesses are the ones that can cause people to have hallucinations, paranoia, severe depression or mania. And then these symptoms can cause people to experience a lot of impairment in their functioning. By that I mean they're often unable to maintain a steady job. They're at greater risk for poverty, homelessness. They're also at a greater risk for incarceration. So, they may have impairments with interpersonal skills and self-care. And as a result of all of this, they are also at greater risk for multiple psychiatric hospitalizations. So, as you can tell, these are really the reasons these types of mental illnesses are defined as serious mental illnesses.
So, some of the hallmarks of ICMH R programs are frequent visits with veterans in their homes and communities and providing clinically complex care. So, to deliver frequent care to veterans in their communities, the caseload of the teams of professionals are kept small, usually anywhere from seven to 15 veterans for each case manager on a team. And a team usually includes many professionals, social workers, nurses, psychologists, psychiatrists, pharmacists, really whatever the veteran needs to reach their recovery goals.

Adam Roy
Why are programs like intensive community mental health recovery so important for veteran healthcare?

Dr. Wanda Hunt
Yeah. Well, like any serious illness, staying well and having a good quality of life and staying out of the hospital are paramount for people. And these goals are the same, whether it's chronic, congestive heart failure or diabetes or schizophrenia. Programs like ICMHR have been shown through medical research to reduce psychiatric hospitalizations, decrease homelessness, and also improve quality of life for veterans with serious mental illness. So, with the kind of care that these programs provide, it is much more intense than traditional outpatient mental health care, which is typically in a medical office once a week or a less. And this is not to discount traditional outpatient mental healthcare—I did that for years—because that care can treat many psychiatric illnesses. But a lot of times it's not enough for veterans with these serious mental illnesses to reach their recovery goals. And that's what really is so important. Recovery goals can be a lot of things, but the veterans set their recovery goals for themselves. Their goals could be anything, usually related to their hopes and dreams and how to manage stress and how to communicate better. Some may need more basic skills development, like how to manage grocery shopping, how to eat nutritious meals or manage a budget. This all requires a wider approach than a typical office visit, and it really requires more frequent visits, which is what the intensity is all about with ICMHR.

Adam Roy
And for veterans who need this level of help or have this very specific mental health needs, what are the criteria for a veteran getting into this program?

Dr. Wanda Hunt
Well, the program is, as I said before, for veterans with serious mental illnesses like schizophrenia or bipolar disorder. But some veterans with other mental health disorders such as depression or post-traumatic stress disorder, they could be enrolled in ICMHR also if the veteran is having frequent psychiatric hospitalizations, frequent emergency room visits, a lot of contact with law enforcement, a lot of use of crisis support services. I mean these are veterans also who could really benefit from and need more intensive care. So, they may enroll in ICMHR also. Other criteria for the programs are that veterans haven't been served adequately by traditional office-based mental health outpatient care, and that they are clinically appropriate for outpatient care. Though one of the goals of enrolling veterans in CMHR is to prevent excessive psychiatric hospitalizations, but if they do have acute psychiatric symptoms that require hospitalization, veterans should remain there in the hospital until they are ready to get this type of intensive outpatient care.

Adam Roy
You've used that term intensive care several times in your responses. What makes this particular therapy so intensive?

Dr. Wanda Hunt
Really, that is kind of the hallmark of these services. Its in their title, ICMHR are based on, or its intensity is based on, frequent visits with the veterans and also that those visits are clinically intense. Now, in our report we focused on the frequency of visits as the measure of intensity, and VHA policy states that visits typically should be two to three visits per week per veteran for highly intensive services, and at least one of the weekly visits should be in person. Regarding VHA policy on this visit frequency, the ICMHR teams may have some veterans enrolled who only need low intensity services. These might be veterans who are starting to do better overall and they’re reaching their recovery goals. That VHA policy says that low intensity visit frequency can be fewer than one visit per week. It's really lessening at that. However, the ICMHR teams are not supposed to have more than 20% of their caseloads be veterans with only low intensity needs, and that's really to maintain good accessibility to the program for those veterans with the high intensity needs.

Adam Roy
Sure, that makes sense.

Dr. Wanda Hunt
I'm jumping ahead a little bit, Adam, but we did find a problem related to this low intensity/high intensity ratio that VHA policy stipulates. VHA currently doesn't have a process for distinguishing which veterans enrolled in these programs have high intensity needs or low intensity needs. So, if they're not really distinguishing and identifying them, there's no way to know if team caseloads are being distributed that expected ratio of no more than 20% being veterans with low intensity needs.

