Inside Oversight

Adam Roy:
Hello and welcome back to another episode of inside oversight, a podcast of the Veterans Affairs Office of the Inspector General. This is your host, Adam Roy. Today I'm talking with Corina Riba an audit manager with the Office of Audits and evaluations. We’re going to be discussing a recently published report, Suicide Prevention Coordinators Need Improved Training, Guidance and Oversight. How you doing today, Corina?

Corina Riba:
I'm doing great. Adam, how are you?

Adam Roy:
I'm good, too. Thanks for asking. So, Corina, suicide is a national health crisis. If you take a look at the VA strategic plan, its prevention is VA’s highest clinical priority. And part of that suicide prevention is requiring suicide prevention coordinators located at VA medical facilities across the country to reach out the veterans referred from the Veterans Crisis Line.

Before we get into the findings of the report and what your team recommended, share with the listener a little bit about the Veterans Crisis Line.

Corina Riba:
Yes. in 2007, the Veterans Health Administration launched the Veteran Crisis Line in response to the Joshua Omvig Suicide Prevention Act. The crisis line is available to all veterans, even those veterans that don't receive services at the VA. VHA, or the Veterans Health Administration, encourages all veterans and their loved ones to call in to the crisis line when they feel that the veteran is having issues or other situations that come up that places the veteran at risk for suicide. The crisis line responders will answer calls from veterans, and they'll provide a broad range of services, from giving veterans or their loved ones who call in information about the different services the VHA provides or also providing intervention services in the community, such as initiating a welfare check to make sure the veteran's OK or dispatching emergency services where the veteran will be hospitalized at a local VA or non-VA hospital.

Adam Roy:
And these coordinators, are they social workers?

Corina Riba:
So, these are the crisis line responders. But yes, the crisis line responders are social workers. And then the suicide prevention coordinators—what happens is, after the veteran will call the crisis line, the crisis line responders, the ones who responded to the call, will initiate a referral to a local VA medical facility and they send that referral through a call management system to local suicide prevention coordinators that are located throughout the country.

Adam Roy:
And then the suicide prevention coordinators take action to reach out to the veteran. What kind of services do they provide or offer when they reach out?

Corina Riba:
This is an important step, the suicide prevention coordinators, because after veterans have called the crisis line their risk for suicide is elevated one month after calling the crisis line and continues to be elevated 12 months after. So, the coordinators, what they will do is they will address—
if they reach the veteran, they'll address the referral need, whether or not that's getting more information about the homeless program or connecting with the mental health provider, and they also help them with the continuity of care or coordinating ongoing care.

Adam Roy:
In the report it states that VHA employed 540 coordinators at 135 medical facilities as of June of 2020.

When do we look at the report, they kind of identified some of the things that the following issues: coordinators overstated the number of veterans reached within three days, coordinators didn't intersperse calls as required to increase chances of reaching veterans, and coordinators didn't always make required attempts to reach veterans who received care or assistance in the community.

So as your team began to look at this, did you guys consider like the number of employees that were employed as coordinators and the volume of work that they had to cover in their geographic area?

Corina Riba:
Yes, this is something that we took into consideration, and we had met with over 100 coordinators virtually in conversations and trying to get a handle for their workload because, in addition to managing the crisis line referrals, they also have other responsibilities about tracking high risk veterans that receive care at the VA and providing training to VA staff and the community. So, this was something that was on our radar.

And also, during COVID we also took that into consideration, where that impacted the management of referrals. And what we had found is that, based on our conversations with coordinators, the workload was manageable in terms of the crisis line referrals. There were some newer coordinators who just needed a little more time in training; but other than that, most, based on our conversations with them, had felt that the workload was manageable.

Adam Roy:
So, you mentioned the pandemic. What did VHA do specifically? What changes did they make as a result of the pandemic in relation to the roles and responsibilities of the suicide prevention coordinators?

Corina Riba:
In response to the pandemic, VHA had made a couple of changes, albeit slight but important. One change was to require the coordinators to make one additional attempt. Prior to the issuance of this policy, coordinators were required to make two phone call attempts and send a letter or make three phone call attempts and send a letter. With the issuance of the policy, it required coordinators to make four attempts. They were required to make three phone call attempts and send a letter. In addition, prior to this policy, coordinators could make calls whenever they felt like it or if it fit in their schedules so they could make all of their attempts on the same day or within an hour or 30 minutes of receiving the referral. And this policy changed that to require coordinators to intersperse their calls and make the three phone call attempts on three separate days. The reason why they did it is so that the coordinators would have a better chance of reaching the veterans, instead of potentially making calls that within one hour, and the veterans at work or gone for the day and not available.

Adam Roy:
And these changes were made during the pandemic.

Corina Riba:
Correct.

Adam Roy:
Do they still remain in place today, these policies?

Corina Riba:
Yeah. The changes do remain in place today. Another part of why VHA made this change is to align closer to their general and mental health scheduling policies that are in place when a veteran is making an appointment and other staff are following up to schedule the appointment with veterans.

