VA Health Care
VA Should Expedite the Implementation of Recommendations Needed to Improve Post-Traumatic Stress Disorder Services Gao ID: GAO-05-287 February 14, 2005Post-traumatic stress disorder (PTSD), which is caused by an extremely stressful event, can develop after military combat and exposure to the threat of death or serious injury. Mental health experts estimate that the intensity of warfare in Iraq and Afghanistan could cause more than 15 percent of servicemembers returning from these conflicts to develop PTSD. Symptoms of PTSD can be debilitating and include insomnia; intense anxiety; and difficulty coping with work, social, and family relationships. Left untreated, PTSD can lead to substance abuse, severe depression, and suicide. Symptoms may appear within months of the traumatic event or be delayed for years. While there is no cure for PTSD, experts believe early identification and treatment of PTSD symptoms may lessen their severity and improve the overall quality of life for individuals with this disorder. The Department of Veterans Affairs (VA) is a world leader in PTSD treatment and offers PTSD services to eligible veterans. To inform new veterans about the health care services it offers, VA has increased outreach efforts to servicemembers returning from the Iraq and Afghanistan conflicts. Outreach efforts, coupled with expanded access to VA health care for these new veterans, are likely to result in greater numbers of veterans with PTSD seeking VA services. Congress highlighted the importance of VA PTSD services more than 20 years ago when it required the establishment of the Special Committee on Post-Traumatic Stress Disorder (Special Committee) within VA, primarily to aid Vietnam-era veterans diagnosed with PTSD. A key charge of the Special Committee is to make recommendations for improving VA's PTSD services. The Special Committee issued its first report on ways to improve VA's PTSD services in 1985 and its latest report, which includes 37 recommendations for VA, in 2004. The Special Committee reports also include evaluations of whether VA has met or not met the recommendations made by the Special Committee in prior reports. The Department of Veterans Affairs (VA) is a world leader in PTSD treatment and offers PTSD services to eligible veterans. To inform new veterans about the health care services it offers, VA has increased outreach efforts to servicemembers returning from the Iraq and Afghanistan conflicts. Outreach efforts, coupled with expanded access to VA health care for these new veterans, are likely to result in greater numbers of veterans with PTSD seeking VA services. Congress asked us to determine whether VA has addressed the Special Committee's recommendations to improve VA's PTSD services. We focused our review on 24 recommendations related to clinical care and education made by VA's Special Committee on PTSD in its 2004 report to determine (1) the extent to which VA has met each recommendation related to clinical care and education and (2) VA's time frame for implementing each of these recommendations.
GAO determined that VA has not fully met any of 24 Special Committee recommendations in our review related to clinical care and education. Specifically, we determined that VA has not met 10 recommendations and has partially met 14 of these 24 recommendations. For example, the Special Committee recommended that VA develop, disseminate, and implement a best practice treatment guideline for PTSD. The Special Committee designated the recommendation as met because VA had developed and disseminated the guideline. However, because we found that VA does not have documentation to show that the treatment part of the guideline is being implemented at its medical facilities and community-based clinics, we designated the recommendation as partially met. We also determined that VA does not plan to fully implement 23 of 24 recommendations until fiscal year 2007 or later. Ten of these are long-standing recommendations that were first made in the Special Committee report issued in 1985. VA's delay in fully implementing the recommendations raises questions about VA's capacity to identify and treat veterans returning from military combat who may be at risk for developing PTSD, while maintaining PTSD services for veterans currently receiving them. This is particularly important because we reported in September 2004 that officials at six of seven VA medical facilities stated that they may not be able to meet an increase in demand for PTSD services. In addition, the Special Committee reported in its 2004 report that VA does not have sufficient capacity to meet the needs of new combat veterans while still providing for veterans of past wars. If servicemembers returning from military combat do not have access to PTSD services, many mental health experts believe that the chance may be missed, through early identification and treatment of PTSD, to lessen the severity of the symptoms and improve the overall quality of life for these combat veterans with PTSD. Moreover, VA has identified geographic areas of the country where large numbers of servicemembers are returning from the current conflicts in Iraq and Afghanistan. VA could consider focusing first on ensuring service availability at facilities in areas that are likely to experience the most demand for PTSD services.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-05-287, VA Health Care: VA Should Expedite the Implementation of Recommendations Needed to Improve Post-Traumatic Stress Disorder Services
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Report to the Ranking Democratic Member, Committee on Veterans'
Affairs, House of Representatives:
United States Government Accountability Office:
GAO:
February 2005:
VA Health Care:
VA Should Expedite the Implementation of Recommendations Needed to
Improve Post-Traumatic Stress Disorder Services:
GAO-05-287:
Contents:
Letter:
Summary:
Recommendation for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Briefing Slides:
Appendix II: The 24 Special Committee Recommendations in Our Review:
Appendix III: Scope and Methodology:
Appendix IV: GAO's Analysis of the Implementation Status of 24 Special
Committee Recommendations:
Appendix V: Comments from the Department of Veterans Affairs:
Appendix VI: GAO Contact and Staff Acknowledgments:
GAO Contact:
Acknowledgments:
Tables:
Table 1: The Special Committee's Clinical Care and Education
Recommendations in Our Review:
Table 2: Fourteen Recommendations that GAO Determined Were Partially
Met by VA:
Table 3: Ten Recommendations that GAO Determined Were Not Met by VA:
Abbreviations:
DOD: Department of Defense:
OEF: Operation Enduring Freedom:
OIF: Operation Iraqi Freedom:
PTSD: post-traumatic stress disorder:
VA: Department of Veterans Affairs:
United States Government Accountability Office:
Washington, DC 20548:
February 14, 2005:
The Honorable Lane Evans:
Ranking Democratic Member:
Committee on Veterans' Affairs:
House of Representatives:
Dear Mr. Evans:
Post-traumatic stress disorder (PTSD), which is caused by an extremely
stressful event, can develop after military combat and exposure to the
threat of death or serious injury. Mental health experts estimate that
the intensity of warfare in Iraq and Afghanistan could cause more than
15 percent of servicemembers returning from these conflicts to develop
PTSD.[Footnote 1],[Footnote 2] Symptoms of PTSD can be debilitating and
include insomnia; intense anxiety; and difficulty coping with work,
social, and family relationships. Left untreated, PTSD can lead to
substance abuse, severe depression, and suicide. Symptoms may appear
within months of the traumatic event or be delayed for years. While
there is no cure for PTSD, experts believe early identification and
treatment of PTSD symptoms may lessen their severity and improve the
overall quality of life for individuals with this disorder.
The Department of Veterans Affairs (VA) is a world leader in PTSD
treatment and offers PTSD services to eligible veterans. To inform new
veterans about the health care services it offers, VA has increased
outreach efforts to servicemembers returning from the Iraq and
Afghanistan conflicts. Outreach efforts, coupled with expanded access
to VA health care for these new veterans, are likely to result in
greater numbers of veterans with PTSD seeking VA services.