Adam Roy
So that was something that your team found was that VHA maybe needs to improve some oversight of that 20/80 ratio rule?

Dr. Wanda Hunt
Absolutely.

Adam Roy
Great. So, intensity has to do with number of visits, you explained that. And based on your review, do the programs meet that requirement for high Intensity services?

Dr. Wanda Hunt
No. We reviewed VHA’s data on ICMHR visits for approximately one year before the pandemic, and then one year after the onset of the pandemic. Like you said, we found that for the year prior to the pandemic onset, ICMHR staff had an average of 1.18 visits per week per veteran. And for the first year after the pandemic onset staff had an average of 1.23 visits per week per veteran. This was below the expected average of two to three visits weekly.

Adam Roy
So, staff was already below the expected weekly average for visits leading up to and during the pandemic.

Dr. Wanda Hunt
Right.

Adam Roy
So how did the pandemic further impact average visits, and what did VHA do to address these challenges?

Dr. Wanda Hunt
As I stated before, policy states that at least one of the weekly visits is expected to occur in person with the veteran. So VHA, just like everybody else, had to address this expectation pretty quickly after the start of the pandemic. In late March 2020, the deputy under secretary for health for operations and management put out a memo specific to ICMHR programs to allow the required in-person visits to happen virtually, either by video telehealth or by telephone.

Adam Roy
Okay. So, despite policy changes, we didn't find that visits went up given the virtual option. That must have surprised you a bit.

Dr. Wanda Hunt
We were a little surprised by that. Like you said, prior to the pandemic, as visits were expected to be in veterans’ homes and communities, traveling to see some veterans could take a long time for the clinician, especially for veterans that live in rural communities. They may be out pretty far out there. We were surprised that they didn't have a more significant increase in visit frequency after the pandemic onset—the use of virtual care since virtual care eliminates that need to travel—their visit frequency was higher, but just not by much. We were expecting it might go up more than that.

Adam Roy
Okay. Now changing gears, a little bit, the review also looked at the program's contingency plans for veterans’ access to medications during emergencies. What is a contingency plan and why are contingency plans important, and what did your team learn from looking at this specific program?

Dr. Wanda Hunt
A contingency plan is a plan that basically outlines all the steps that need to be taken during emergencies or disasters that's going to disrupt the usual way of doing business. For example, some veterans get psychiatric medications by injection from nurses, but in a situation like the pandemic when in-person visits were shut down for a while, both in medical offices and out in the community, how is that veteran going to get that injection they need? These are psychiatric medications that can't simply be mailed out to them for them to administer to themselves. They have to be injected by a medical professional. And on top of that, missing some of these injections, even a few days, could cause the veteran to have significant destabilization, return of more significant symptoms. So having a contingency plan for a program like ICMHR, it just helps ensure the staff knows what to do in various emergencies so there are no disruptions, particularly to medication access for veterans. As well as VHA policy requires contingency plans for programs that base their care in the community like ICMHR. So, we requested contingency plans from VHA healthcare systems, and what we learned was that the majority of VHA healthcare systems did not have contingency plans specific for ICMHR processes regarding veteran access to their medications. So, we reviewed 131 healthcare systems and 57 of them, or 44%, were able to provide ICMHR-specific contingency plans that included processes to maintain veterans’ medication access.

Adam Roy
Okay.

Dr. Wanda Hunt
And 38 healthcare systems out of the 131, which is 29% of them, had contingency plans that specifically address veteran access to those psychiatric medications that need to be injected.

Adam Roy
How did your team go about developing the questionnaire, and how do you distribute that and bring that data back in for review?

Dr. Wanda Hunt
Our process to set up, send out, and then analyze the questionnaires, it's pretty involved. Our review team first develops the content of the questionnaire that we'd like, and then we make sure our leadership approves of it. It has to go through a legal review too, of course. Then we move on to distribution, which actually involves several steps, too. First, we need to identify the right people for the responses. So, in this case, we ask VHA to identify all their ICMHR program coordinators. Next, we had our technical team set up an automated distribution to the list of people identified. And thank goodness for them because it was a list of 151 coordinators. We were glad for any automation we could get. Respondents were given 10 days to get their responses back to us, and answers were completely separated from their identities. So, their responses were anonymous. And because we asked a number of open-ended questions, we then had to do a pretty lengthy analysis, thematic analysis, if you will, to categorize those responses and validate them. So, to do this, two team members independently coded those responses into themes or categories, and a third team member validated those themes. If any of their independent coding didn't align, the two coders talked through the discrepancies. If they still couldn't agree, then a third team member weighed in and also validated those discrepancies. If it sounds like that took a long time, it did.