Adam Roy:
So, when we look at the report, and I mentioned it earlier, sort of the primary issues you found and you've kind of touched on that a little bit, one being that they didn't intersperse their calls as much and we covered that, some would make all three phone calls in one day, and now they're required to space those calls out.

One of the issues identify was coordinators overstated the number of veterans reached within three days. Can you expand on that a little bit? What does that mean?

Corina Riba:
Yes, so this was one of our primary issues, and having accurate data and information, especially on such a sensitive topic, is key so management can make decisions on whether or not their current procedures are working—because the goal is for these coordinators to reach as many veterans as possible, to see if their needs were met if they have additional needs. And what coordinators do is they assess the veteran again at that time for potential risk for suicide. So that is the primary goal for these coordinators to reach veterans.

What we had found when we looked at the call management system is that the system had showed that coordinators had reached a really high percentage, 82% of these veterans, and provided services or answered questions, whatever the veteran’s need was. But in looking at the veteran’s electronic records as well as coordinator’s detailed notes in the system, when we looked at a sample, we found that the coordinators had not reached as many. It was about 20% less. So VHA believes that the coordinators reached about 82%. It was really 62%.

In working with the coordinators and trying to get to the bottom of why this was occurring or what had happened, the coordinators weren't familiar with, or they didn't have the training on what code to select when they were closing out the referral. As they process these referrals, they make their attempts. If they reach the veteran, they talk to the veteran, and still close out the referral and documenting their actions. So, they select patient codes that reflect their actions. And what had occurred is that these coordinators were selecting codes that reflected the crisis line responder’s action.

So, let's say a veteran called the crisis line and the responder had initiated a welfare check or sent an emergency dispatch, and the veteran ended up in the hospital. The coordinator would make their attempts. It was clear in the notes that they had not reached the veteran, but as they closed out this referral, they would have selected welfare check even though they didn't talk to the veteran and initiate a welfare check—the crisis line responder. There was a lot of confusion at the coordinators about what patient outcome code to select. And then also managers were not reviewing or training these coordinators to make sure they knew what the right process was. And the individuals that the crisis line who were collecting this information and data and reporting it to officials, they were also not verifying the accuracy of the information to make sure it was correct.

Adam Roy:
You touched on a lot there, but would it be accurate to say that there's some training deficiencies and some management oversight through the review that you found?

Corina Riba:
Right. I would say in general that the oversight and the management, the oversight at the various levels wasn't as consistent as it should be with reviewing these crisis line referrals and overseeing the coordinators in this aspect of their responsibilities.

Adam Roy:
Kind of continuing along with those issues we talked about, the report says, to quote: these conditions occurred because VHA and VISN and medical facility management officials needed to enhance the management of crisis line referrals and coordinator supervision.

Can you talk a little bit about that? And I believe we're talking a little bit about metrics here, right?

Corina Riba:
Right. So VHA had established metrics that were really focused on timeliness, on processing these referrals quickly to make sure the coordinators were responsive to these referrals and not focused on the quality of these referrals. Also, VHA's policy wasn't very specific and direct to make sure that, at the other two levels at the regional level, the VISN and at the local level at the medical facilities,
they provided enough oversight, and there was clear direction and guidance about what they should be reviewing to make sure that supervisors at the local level had identified some of the issues that we've already talked about.

Adam Roy:
Let's go back and talk about the VHA policy change, where they now have to call on separate days. Prior to that, what was happening with that situation? When you looked into that, what was going on with coordinators maybe reaching out to a veteran three times within an hour, as you provided as an example earlier?

Corina Riba:
When we reached out to coordinators and talked to them, they had mentioned that they were trying to process these referrals quickly. In some cases, they had incorrectly believed that they had to process these referrals quickly and close them out in the call management system for veterans, providers, physicians to be able to see the detailed notes from the crisis line and so the provider could contact the veteran quickly, which was not the case. So, there was a lack of awareness in some coordinators on that part.

There was also some coordinators that had said they weren't aware of the change in policy, despite program officials, once they issued this change in policy, they emailed it out to the coordinators as well as during one of their monthly calls with coordinators they had also discussed this change. So some coordinators, when we looked at the data and information about closing these referrals quickly without reaching the veterans—what happened prior to the issuance of this memo, what happened after, we looked at the same coordinators, where the data showed that they did this consistently and they just continued that practice for the two reasons that I talked about—just trying to get through the referrals thinking that they didn't have that requirement or believing that they needed to close these referrals out quickly.

Adam Roy:
What about veterans who received care in the community? Am I accurate in saying that veterans often were referred to a VA facility and then often could have been referred to a care in the community facility, a non-VA facility? So would the responsibility of the suicide prevention coordinators, are they the same when the veteran received services at a VA location or a non-VA location?

Corina Riba:
Yeah. The responsibility should be the same. Coordinators should continue to, once they receive the referral, make their required phone call attempts, try to reach the veteran. That's the goal because it is important for the continuity of care, like I mentioned, and to assess the veteran again—where they’re at, are they still at risk for suicide? Do we need to offer additional services?