Congress highlighted the importance of VA PTSD services more than 20
years ago when it required the establishment of the Special Committee
on Post-Traumatic Stress Disorder (Special Committee) within VA,
primarily to aid Vietnam-era veterans diagnosed with PTSD.[Footnote 3]
A key charge of the Special Committee is to make recommendations for
improving VA's PTSD services. The Special Committee issued its first
report on ways to improve VA's PTSD services in 1985 and its latest
report, which includes 37 recommendations for VA, in 2004.[Footnote 4]
The Special Committee reports also include evaluations of whether VA
has met or not met the recommendations made by the Special Committee in
prior reports. We did not conduct an analysis to determine the merits
of each recommendation since VA generally concurred in concept with the
recommendations made by the Special Committee. In some cases, VA
provided further information that it believed would meet the intent of
the Special Committee's recommendations.
You asked us to determine whether VA has addressed the Special
Committee's recommendations to improve VA's PTSD services. We focused
our review on 24 recommendations related to clinical care and
education[Footnote 5] made by VA's Special Committee on PTSD in its
2004 report to determine (1) the extent to which VA has met each
recommendation related to clinical care and education and (2) VA's time
frame for implementing each of these recommendations.
To determine the extent to which VA has met each recommendation related
to clinical care and education, we (1) reviewed and analyzed the
criteria used by the Special Committee to determine whether a
recommendation was met and obtained information from members of the
Special Committee on the information and process the Special Committee
used to designate a recommendation as met, (2) interviewed VA officials
responsible for implementing the Special Committee's recommendations to
determine the status of each recommendation, and (3) analyzed VA's
written responses to each of the recommendations in the Special
Committee's 2004 report. We made our determination of the extent to
which VA has met each recommendation based on documented evidence that
VA has implemented all (fully met) or some (partially met) components
of a recommendation, or has not implemented any (not met) components of
a recommendation. To determine VA's time frames for implementing each
Special Committee recommendation, we (1) determined when the Special
Committee initially made the recommendation by reviewing Special
Committee reports from 1985 to 2004 and (2) reviewed VA's planning
documents, including VA's draft mental health strategic plan. We
conducted our review from September 2004 through February 2005 in
accordance with generally accepted government auditing standards. On
February 1, 2005, we briefed your staff on the results of our work.
This letter formally conveys our findings, conclusions, and
recommendation provided during the briefing. Appendix I contains the
briefing slides, appendix II lists the Special Committee
recommendations included in our review, and appendix III contains a
more detailed discussion of our scope and methodology.
Summary:
In summary, we determined that VA has not fully met any of 24 Special
Committee recommendations in our review related to clinical care and
education. Specifically, we determined that VA has not met 10
recommendations and has partially met 14 of these 24 recommendations.
For example, the Special Committee recommended that VA develop,
disseminate, and implement a best practice treatment guideline for
PTSD. The Special Committee designated the recommendation as met
because VA had developed and disseminated the guideline. However,
because we found that VA does not have documentation to show that the
treatment part of the guideline is being implemented at its medical
facilities and community-based clinics, we designated the
recommendation as partially met. We also determined that VA does not
plan to fully implement 23 of 24 recommendations until fiscal year 2007
or later. Ten of these are long-standing recommendations that were
first made in the Special Committee report issued in 1985.
VA's delay in fully implementing the recommendations raises questions
about VA's capacity to identify and treat veterans returning from
military combat who may be at risk for developing PTSD, while
maintaining PTSD services for veterans currently receiving them. This
is particularly important because we reported in September 2004 that
officials at six of seven VA medical facilities stated that they may
not be able to meet an increase in demand for PTSD services. In
addition, the Special Committee reported in its 2004 report that VA
does not have sufficient capacity to meet the needs of new combat
veterans while still providing for veterans of past wars. If
servicemembers returning from military combat do not have access to
PTSD services, many mental health experts believe that the chance may
be missed, through early identification and treatment of PTSD, to
lessen the severity of the symptoms and improve the overall quality of
life for these combat veterans with PTSD. Moreover, VA has identified
geographic areas of the country where large numbers of servicemembers
are returning from the current conflicts in Iraq and Afghanistan. VA
could consider focusing first on ensuring service availability at
facilities in areas that are likely to experience the most demand for
PTSD services.
Recommendation for Executive Action:
To help ensure that VA has the capacity to diagnose and treat veterans
returning from the Iraq and Afghanistan conflicts, as well as to
maintain these services for other veterans, we recommend that the
Secretary of Veterans Affairs direct the Under Secretary for Health to
prioritize those recommendations needed to improve PTSD services and to
expedite VA's time frames for fully implementing those recommendations.
Agency Comments and Our Evaluation:
In commenting on a draft of this report, VA disagreed with our
assessment of its progress in implementing the recommendations made by
its Special Committee and disagreed with our recommendation. VA stated
that our report does not accurately portray the actual provision of
PTSD services to veterans by VA over the past 20 years or VA's ability
to provide future PTSD services to veterans. VA's comments are
reprinted in appendix V. VA also provided technical comments, which we
incorporated as appropriate.
VA stated that this report will leave the average reader with the
impression that VA's services to veterans with PTSD are woefully
inadequate. The adequacy of services was not within the scope of our
review. Instead, our analysis addresses the status of VA's
implementation of the Special Committee's 24 recommendations and VA's
planned time frames for fully implementing them.
VA also said that our report misrepresents VA's ability to provide care
to returning Operation Enduring Freedom (OEF) and Operation Iraqi
Freedom (OIF) veterans. VA cited as evidence its provision of PTSD
services to 6,400 OEF and OIF veterans to date, and added that VA has
sufficient capacity because this is a small percentage of the more than
244,000 veterans treated for PTSD in its health care system. We
disagree with VA's conclusion. First, we do not know if the 6,400
veterans treated by VA represent all OEF and OIF veterans seeking VA
PTSD services. In fact, there could be unmet need because VA's data for
the fourth quarter of fiscal year 2004 show that less than half of
veterans accessing VA health care are screened for PTSD. Second,
although 6,400 veterans is a relatively small percentage of 244,000, VA
has not presented evidence of its capacity to absorb increasing numbers
of veterans needing treatment for PTSD in the future. Given that we
reported in September 2004 that officials at six of seven medical
centers told us that they may not be able to meet an increase in demand
for PTSD services and that the VA Inspector General found that VA's
PTSD capacity data are error-prone and inadequately supported, we
believe our report appropriately raises questions about VA's capacity
to meet veterans' needs for PTSD services. Moreover, the Special
Committee in its 2004 report concluded that "VA must meet the needs of
new combat veterans while still providing for veterans of past wars.
Unfortunately, VA does not have sufficient capacity to do this. VA PTSD
services had been steadily losing capacity even before OEF/OIF
began.[Footnote 6]":
VA commented that the co-chairs of the Special Committee reviewed VA's
draft mental health strategic plan and concurred that the Special
Committee's recommendations are fully addressed in the plan and that
the implementation time frames are appropriate. We did not assess
whether the Special Committee's recommendations are fully addressed in
VA's draft mental health strategic plan. Instead, we relied on VA's
comparison of the Special Committee's recommendations and its draft
mental health strategic plan to determine the time frames VA targeted
for implementation of a recommendation. Moreover, we did not determine
whether the time frames targeted in the draft mental health strategic
plan for full implementation of the recommendations are appropriate. We
found, however, that none of the 24 recommendations included in the
Special Committee's 2004 report is fully met--14 recommendations are
partially met and 10 recommendations are not met--even though they
range from 4 to 20 years old. This continues to concern us in light of
the potential increase in demand for PTSD services predicted by mental
health experts.