Adam Roy
That was a great description of the process, and I think the listeners up there gives them a little bit understanding of just the amount of work that goes into some of the things that we do. From this questionnaire, what did your team learn from the responses specific to the ICMHR program?

Dr. Wanda Hunt
What we were really wanting to get was coordinators perspectives on resources that their programs needed, if any, and after l looking at the visit data, we were wondering what their perceived barriers might be for more frequent visits. For those coordinators who responded that their programs were in need of resources to see veterans with that high intensity frequency, the themes that came up over and over were staffing needs. So essentially everything related to needing more staffing and technology needs, especially when these people are out on the road and in communities, they need their technology to work. While these may be their perceptions, we viewed it as an opportunity for VHA to assess factors that may be contributing to lower-than-required visit frequency. We were also wanting to see coordinators perspective on the use of virtual care for their services and in the future. And the most common comment we saw was really along the lines of they found virtual care helpful, especially during the pandemic, but they really wanted virtual care to only be a supplement to in-person visits. Again, that's such a critical piece of ICMHR care. They wrote often that virtual care allowed more flexibility to stay connected with veterans, but still felt like the use of it should be limited under normal circumstances.

Adam Roy
Sure, sure. And with the emphasis on using technology, virtual environments to address healthcare needs, that's an interesting perspective

Dr. Wanda Hunt
And we felt that that really should allow the VHA an opportunity to assess and clarify the future role of virtual care for these types of programs.

Adam Roy
Absolutely. Like we do in almost all of our reports, we presented some recommendations regarding the intensive community mental health recovery programs. And what were those recommendations?

Dr. Wanda Hunt
We had three recommendations. Our first recommendation was for VHA to develop and implement action plans to meet ICMHR visit frequency requirements and to assess program resources needed and the role of virtual care. Our second recommendation was for VHA to ensure veterans needing and receiving only low intensity services did not represent greater than 20% of the team caseloads. And then our final recommendation was on contingency planning. We recommended the under secretary for health ensures the healthcare systems develop and maintain contingency plans specific to ICMHR, which is, again, out in the community a lot, for veteran’s medication access and to include consideration of injectable psychiatric medications. So, there's no disruption during emergencies.

Adam Roy
Okay. So, the first recommendation addresses those actions, whether it be more resources like staffing and increased use of virtual care to increase visits. And the second insures were focusing on those vets with high intensity needs. Is that accurate?

Dr. Wanda Hunt
Yes, that's accurate.

Adam Roy
And then the third one addresses contingency planning in the event of another emergency or a situation like the pandemic happening in the future. In your line of work, is that a common theme now? Do you see that across a lot of your work? That better contingency planning for future events like the pandemic is a common occurrence?

Dr. Wanda Hunt
I would say so across the OIG. I mean, I think particularly the pandemic really set off having that as a focus for a lot of reviews and reports that have been done in the last couple years in particular.

Adam Roy
Absolutely. And now regarding these recommendations, what were VHA’s action plans to respond to them?

Dr. Wanda Hunt
For those last two recommendations that we talked about, VHA concurred with them, and they provided us acceptable action plans. However, for our first recommendation related to high intensity visit frequency, VHA provided an action plan—we do have some concerns about the action plan. As well as other follow up communication we had with VHA led us to be concerned that VHA may attempt to resolve this recommendation by rewriting policy to reduce visit frequency expectations instead of identifying actions and resources that might help them improve frequency. VHA expressed in conversation with us that the visit frequency is for at least one visit a week, even though their current policy states an average of two to three visits weekly per veteran, those veterans with the high intensity needs, at least. The OIG wants VHA to just ensure that this vulnerable veteran population with complex needs, that they receive the clinical visits at the frequency outlined in current ICMHR policies.

Adam Roy
So, the major crux is that we have a program here where success is determined by frequent visits and touch touchpoints by staff with veterans with serious mental illness, and a potential change in VHA policy that would reduce that requirement removes almost the program's uniqueness. Is that the case?