And what was happening is coordinators, when they had looked at the notes from the crisis line responder and they saw that a veteran was hospitalized at a local non-VA hospital, they would sometimes just call the hospital, confirm that the veteran had been hospitalized and close out the referral, not make anymore attempts. Same situation with the welfare check. OK, the veteran had a welfare check, someone checked on them, they must be OK. I see the notes in that case, and then I'll just close out the referral without making their required attempts to reach the veteran.

So, when we had looked at a sample of these cases where veterans had received different types of assistance in the community, we had found that coordinators were not always making their required attempts, with situations that I had just to just described. And so, there was a lot of confusion on the coordinators’ part.

Did they need to continue to follow up with the veteran or was it enough that they checked and make sure that the veteran was in a non-VA hospital?

Adam Roy:
And why is it so important? We touched on it a little bit earlier. Why is it so important for these coordinators to continue to reach out to the veterans and ensure that they're getting the services that they need, even though maybe a veteran calls and has thoughts, but then receives help?

Why is it so important to continue to reach out to them based on the information available to your team?

Corina Riba:
Yeah. For these particular cases, a lot of these veterans were at higher risk for suicide. They either had had an attempt, or the case was so severe that the crisis line responder had initiated that welfare check or someone to check on these veterans to make sure they were OK because at this point the crisis line responder had believed that there was an imminent threat either to the veteran or someone else. So that's usually the reason behind initiating a welfare check or dispatching emergency services for the veteran. So, these veterans were generally higher risk based on the crisis line responder’s information and notes and their actions.

And then also, like I had mentioned earlier, studies have shown that these veterans, after they call the crisis line, they are at a particularly high risk within one month of calling the crisis line and it continues to be elevated at 12 months. So, if you have another individual such as a coordinator who is a social worker and has experience, a background working with veterans or patients that need additional mental health services if deemed necessary at risk for suicide. It is important that these coordinators make contact with these veterans and assess them for potential risk at that time and then ask them if they need additional services at the VA or even in the community. They can also assist with trying to coordinate care with them or sending them to the right person.

Adam Roy:
Do the coordinators stay with the veteran and for a long period of time as part of the case management? Do they stay with that veteran beyond the required attempts, beyond talking to them, beyond providing the services? Do they go back and check on those veterans six, seven, 12 months down the road?

Corina Riba:
Generally speaking, no, not in all cases. However, the part of the coordinator’s responsibility is if a veteran who receives care within the VA— it's called a high-risk flag and it's for those veterans that are at higher risk or have had an attempt, then they will follow and track these veterans, check in with them every couple of months, help them coordinate appointments and services for the care that they need. So, in some cases, yes; but, no, not in all cases.

Adam Roy:
And what ultimately did your team’s report recommend to the VA?

Corina Riba:
So we had five recommendations to address the issues that we had identified.

Number one, with the first issue that we've talked about, make sure your data is accurate so managers can make better, more informed decisions about the current processes and coordinators and managing the crisis line. Train the coordinators, make sure that they know how to use the patient outcome codes when they're closing out these referrals.

Require managers to review referral information—so tied to that oversight, making sure local managers are reviewing the referrals to verify that coordinators are following up with the veterans, such as received care in the community and assistance, and also making sure that they're making their required attempts. And then clarify expectations for coordinators so there's not that confusion of if a veteran receives care in the community, what are their next steps, what are the expectations.

And then monitor the referrals, continue to monitor their referrals, establish essentially a quality assurance system to make sure that supervisors are reviewing these referrals to identify the issues that we had discovered in the report and do it on a routine basis. So do it every periodically so you can address the issues as they come up.

Adam Roy:
And what happens next? What steps does your team take now that the report is published? Where the findings and working through those recommendations?

Corina Riba:
Generally the next steps are every month we will get a report on the actions taken by VHA to close these recommendations. The OIG staff will monitor these actions and I'll review the information that VHA provides to make sure that they're adequately addressing these recommendations. Generally, VHA is trying to close these recommendations within a year.

Adam Roy:
Excellent. Alright. Is there anything else you want to add today, Corina, before we log off? Anything else that you about the report or about the type of oversight work that this report covered?

Corina Riba:
No, thank you for taking the time to meet with me on such a sensitive topic. And I really believe that the work that my team did, and the issues identified are important for helping the VHA continue to grow in terms of suicide prevention and ensuring that these higher risk veterans are taken care of and get the care that they need.

Adam Roy:
I couldn’t agree more. Corina, thank you so much for joining me today. Your team does very important work on behalf of the VA OIG, and it’s reflected in the report that we just talked about.

Listeners, if you want to go out and read the report Suicide Prevention Coordinators Need Improved Training, Guidance, and Oversight, go to our website and search for the reports underneath the reports tab.

Well, that’s it for this episode of Inside Oversight. I encourage you to check out other episodes wherever you listen to podcasts. Thanks for tuning in.

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