VA also stated that our report significantly discounts the progress
made on each of the Special Committee recommendations and ignores
relevant information provided by VA experts. During our exit briefing
with VA officials and mental health experts, a co-chair of the Special
Committee stated that our findings were a fair representation of the
status of the 24 recommendations. Subsequently, VA submitted two
letters signed by the Special Committee co-chairs who wrote that our
report fails to address the many efforts undertaken by VA and the
members of the Special Committee to improve the care delivered to
veterans with PTSD. However, some of the efforts cited in the Special
Committee co-chairs' letters are included in our analysis of those
recommendations that are partially implemented. Other efforts cited by
VA and the Special Committee co-chairs address recommendations not
within the scope of our review. The two letters signed by the Special
Committee co-chairs are reproduced in appendix V.
VA requested that we include, as part of its comments, the Secretary's
2004 Special Committee report transmittal letter to the Ranking
Democratic Member, House Committee on Veterans' Affairs, the executive
summary, and excerpts from the Special Committee's 2004 report,
including the Special Committee's table designating the status of all
37 of its recommendations and the Under Secretary for Health's
responses to 7 priority actions. One action is a recommendation
included in our review, which the Special Committee highlighted in its
2004 report. However, VA did not include as part of the excerpts its
responses to the recommendations we reviewed that the Special Committee
designated as not met. We did not reprint this material from VA because
we believe our report better captures the status of VA's implementation
of the Special Committee's recommendations. To obtain a copy of the
Special Committee's 2004 report, contact VA's Office of Public Affairs
at (202) 273-6000.
As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 15 days
after its date. We will then send copies of this report to the
Secretary of Veterans Affairs and other interested parties. We will
also make copies available to others upon request. In addition, this
report will be available at no charge on the GAO Web site at http://
www.gao.gov.
If you or your staff have any questions about this report, please call
me at (202) 512-7101. Another contact and key contributors are listed
in appendix VI.
Sincerely yours,
Signed by:
Cynthia A. Bascetta:
Director, Health Care--Veterans' Health and Benefits Issues:
[End of section]
Appendix I: Briefing Slides:
VA HEALTH CARE: VA Should Expedite the Implementation of
Recommendations Needed to Improve Post-Traumatic Stress Disorder
Services:
Briefing for the Staff of Representative Lane Evans:
Ranking Democratic Member:
House Committee on Veterans' Affairs:
February l, 2005:
VA HEALTH CARE: VA Should Expedite the Implementation of
Recommendations Needed to Improve Post-Traumatic Stress Disorder
Services:
* Briefing contents:
* Introduction
* Objectives:
* Scope and methodology
* Results in brief:
* Background
* GAO findings
* Conclusions:
* Recommendation:
Introduction:
* Post-traumatic stress disorder (PTSD), which is caused by an
extremely stressful event, can develop after military combat and
exposure to the threat of death or serious injury. Mental health
experts estimate that the intensity of warfare in Iraq and Afghanistan
could cause more than 15 percent of servicemembers returning from these
conflicts to develop PTSD. [NOTES 1,2]
* Symptoms of PTSD can be debilitating and include insomnia; intense
anxiety; and difficulty coping with work, social, and family
relationships. Left untreated, PTSD can lead to substance abuse, severe
depression, and suicide. Symptoms may appear within months of the
traumatic event or be delayed for years.
* While there is no cure for PTSD, mental health experts believe early
identification and treatment of PTSD symptoms may lessen their severity
and improve the overall quality of life for individuals with this
disorder.
* The Department of Veterans Affairs (VA) is a world leader in PTSD
treatment and offers PTSD services to eligible veterans. To inform new
veterans about the health care services it offers, VA has increased
outreach efforts to servicemembers, including members of the National
Guard and Reserves, [NOTE 3] returning from the Iraq and Afghanistan
conflicts. Outreach efforts, coupled with expanded access to VA health
care for these new veterans, are likely to result in a greater number
of veterans with PTSD seeking VA services.
* In September 2004, we reported that VA does not have a reliable
estimate of the total number of veterans it currently treats for PTSD
and lacks the information it needs to determine whether it can meet an
increased demand for PTSD services. [NOTE 4]
* We concluded that VA could use demographic data from the Department
of Defense (DOD) to estimate which VA medical facilities might
experience an increase in demand for PTSD services. We also concluded
that in light of experts' predictions on the percentage of returning
servicemembers likely to develop PTSD, VA would be able to broadly
project the number of returning servicemembers needing VA PTSD
services. VA concurred with our conclusions.
* Congress highlighted the importance of PTSD services more than 20
years ago when it required the establishment of the Special Committee
on PTSD (Special Committee) within VA, primarily to aid Vietnam-era
veterans diagnosed with PTSD. [NOTE 5] A key charge of the Special
Committee is to carry out an ongoing assessment of VA's capacity to
diagnose and treat PTSD and to make recommendations for improving VA's
PTSD services. The Special Committee first issued a report on ways to
improve PTSD services in 1985. The Special Committee's 2004 report
includes 37 recommendations to improve VA's PTSD services in the areas
of clinical care, education, research, and benefits. [NOTE 6]
* In 2004, you asked us to determine whether VA has addressed the
Special Committee's recommendations to improve its PTSD services.
Objectives:
* We focused our review on 24 recommendations related to clinical care
and education [NOTE 7] made by VA's Special Committee on PTSD in its
2004 report to determine:
1) the extent to which VA has met each recommendation related to
clinical care and education and:
2) VA's time frame for implementing each of these recommendations.
Scope and Methodology:
* To determine the extent to which VA met each of the Special
Committee's recommendations in the areas of clinical care and
education, we:
- reviewed and assessed the information and process used by the Special
Committee to determine whether a recommendation was met and obtained
information from members of the Special Committee on the process it
used to designate a recommendation as met,
- interviewed VA officials responsible for implementing the Special
Committee's recommendations to determine the status of each
recommendation, and:
- analyzed VA's written responses to recommendations in the Special
Committee's 2004 report.
* Unlike the Special Committee, which used two categories-met or not
met-to designate the implementation status of each recommendation, we
made our determinations based on the following three categories:
- Fully met-VA has documented evidence that it has fully implemented
all components of a recommendation.
- Partially met-VA has documented evidence that it has implemented some
but not all components of a recommendation.
- Not met-VA has not implemented any components of a recommendation.
* We did not conduct an analysis to determine the merits of each
recommendation since VA generally concurred in concept with the
recommendations made by the Special Committee. In some cases, VA
provided further information that it believed would meet the intent of
the Special Committee's recommendations.
* To determine VA's time frame for implementing each Special Committee
recommendation, we:
- determined when the Special Committee initially made each of 24
recommendations in the 2004 Special Committee report by reviewing
Special Committee reports from 1985 to 2004 and:
- reviewed VA's planning documents, including VA's draft mental health
strategic plan, which addresses PTSD services.
* Our work was conducted from September 2004 through February 2005 in
accordance with generally accepted government auditing standards. See
appendix III for a more detailed discussion of our scope and
methodology.
Results in Brief:
* We determined that VA has not fully met any of the Special
Committee's 24 recommendations related to clinical care and education
in our review, but has partially met 14 of the 24 recommendations.
* Additionally, our analysis shows that VA may not fully implement 23
of 24 recommendations until fiscal year 2007 or later.