Dr. Wanda Hunt
Very much so. These types of recovery programs are built on teams having small caseloads and frequent visits in people's communities and homes, and there's good medical evidence showing that this model of care can really improve the lives of people with serious mental illness. And we believe VHA has an opportunity to assess what resources are needed for their ICMHR programs, as well as to review how ongoing and future use of virtual care may help meet needs to some extent regarding high intensity visit frequency.

Adam Roy
I guess I'd add during a time here where VHA staffing considerations seem to be front and center, how do we justify programs with low caseloads but also less visit frequency?

Dr. Wanda Hunt
The ICMHR program is built to allow the case managers and teams to see veterans multiple times weekly by keeping the number of veterans they have in their caseloads very low. Low caseloads and frequent visits. Those are hallmarks of this program. If they're not doing frequent visits, we really aren't sure how low caseloads are a justified use of staff.

Adam Roy
Well, Wanda, I really appreciate your time today and thank you for talking about this review. Before we sign off, is there anything you want to add?

Dr. Wanda Hunt
Yeah, I mean, I guess I just still feel a need to reiterate the importance of ICMHR in helping veterans with serious mental illness live their best lives in their chosen communities. And I think VHA is so important in providing this service to a very vulnerable veteran population.
I do also want to add that our review team found the ICMHR staff dedicated to veterans and very responsive to our questions. And so, we want that staff to have the resources they need to provide excellent care.
Thank you for the opportunity to discuss my team's work on this review and on the report. We really appreciate the opportunity.

Adam Roy
No worries at all. And you made some really great points there. I really appreciate you being with us today. And I'll just share for the listener, the report we talked about is titled Improvements Recommended in Visit Frequency and Contingency Planning for Emergencies and Intensive Community Mental Health Recovery programs. And as always, you can find this report on our website.

And before I sign off today, I'd like to talk to you a little bit about a recent fraud alert published by the VA OIG. Recently we published a fraud alert on stopping education benefits fraud. The VA OIG asked you to report any VA approved school that is billing veterans whose enrollment is funded by VA, a higher tuition rate than civilian students for the same courses. VA-approved schools that engage in education benefit fraud often advertise a lower tuition rate than they are billing VA for veteran student enrollments; offer discounts, tuition waivers, or scholarships exclusively to civilian students; or bill at least 20% more than non-VA approved schools with similar course offerings. If these practices sound familiar or you know a veteran taking education courses from a school that may be engaging in education fraud, I encourage you to submit a complaint to the VA OIG hotline. If you have any questions about the GI Bill and any other VA education benefits, visit the GI Bill School feedback tool atva.gov or call 888-442-4551. This fraud alert is the third in a series of periodic alerts for fraud and other crimes. Visit the VA OIG website to learn more about potential indicators for 10 different types of fraud.

And lastly, check out our other podcast, Veteran Oversight Now. In the most recent episode, host Fred Baker chats with Dr. Beth Winter, a psychiatrist with the VA OIG’s Office of Healthcare Inspections. They discuss their path from wanting to provide care for exotic animals to choosing to be a people doctor instead of an animal doctor. Dr. Winter's distinguished career eventually led the granddaughter and daughter of veterans to the VA, OIG, helping provide oversight of VHA’s healthcare system. In this podcast episode, Dr. Winter discusses her work related to the prevention of veteran suicide by lethal means in the recently released report Deficiencies and Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning for Patients with Suicidal Behaviors by Firearms. She explains that the time between a veteran deciding to act and actually attempting suicide can be just five or 10 minutes, and relatively simple interventions during that period can be critical in preventing suicide. The episode concludes with a summary of the VA OIG’s oversight highlights for December 2022. Find all OIG podcasts on major directories such as Apple, Spotify, or Google, as well as on our YouTube channel at Vet Affairs OIG. Again, thank you for listening and see you next time. Adam Roy signing off.

This has been an official podcast of the VA Office of Inspector General. Inside Oversight is produced by the Office of Communications and Public Affairs and is available at va.gov/oig. Please subscribe and tune in monthly to hear how our work is helping to improve the lives of veterans. Visit the website to learn more about how the VA OIG conducts meaningful independent oversight. Report potential crimes related to VA waste or mismanagement, potential violations of laws, rules or regulations or risks to patients, employees, or property to the OIG Online, or call the hotline at 1-800-488-8244. If you are a veteran in crisis or concerned about one, call the Veterans Crisis line at 1-800-2-73-8255, press one and speak with a qualified responder now.