Photo of Bradley Karlin courtesy of U.S. Dept. of Veterans Affairs; photographer: Robert Turtil
Serving an aging population and an influx of new veterans from recent conflicts, the U.S. Department of Veterans Affairs (VA) has received much public scrutiny lately. The VA's behavioral healthcare services especially have been in the glare of the media's spotlight, and some of the coverage has questioned the VA's quality of care and practices. Advocates, investigative reporters, and members of Congress have raised serious and important questions regarding the VA's mental health services, and surely this large and complex system has much work ahead as more veterans acknowledge and present with these problems. Yet what seemingly hasn't received as much attention is the VA's system-wide transformation of its mental health and substance use treatment services, prompted and guided by the recommendations issued by the President's New Freedom Commission on Mental Health in 2003.
“VA saw this event as an opportunity, a real focusing event, and really took quick action,” says Bradley E. Karlin, PhD, who directs the VA's psychotherapy programs. Dr. Karlin agreed to speak to Behavioral Healthcare specifically about the VA's transformation of its behavioral healthcare services, which cared for 1.5 million veterans with a mental health diagnosis in FY 07.
After reviewing the New Freedom Commission's report, a VA workgroup developed a mental health strategic plan in 2005 to meet the commission members' call for fundamental changes in mental health and substance use services across the nation. One main area the VA has focused on is the integration of primary and behavioral healthcare—treating both with “equal urgency,” says Dr. Karlin. While many care systems talk about service integration, the “VA has developed a national initiative to integrate mental health services into the primary care setting to break down silos that have traditionally separated the primary care sector from mental health,” he notes.
The VA has adopted two evidence-based approaches to integrate care. Some VA sites employ care managers (usually nurses or social workers) who support primary care physicians with implementing guideline-concordant mental health treatment plans, often focused on pharmacotherapy. The care managers also follow up with patients. Other VA facilities use a co-location/collaborative care model, in which mental health providers work alongside primary care physicians on treatment planning, implementation, and monitoring. Recognizing each approach's benefits, the VA is “blending” the two integration models at all of its sites.
“Our vision is that we would be able to treat a significant map of mental health and substance use problems in primary care,” Dr. Karlin explains. “By integrating care and services for these problems, we will then free up our mental health specialty settings to serve those veterans with more serious or severe mental health problems.”
This plan includes adding mental healthcare providers to primary care teams that visit veterans in their own homes, a concept in which “a lot of other public service settings have expressed significant interest,” notes Dr. Karlin. Across the country, the VA has included clinicians (usually psychologists) on the teams to administer psychological testing, psychotherapy, and capacity assessments for decision-making and independent-living abilities. The VA also has placed 23 mental health providers in its “community living centers” (its new term for nursing homes) to deliver psychosocial services for managing behavioral symptoms associated with dementia and other neuropsychiatric conditions.
As the VA integrates behavioral healthcare services with primary care, it is moving away from an emphasis on “stabilization and maintenance” to recovery and psychosocial rehabilitation, another goal in line with the New Freedom Commission's recommendations. The VA has assigned recovery coordinators to medical centers to “work as champions to promote recovery-oriented care,” explains Dr. Karlin. In addition, the VA has hired 120 peer support technicians during the past three years to share their recovery experiences with veterans, and it is looking into developing standards for peer employee certification.
Complementing this focus on recovery is the VA's emphasis on evidence-based treatments, one of Dr. Karlin's main responsibilities. The VA has trained more than 1,100 clinicians to administer cognitive-processing therapy or prolonged exposure therapy to veterans with post-traumatic stress disorder. Instead of sitting through CE lectures, VA clinicians are trained in two- to four-day intensive workshops using didactic materials and experiential components (e.g., role playing). Clinicians also have ongoing consultation with experts.
To reach more veterans with this transformed array of services, the VA has hired 3,900 mental health providers during the past three years, enlarging its mental health workforce (including psychologists, psychiatrists, nurses, and social workers) to more than 13,000. Reaching veterans in rural areas remains particularly challenging, so the VA has enhanced its capacity for telemental healthcare.
“We really believe in telemental health, and there is increasing evidence for the use of telemental health, including for both psychopharmacological treatment and for psychotherapy,” says Dr. Karlin. “I'm really trying to connect telemental health with our significant efforts to disseminate and promote the delivery of evidence-based psychotherapies and medication treatments. We have a real opportunity to not only provide care, but provide high-quality care to folks using this still relatively new modality.”
Some mental health centers and community health agencies not affiliated with the VA host telemental health equipment to provide veterans in rural areas with a link to VA providers. The number of unique VA patients receiving telemental health services from October 2007 through May 2008 is 22,578.
In addition to a focus on “virtual” services, the VA is improving its “brick and mortar” facilities.
“The environment sends significant messages to patients and families…about treatment expectations and how much the patient is valued,” explains Dr. Karlin, who cites facility design as one of his main research areas. “When a patient is in a pleasant environment and feels valued, there is a psychological impact. So VA is working to make inpatient psychiatric units warm, welcoming, and safe environments.”
Dr. Karlin has consulted on a number of new construction and renovation projects, including the facility in Palo Alto, California, and the VA is developing a mental health facility design guide.
The VA has many other initiatives to transform its services and better meet veterans' behavioral health needs, such as specific outreach programs for those returning from Iraq and Afghanistan. A suicide-prevention hotline (800-273-TALK; press 1 for veterans) launched last year is staffed 24/7 by VA mental health professionals who have access to patients' electronic medical records; the service is credited for 885 “rescues” so far.
So why does the public and media often focus on some of the VA's missteps, ignoring the bigger picture? Dr. Karlin believes that “everybody wants to make sure that we are meeting the mental health and healthcare needs of our veterans as much as possible. Everybody wants to make sure that we are serving our nation's heroes, responding to their needs quickly with the most effective treatments and services available…. Everybody wants to do the right thing for veterans. I hope that our efforts to transform mental healthcare will increasingly allow us to do that.”
Discuss this article in Behavioral Healthcare's discussion board. Behavioral Healthcare 2008;28(7):14-17.