- Ten of the 24 recommendations are long-standing and were first made
in the Special Committee's 1985 report. Based on VA's targeted time
frames in its draft mental health strategic plan, which includes PTSD
services, it may take VA until fiscal year 2007 or later to implement
recommendations that it agreed 20 years ago were needed to improve the
provision of PTSD services to veterans.
* VA officials have cited resource constraints as the primary reason
for not implementing many of the recommendations.
Background:
* Congress required the establishment of VA's Special Committee on PTSD
in 1984.
* The Special Committee consists of VA PTSD experts and is charged
with:
- assessing VA's capacity to diagnose and treat veterans with PTSD;
- advising VA on the development of policies and providing guidance and
coordination of services related to the diagnosis and treatment of
PTSD; and:
- providing guidance on VA's education, employee training, and research
regarding PTSD.
* Since 1985, the Special Committee has issued 15 reports containing
numerous recommendations to improve VA's PTSD services. [NOTE 8]
* Although VA is not statutorily required to implement the Special
Committee's recommendations, VA is required to review the
recommendations and forward VA's written comments on the
recommendations, if any, to the House and Senate Committees on
Veterans' Affairs.
- VA has generally concurred in concept with the recommendations made
by the Special Committee. In some cases, VA provided further
information that it believed would meet the intent of the Special
Committee's recommendations.
* In July 2004, VA drafted a mental health strategic plan that,
according to VA, includes PTSD services and will serve as a guide to
the future course of VA mental health services. [NOTE 9] The plan,
though reviewed by VA's Secretary, has not been officially approved
pending review by the Office of Management and Budget.
VA Has Not Fully Met Any of the 24 Special Committee Recommendations:
* We determined that VA has not fully met any of the Special
Committee's 24 recommendations related to clinical care and education.
[NOTE 10]
- Specifically, we found that VA has partially met 14 recommendations
and not met 10 recommendations.
* We determined 10 of 24 recommendations were not met because VA has
not fully implemented any components of the recommendations.
- The Special Committee designated 12 recommendations as not met.
* We determined 14 recommendations were partially met because VA has
implemented at least some component of each recommendation.
- The Special Committee did not categorize any recommendations as
partially met, but instead designated recommendations as met if VA had
taken any action to implement them.
- For example, the Special Committee recommended that VA develop,
disseminate, and implement a treatment guideline for PTSD. We
determined the recommendation was partially met because VA does not
have documentation that shows the treatment part of the guideline is
being implemented. The Special Committee designated the recommendation
as met because VA had completed two components of the recommendation-
development and dissemination of the guideline.
* We determined that VA has partially met 14 of the 24 Special
Committee recommendations related to PTSD clinical care and education.
Recommendation: Develop and implement procedures to prevent closure of
PTSD programs without authorization from VA headquarters;
Recommendation: Reinvest resources from closed PTSD programs into other
PTSD programs;
GAO analysis of VA‘s actions not completed: We determined these
recommendations were partially met because VA headquarters has not
received any closure requests, yet VA data shows that in at least two
instances, VA facilities did not follow procedures and closed PTSD
programs without authorization in fiscal year 2003. Moreover, VA does
not know whether these facilities have reinvested resources from the
closed PTSD programs into other PTSD programs.
Recommendation: Improve VA collaboration with DOD on PTSD education;
GAO analysis of VA‘s actions not completed: We determined this
recommendation was partially met because although VA and DOD
collaborated to develop educational materials, such as the PTSD
clinical practice guideline, VA and DOD are still formalizing their
future plans for PTSD education.
Recommendation: Implement a network director performance measure on
PTSD capacity;
GAO analysis of VA‘s actions not completed: We determined this
recommendation was partially met because VA cites its annual report on
capacity to provide PTSD services as support for meeting this
recommendation. However, the annual report on capacity does not address
the care delivered to all veterans treated by VA for PTSD. In addition,
the VA Inspector General found that data supporting the number of VA
specialized PTSD programs are incorrect.
Recommendation: Coordinate PTSD care with VA community-based clinics;
GAO analysis of VA‘s actions not completed: We determined this
recommendation was partially met because a VA official acknowledged
that they need to develop referral mechanisms to provide PTSD services
when these services are not available at VA community-based clinics. In
addition, although VA developed and disseminated a clinical practice
guideline for PTSD, VA does not have documentation to show the extent
of treatment provided in accordance with the guideline at VA medical
facilities and community-based clinics.
Recommendation: Provide increased access to PTSD services;
GAO analysis of VA‘s actions not completed: We determined this
recommendation was partially met because although VA has increased the
number of veterans it treats for PTSD, it has not developed referral
mechanisms in all community-based clinics that do not offer mental
health services.
Recommendation: Develop and implement an integrated clinical approach
for assisting aging veterans with PTSD;
GAO analysis of VA‘s actions not completed: We determined this
recommendation was partially met because VA‘s study conducted to
determine the access that aging veterans have to primary care,
including veterans with PTSD, was the first step toward developing an
integrated approach for assisting aging veterans with PTSD. However, VA
has not implemented this integrated approach.
Recommendation: Recognize specialized PTSD programs as an important
component of care;
GAO analysis of VA‘s actions not completed: We determined this
recommendation was partially met because VA is collecting data on the
results of its efforts to annually screen all veterans to identify
those at risk for PTSD. However, VA‘s Office of Quality and Performance
told us that VA uses the data on PTSD screening as a supporting
indicator, an interim step in the development of a performance measure.
Research shows that quality is highest in areas where VA has
established performance measures and actively monitors performance. VA
cites its annual report on capacity to provide PTSD services as support
for meeting this recommendation. However, the annual report on capacity
does not address the care delivered to all veterans treated by VA for
PTSD. VA has recently demonstrated the importance of PTSD programs
through, for example, adding 50 positions at Vet Centers to be filled
by veterans from the current conflicts to perform outreach and
requiring community-based clinics treating more than 1,500 veterans to
provide mental health services.
Recommendation: Develop more effective treatment approaches for
veterans with PTSD and coexisting substance abuse;
Recommendation: Develop and implement a rehabilitation approach to PTSD
and coexisting conditions;
Recommendation: Develop guidelines for aging veterans, various cultural
groups, and other special populations;
GAO analysis of VA‘s actions not completed: We determined these
recommendations were partially met because the existing clinical
practice guideline addresses two of these issues”PTSD and coexisting
substance abuse and the rehabilitation approach (recovery model)”to
some extent. Treatment approaches are now being developed and evaluated
for veterans with PTSD and coexisting substance abuse and VA needs to
continue its efforts to implement the recovery model through training
of staff on this approach to PTSD treatment. The clinical practice
guideline mentions a few special needs of the aging veteran and
veterans in various cultural groups and special populations, such as
women and the homeless. In addition, other educational materials are
available for clinicians on a VA Web site.
Recommendation: Develop, disseminate, and implement a best practice
treatment guideline for PTSD;
Recommendation: Establish a PTSD screening and referral mechanism in
every VA community-based clinic;
Recommendation: Develop and implement a national standardized set of
tools for assessment of PTSD;
GAO analysis of VA‘s actions not completed: We determined these
recommendations were partially met because although VA developed and
disseminated a clinical practice guideline for PTSD, it does not have
documentation to show that the clinical practice guideline,
specifically the treatment part of the guideline, is being implemented
at VA medical facilities and community-based clinics. Additionally, VA
does not have documentation to show that its community-based clinics
have developed referral mechanisms for veterans who need PTSD services
when those services are not available. However, VA has started
collecting data to monitor use of one of the assessment tools for PTSD
in the clinical practice guideline”a four-question screening tool. VA‘s
fourth quarter data for fiscal year 2004 indicate that 47 percent of
veterans were screened for PTSD using this tool. However, this
calculation includes those already diagnosed with PTSD.
Source: GAO.
[End of table]
* We determined that VA has not met 10 of the 24 Special Committee
recommendations related to PTSD clinical care and education.
1. Provide sustained treatment settings for PTSD and coexisting
psychiatric and medical conditions.
2. Extend efforts to monitor productivity and quality of specialized
services across the PTSD continuum of care.
3. Utilize Vet Center appointments to satisfy VA performance standards
for PTSD follow-up care.
4. Expand PTSD treatment to include family assessment and treatment
services.
5. Designate a PTSD coordinator in each VA network." [NOTE 11]
6. Improve VA medical facility and Vet Center collaboration.
7. Develop a national PTSD education plan for VA.
8. Develop credentialing standards for VA clinicians specializing in
PTSD.
9. Establish electronic clinical records that follow veterans across
VA's system of care.
10. Improve the continuum of care for PTSD.
* The Special Committee designated 12 recommendations as not met. [NOTE
12]
* VA officials have cited resource constraints as the primary reason
for not implementing many of the recommendations.
VA Does Not Plan to Fully Implement Many Special Committee
Recommendations until Fiscal Year 2007 or Later:
* We determined that based on the time frames in VA's draft mental
health strategic plan, 23 of the 24 recommendations may not be fully
implemented until fiscal year 2007 or later. The remaining
recommendation is targeted for full implementation by fiscal year 2005,
4 years after the Special Committee first recommended it. [NOTE 13]
VA Does Not Plan to Fully Implement Many Special Committee
Recommendations until Fiscal Year 2007 or Later:
Ten of the 24 recommendations are long-standing recommendations
consistent with recommendations first made in 1985. They are not
scheduled for full implementation until fiscal year 2007 or later, even
though VA agreed 20 years ago that these recommendations would improve
the provision of PTSD services to veterans.
1. Develop and implement a national standardized set of tools for
assessment of PTSD.
2. Establish electronic clinical records that follow veterans across
VA's system of care.
3. Improve the continuum of care for PTSD. [NOTE 14]
4. Improve VA medical facility and Vet Center collaboration.
5. Provide increased access to PTSD services.
6. Develop a national PTSD education plan for VA.
7. Extend efforts to monitor productivity and quality of specialized
services across the PTSD continuum of care.
8. Develop more effective treatment approaches for veterans with PTSD
and coexisting substance abuse.
9. Improve VA collaboration with DOD on PTSD education.
10. Develop, disseminate, and implement the best practice treatment
guideline for PTSD.
* The other 14 recommendations we reviewed appeared for the first time
in the Special Committee's 2001 report.
* VA may take up to 6 years or longer to fully implement 13 of these 14
recommendations (fiscal years 2001-2007).
* VA may take up to 4 years to fully implement 1 of these 14
recommendations (fiscal years 2001-2005).
1. Provide sustained treatment settings for PTSD and coexisting
psychiatric and medical conditions.
* The 13 recommendations VA may take up to 6 years or more to fully
implement:
1. Develop and implement procedures to prevent closure of PTSD programs
without authorization from VA headquarters.
2. Reinvest resources from closed PTSD programs into other PTSD
programs.
3. Implement a network director performance measure on PTSD capacity.
4. Coordinate PTSD care with VA community-based clinics.
5. Establish a PTSD screening and referral mechanism in every VA
community-based clinic.
6. Develop and implement an integrated clinical approach for assisting
aging veterans with PTSD.
7. Recognize specialized PTSD programs as an important component of
care.
8. Develop and implement a rehabilitation approach to PTSD and
coexisting conditions.
9. Develop guidelines for aging veterans, various cultural groups, and
other special populations.
10. Utilize Vet Center appointments to satisfy VA performance standards
for PTSD follow-up care.
11. Expand PTSD treatment to include family assessment and treatment
services.
12. Designate a PTSD coordinator in each VA network.
13. Develop credentialing standards for VA clinicians specializing in
PTSD.
Conclusions:
* VA has not fully implemented any of the 24 Special Committee
recommendations.
* VA's delay in fully implementing the recommendations raises questions
about VA's capacity to identify and treat veterans returning from the
Iraq and Afghanistan conflicts who may be at risk for developing PTSD,
while maintaining PTSD services for veterans currently receiving them.
* Moreover, VA outreach efforts, coupled with expanded access to VA
health care for many new combat veterans, could result in a greater
number of veterans with PTSD seeking VA services.
* It is critical that VA's PTSD services be available when
servicemembers return from military combat, particularly since mental
health experts believe that early identification and treatment of PTSD
may lessen the severity of the symptoms and improve the overall quality
of life for individuals with PTSD.
* Moreover, VA has identified geographic areas of the country where
large numbers of servicemembers are returning from the Iraq and
Afghanistan conflicts. VA could consider focusing first on ensuring
service availability at facilities in areas that are likely to
experience the most demand for PTSD services.
Recommendation:
* To help ensure that VA has the capacity to diagnose and treat
veterans returning from the Iraq and Afghanistan conflicts, as well as
to maintain these services for other veterans, we recommend that the
Secretary of Veterans Affairs direct the Under Secretary for Health to
prioritize those recommendations needed to improve PTSD services and to
expedite VA's time frames for fully implementing those recommendations.
NOTES:
[1] Servicemembers include active duty members of the Army, Marines,
Air Force, and Navy and members of the Reserves and National Guard.
[2] Based on data under the broad definition of PTSD provided in
Charles W. Ho e MD et. al. "Combat Duty in Iraq and Afghanistan, Mental
Health Problems, and Barriers to Care," The New England Journal of
Medicine, 351 (20043-22.
[3] Veterans serving in any conflict after November 11, 1998, are
eligible for health care services for 2 years from the date of
separation from military service, even if the condition is not
determined to be attributable to military service.
[4] GAO, VA and Defense Health Care: More Information Needed to
Determine If VA Can Meet an Increase in Demand for Post-Traumatic
Stress Disorder Services, GAO-04-1069 (Washington, D.C.: Sept. 20,
2004).
[5] Veterans' Health Care Act of 1984, Pub. L. No. 98-528, § 110(b)(1),
98 Stat. 2686, 2691.
[6] All 37 recommendations in the Special Committee's 2004 report were
included in prior Special Committee reports.
[7] The Special Committee's 2004 report designated 26 of 37
recommendations as PTSD clinical care and education issues. We excluded
2 of 26 recommendations, however, because one relates to VA's role
during a national emergency and the Special Committee stated that the
other requires a legislative change in order for VA to fully implement
the recommendation. See app. II for a list of the 24 Special Committee
recommendations included in our review.
[8] The Special Committee did not issue a report in every year.
[9] According to VA, its July 2004 draft mental health strategic plan
was developed in response to recommendations in a July 2003 report by
the President's New Freedom Commission on Mental Health, Achieving the
Promise: Transforming Mental Health Care in America.
[10] See app. IV for summary information on the current implementation
status of the Special Committee's 24 recommendations included in our
review.
[ll] VA medical facilities are organized into 21 regional networks,
known as Veterans Integrated Service Networks, that were structured to
manage and allocate resources to VA medical facilities.
[12] The Special Committee designated the following two recommendations
as not met: provide increased access to PTSD services and improve VA
collaboration with DOD on PTSD education. We determined that these two
recommendations were partially met.
[13] See app. IV for VA's implementation time frames.
[14] VA targeted this recommendation for full implementation in fiscal
year 2006 or 2007.
[End of section]
Appendix II: The 24 Special Committee Recommendations in Our Review:
The Special Committee's 2004 report contains 37 recommendations related
to PTSD clinical care, education, research, and benefits. We focused
our review on 24 of the 26 recommendations that the Special Committee
designated as clinical care and education issues. We excluded 2 of the
26 recommendations because one relates to VA's role during a national
emergency and the Special Committee stated that the other requires a
legislative change in order for VA to fully implement the
recommendation. Table 1 lists the 24 recommendations in our review.
Table 1: The Special Committee's Clinical Care and Education
Recommendations in Our Review:
Recommendation short title: Recognize specialized PTSD programs as an
important component of care;
Special Committee recommendation: VA should recognize specialized PTSD
programs as a critically important component of VA expertise and
service. In addition to meeting a core need of VA (provision of mental
health services for veterans suffering from PTSD, which is the single
most prevalent mental disorder arising from combat), these programs
maintain America's readiness to deal with survivors of future wars,
disasters, and acts of terrorism and mass destruction.
Recommendation short title: Develop and implement procedures to prevent
closure of PTSD programs without authorization from VA headquarters;
Special Committee recommendation: VA headquarters needs to develop,
announce, and apply clear and prompt consequences when VA network
leaders close PTSD programs without VA headquarters authorization.
Recommendation short title: Reinvest resources from closed PTSD
programs into other PTSD programs;
Special Committee recommendation: VA should establish systemwide
administrative mechanisms to ensure that when PTSD programs are closed,
the resources freed up by the closure are reinvested in other PTSD
programs. This will ensure that VA does not reduce its capacity to
treat PTSD.
Recommendation short title: Implement a VA network director performance
measure on PTSD capacity;
Special Committee recommendation: The Committee will work with VA
headquarters officials to develop a network director's performance
measure aimed at maintaining capacity to treat PTSD within each network
and ensuring that PTSD resources, when reassigned, remain within the
PTSD continuum of care.
Recommendation short title: Develop and implement a national
standardized set of tools for assessment of PTSD;
Special Committee recommendation: VA should develop and implement a
national standardized set of tools for assessment of PTSD.
Recommendation short title: Establish a PTSD screening and referral
mechanism in every VA community-based clinic;
Special Committee recommendation: Every VA community-based clinic
should have a PTSD screening mechanism in place and should define how
veterans who screen positive for PTSD will gain access to PTSD
services.
Recommendation short title: Establish electronic clinical records that
follow veterans across VA's system of care;
Special Committee recommendation: The clinical database derived from
the standardized assessment tools and the medical record of the veteran
with PTSD must follow the veteran across the VA system. The Committee
should work with VA medical record specialists and computer experts to
develop a system for sharing pertinent clinical data across the entire
PTSD continuum of care, including Vet Centers.
Recommendation short title: Improve the continuum of care for PTSD;
Special Committee recommendation: The present continuum of care
established to treat PTSD in VA needs better coordination and further
refinement, which should include early identification and intervention;
assessment, triage, and referral; acute stabilization and intervention
(including option for hospitalization in a general psychiatric unit or
a specialty PTSD unit as clinically appropriate); treatment and
rehabilitation, involving short-or longer-term care on an outpatient or
residential basis; and other outpatient care, encompassing continuing
care, monitoring, and relapse prevention for those who also have
substance use disorders.
Recommendation short title: Provide sustained treatment settings for
PTSD and coexisting psychiatric and medical conditions;
Special Committee recommendation: Because PTSD is a chronic condition
with frequent coexisting psychiatric and medical conditions, sustained
treatment settings of varying intensities are required.
Recommendation short title: Utilize Vet Center appointments to satisfy
VA performance standards for PTSD follow-up care;
Special Committee recommendation: Vet Center appointments should
satisfy VA performance standards for follow-up care.
Recommendation short title: Improve VA medical facility and Vet Center
collaboration;
Special Committee recommendation: VA medical facilities and Vet Centers
need to work together to ensure full collaboration in the service of
veterans with PTSD. The Committee recognizes the unique contributions
of VA medical facilities and Vet Centers and the critical importance of
maintaining their distinct identities. At the same time, we advocate
innovations, including (but not limited to) a common PTSD database for
each veteran with PTSD, joint access to clinical notes relevant to PTSD
treatment across the two systems, and joint assessment of local and
national needs within each system that could be addressed by sharing
clinical resources through such programs as collocation and
telemedicine.
Recommendation short title: Develop, disseminate, and implement best
practice treatment guidelines for PTSD;
Special Committee recommendation: VA should disseminate and implement
"best practice" PTSD treatment guidelines.
Recommendation short title: Develop PTSD guidelines for aging veterans,
various cultural groups, and other special populations;
Special Committee recommendation: VA should develop special guidelines
for work with aging veterans; for ethnic and cultural groups shown to
have different risks and needs with respect to PTSD; for veterans of
peacekeeping missions; for female and male survivors of sexual and
other noncombat trauma in the military; and for other populations for
whom specific needs are identified.
Recommendation short title: Develop more effective treatment approaches
for veterans with PTSD and coexisting substance abuse;
Special Committee recommendation: More effective treatment approaches
are needed for veterans with PTSD and coexisting substance abuse. These
include improved methods of identifying PTSD among substance abusers.
Recommendation short title: Develop and implement a rehabilitation
approach to PTSD and coexisting conditions;
Special Committee recommendation: In addition to aiming at decreasing
PTSD severity, treatment efforts should be directed toward decreasing
the effects of coexisting conditions, improving function, and improving
social support systems. This "rehabilitation" perspective (recovery
model) is more appropriate in dealing with a chronic and complex
disorder.
Recommendation short title: Develop and implement an integrated
clinical approach for assisting aging veterans with PTSD;
Special Committee recommendation: The medical problems of our aging
population of veterans with PTSD require an integrated approach of
primary care, geriatric, and PTSD experts.
Recommendation short title: Coordinate PTSD care with VA community-
based clinics;
Special Committee recommendation: VA needs to improve coordination of
care between specialized PTSD programs and VA clinics, including
community-based clinics. The goal is to improve health habits and to
identify and manage coexisting medical disorders. This will improve
health-related quality of life and lower unnecessary health care costs.
Recommendation short title: Provide increased access to PTSD services;
Special Committee recommendation: VA needs to increase access to PTSD
services. This can be facilitated through the continued expansion of
Vet Centers, community-based clinics (with specialized PTSD services),
and telemedicine services into underserved geographic areas.
Recommendation short title: Extend efforts to monitor productivity and
quality of specialized services across the PTSD continuum of care;
Special Committee recommendation: VA should extend its efforts to
monitor the productivity and quality of specialized PTSD services
across the PTSD continuum of care, including measures of functionality,
quality of life, and social support.
Recommendation short title: Expand PTSD treatment to include family
assessment and treatment services;
Special Committee recommendation: VA must expand the focus of PTSD
treatment to include family assessment and intervention, in order to
help veterans and their families deal with the symptoms of PTSD.
Recommendation short title: Develop a national PTSD education plan for
VA;
Special Committee recommendation: VA should create a national PTSD
education plan for VA staff with consistent access across the system.
Recommendation short title: Develop credentialing standards for VA
clinicians specializing in PTSD;
Special Committee recommendation: VA should develop multidisciplinary
credentialing standards for VA clinicians specializing in PTSD.
Recommendation short title: Improve VA collaboration with DOD on PTSD
education;
Special Committee recommendation: VA should improve educational
collaboration with DOD.
Recommendation short title: Designate a PTSD coordinator in each VA
network;
Special Committee recommendation: VA should designate a PTSD
coordinator in each VA network to ensure implementation of the PTSD
continuum of care in each network.
Source: VA Special Committee on PTSD.
[End of table]
[End of section]
Appendix III: Scope and Methodology:
VA's Special Committee on PTSD has submitted 15 reports to Congress
since 1985 with recommendations on how VA could improve the provision
of PTSD services to veterans. In its 2004 report, the Special Committee
made 37 recommendations to VA related to PTSD clinical care, education,
research, and benefits. Twenty-six of these recommendations relate to
PTSD clinical care and education. We focused our review on 24 of these
26 recommendations and excluded 2 recommendations because one relates
to VA's role during a national emergency and the Special Committee
stated that the other requires a legislative change in order for VA to
fully implement the recommendation. Our objectives were to determine
(1) the extent to which VA has met each recommendation related to
clinical care and education and (2) VA's time frame for implementing
each of these recommendations.
To determine the extent to which VA has met each recommendation related
to clinical care and education, we reviewed the Special Committee's
2004 report to determine whether the Special Committee had designated a
recommendation as having been met or not met, and interviewed members
of the Special Committee to determine the information and process they
used to make a designation. We also reviewed VA policy documents,
memorandums, and reports related to VA's provision of PTSD services,
including reports by the VA Inspector General. Furthermore, we analyzed
VA's written responses to recommendations contained in the Special
Committee's 2004 report and interviewed VA officials responsible for
implementing the recommendations and DOD officials responsible for
working on joint VA/DOD efforts recommended by the Special Committee.
Based on our review of VA documents and our discussions with VA
officials, we determined that the information we obtained was
sufficient to analyze the extent to which VA met each recommendation.
We did not conduct an analysis to determine the merits of each
recommendation since VA generally concurred in concept with the
recommendations made by the Special Committee. In some cases, VA
provided further information that it believed would meet the intent of
the Special Committee's recommendations. Unlike the Special Committee,
which used two categories--met or not met--to designate the
implementation status of each recommendation, we made our
determinations based on the following three categories:
* Fully met. We determined that a recommendation was fully met if VA
has documented evidence that it has fully implemented all components of
a recommendation.
* Partially met. We determined that a recommendation was partially met
if VA has documented evidence that it has implemented some but not all
components of a recommendation.
* Not met. We determined that a recommendation was not met if VA has
not implemented any components of a recommendation.
We decided the implementation status of each recommendation by
determining whether any of the components of the recommendation had
been fully implemented. For example, the components for one
recommendation--to improve VA medical facility and Vet Center
collaboration--include a common database for veterans with PTSD, joint
access to clinical notes across the two systems, and a joint medical
center and Vet Center assessment of local and national needs within
each system that could be addressed by sharing resources through
collocation and telemedicine. All three components of this
recommendation had to be fully implemented for us to make a
determination that the recommendation was fully met; one of the three
components had to be fully implemented for a determination of partially
met; and if none of the components were fully implemented, we
determined that the recommendation was not met.
To determine VA's time frames for implementing each of 24 Special
Committee recommendations in our review, we analyzed 15 Special
Committee reports from 1985 to 2004 to determine when a recommendation
was first made.[Footnote 7] We also reviewed VA planning documents,
including its draft mental health strategic plan, which contains VA's
planned activities and associated targeted time frames to improve
mental health services, including those for PTSD.[Footnote 8] We
obtained VA's comparison of the recommendations in the Special
Committee's 2004 report with the planned activities and their
associated time frames in VA's draft mental health strategic plan. We
used this comparison to determine the time frames that VA had targeted
to implement each recommendation. We calculated the total number of
years it may take VA to implement a recommendation as the difference
between the date the recommendation was first made and the date
targeted for full implementation in VA's draft mental health strategic
plan.
Our work was conducted from September 2004 through February 2005 in
accordance with generally accepted government auditing standards.
[End of section]
Appendix IV: GAO's Analysis of the Implementation Status of 24 Special
Committee Recommendations:
This appendix summarizes our analysis of the extent to which VA has met
each of 24 clinical care and education recommendations included in our
review. Table 2 provides information on the 14 recommendations that we
determined were partially met by VA because VA has implemented some
component of each recommendation. Table 3 provides information on the
10 recommendations we determined that VA has not met because VA has not
fully implemented any component of the recommendation.
Table 2: Fourteen Recommendations that GAO Determined Were Partially
Met by VA:
Recommendation: Develop and implement procedures to prevent closure of
PTSD programs without authorization from VA headquarters;
Year recommendation initially made by Special Committee: 2001;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2006-2007;
Recommendation: Reinvest resources from closed PTSD programs into other
PTSD programs;
Year recommendation initially made by Special Committee: 2001;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2006-2007;
GAO analysis of VA's actions not completed: We determined these
recommendations were partially met because VA headquarters has not
received any closure requests, yet VA data shows that in at least two
instances VA facilities did not follow procedures and closed PTSD
programs without authorization in fiscal year 2003. Moreover, VA does
not know whether these facilities have reinvested resources from the
closed PTSD programs into other PTSD programs. The Special Committee
designated these recommendations as met because VA issues an annual
report on its capacity to provide specialized PTSD programs for
seriously mentally ill veterans, a subset of the veterans receiving VA
PTSD services.
Recommendation: Develop and implement an integrated clinical approach
for assisting aging veterans with PTSD;
Year recommendation initially made by Special Committee: 2001;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
GAO analysis of VA's actions not completed: We determined this
recommendation was partially met because VA's study conducted to
determine the access that aging veterans have to primary care,
including veterans with PTSD, was the first step toward developing an
integrated approach for assisting aging veterans with PTSD. However, VA
has not implemented this integrated approach. The Special Committee
designated this recommendation as met because the study was completed.
Recommendation: Implement a VA network director performance measure on
PTSD capacity;
Year recommendation initially made by Special Committee: 2001;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2006-2007;
GAO analysis of VA's actions not completed: We determined this
recommendation was partially met because VA cites its annual report on
capacity to provide PTSD services as support for meeting this
recommendation. However, the annual report on capacity does not address
the care delivered to all veterans treated by VA for PTSD. In addition,
the VA Inspector General found that data supporting the number of VA
specialized PTSD programs are incorrect. The Special Committee
designated this recommendation as met because VA issues an annual
report on its capacity to provide specialized PTSD programs for
seriously mentally ill veterans, a subset of the veterans receiving VA
PTSD services.
Recommendation: Coordinate PTSD care with VA community-based clinics;
Year recommendation initially made by Special Committee: 2001;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
GAO analysis of VA's actions not completed: We determined this
recommendation was partially met because a VA official acknowledged
that they need to develop referral mechanisms to provide PTSD services
when these services are not available at VA community-based clinics. In
addition, although VA developed and disseminated a clinical practice
guideline for PTSD, VA does not have documentation to show the extent
of treatment provided in accordance with the guideline at VA medical
facilities and community- based clinics. The Special Committee
designated this recommendation as met because VA developed and
disseminated the clinical practice guideline for PTSD.
Recommendation: Develop, disseminate, and implement best practice
treatment guidelines for PTSD;
Year recommendation initially made by Special Committee: 2001;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2006- 2007;
Recommendation: Establish a PTSD screening and referral mechanism in
every VA community-based clinic;
Year recommendation initially made by Special Committee: 1985;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
Recommendation: Develop and implement a national standardized set of
tools for assessment of PTSD;
Year recommendation initially made by Special Committee: 1985;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
GAO analysis of VA's actions not completed: We determined these
recommendations were partially met because although VA has developed
and disseminated a clinical practice guideline for PTSD, it does not
have documentation to show that the clinical practice guideline,
specifically the treatment part of the clinical practice guideline, is
being implemented at VA medical facilities and community-based clinics.
Additionally, VA does not have documentation to show that its community-
based clinics have developed referral mechanisms for veterans who need
PTSD services when those services are not available. However, VA has
started collecting data to monitor use of one of the assessment tools
for PTSD in the clinical practice guideline--a four-question screening
tool. VA's fourth quarter data for fiscal year 2004 indicate that 47
percent of veterans were screened for PTSD using this tool. However,
this calculation includes those already diagnosed with PTSD. The
Special Committee designated these recommendations as met because the
clinical practice guideline on PTSD that includes standardized
assessment tools for PTSD was developed and disseminated at VA medical
facilities and community-based clinics.
Recommendation: Recognize specialized PTSD programs as an important
component of care;
Year recommendation initially made by Special Committee: 2001;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2006- 2007;
GAO analysis of VA's actions not completed: We determined this
recommendation was partially met because VA is collecting data on the
results of its efforts to annually screen all veterans to identify
those at risk for PTSD. However, VA's Office of Quality and Performance
told us that VA uses the data on PTSD screening as a supporting
indicator, an interim step in the development of a performance measure.
Research shows that quality is highest in areas where VA has
established performance measures and actively monitors performance. VA
cites its annual report on capacity to provide PTSD services as support
for meeting this recommendation. However, the annual report on capacity
does not address the care delivered to all veterans treated by VA for
PTSD. VA has recently demonstrated the importance of PTSD programs
through, for example, adding 50 positions at Vet Centers to be filled
by veterans from the current conflicts to perform outreach and
requiring community-based clinics treating more than 1,500 veterans to
provide mental health services. The Special Committee designated this
recommendation as met because VA issues an annual report on its
capacity to provide PTSD services to seriously mentally ill veterans, a
subset of veterans receiving VA PTSD services.
Recommendation: Improve collaboration with DOD on PTSD education;
Year recommendation initially made by Special Committee: 1985;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
GAO analysis of VA's actions not completed: We determined this
recommendation was partially met because although VA and DOD
collaborated to develop educational materials, such as the PTSD
clinical practice guideline, VA and DOD are still formalizing their
future plans for PTSD education. The Special Committee designated this
recommendation as not met because VA has not provided a list of all the
joint VA/DOD ongoing educational efforts and has not provided
information on its plans for improving its collaboration on PTSD with
DOD.
Recommendation: Develop more effective treatment approaches for
veterans with PTSD and coexisting substance abuse;
Year recommendation initially made by Special Committee: 1985;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
Recommendation: Develop and implement a rehabilitation approach to PTSD
and coexisting conditions;
Year recommendation initially made by Special Committee: 2001;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
Recommendation: Develop PTSD guidelines for aging veterans, various
cultural groups, and other special populations;
Year recommendation initially made by Special Committee: 2001;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
GAO analysis of VA's actions not completed: We determined these
recommendations were partially met because the existing clinical
practice guideline addresses two of these issues--PTSD and coexisting
substance abuse and the rehabilitation approach (recovery model)--to
some extent. Treatment approaches are now being developed and evaluated
for veterans with PTSD and coexisting substance abuse and VA needs to
continue its efforts to implement the recovery model through training
of staff on this approach to PTSD treatment. The clinical practice
guideline mentions a few special needs of the aging veteran and
veterans in various cultural groups and special populations, such as
women and the homeless. In addition, other educational materials are
available for clinicians on a VA Web site. The Special Committee
designated these recommendations as met because VA developed and
disseminated the PTSD clinical practice guideline.
Recommendation: Provide increased access to PTSD services;
Year recommendation initially made by Special Committee: 1985;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
GAO analysis of VA's actions not completed: We determined this
recommendation was partially met because although VA has increased the
number of veterans it treats for PTSD, it has not developed referral
mechanisms in all community-based clinics that do not offer mental
health services. The Special Committee designated this recommendation
as not met because PTSD services are not widely available in VA's
community-based clinics.
Source: GAO analysis.
[End of table]
Table 3: Ten Recommendations that GAO Determined Were Not Met by VA:
Recommendation: Provide sustained treatment settings for PTSD and
coexisting psychiatric and medical conditions;
Year recommendation initially made by Special Committee: 2001;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2004-2005;
GAO's analysis actions not completed: We agree with the Special
Committee that this recommendation is not met because VA has not
established a mechanism to ensure the continuity of treatment across
various treatment settings for veterans with PTSD. Further, not all
community-based clinics have mental health services available or
referral mechanisms in place to ensure that veterans who need
specialized PTSD treatment services are transferred to these settings.
We also reported in September 2004 that not all veterans may have
access to PTSD services because officials at six of seven VA medical
facilities we visited stated that they may not be able to meet an
increase in demand for PTSD services.
Recommendation: Extend efforts to monitor productivity and quality of
specialized services across the PTSD continuum of care;
Year recommendation initially made by Special Committee: 1985;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
GAO's analysis actions not completed: We agree with the Special
Committee that this recommendation is not met because according to VA's
response to the Special Committee's 2004 report, VA has developed a
functional measure, which is expected to include a scale for quality of
life and social support, but has not completed the testing of this new
measure. Although VA collects information on employment status and
incidents of violent behavior for veterans treated for PTSD, it does
not collect data on other measures of functionality and productivity,
such as the amount of social support a veteran receives from community
sources.
Recommendation: Expand PTSD treatment to include family assessment and
treatment services;
Year recommendation initially made by Special Committee: 2001;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
GAO's analysis actions not completed: We agree with the Special
Committee that this recommendation is not met because VA has not
developed or implemented a plan to provide services to the families of
veterans with PTSD at VA medical facilities.
Recommendation: Improve VA medical facility and Vet Center
collaboration;
Year recommendation initially made by Special Committee: 1985;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
GAO's analysis actions not completed: We agree with the Special
Committee that this recommendation is not met because VA medical
facilities and Vet Centers do not have a common database for veterans
with PTSD, do not have joint access to clinical notes across the two
systems, and have not completed a joint assessment of local and
national needs within each system that could be addressed by sharing
resources by collocation and telemedicine.
Recommendation: Establish electronic clinical records that follow
veterans across VA's system of care;
Year recommendation initially made by Special Committee: 1985;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
GAO's analysis actions not completed: We agree with the Special
Committee that this recommendation is not met because VA medical
facilities and Vet Centers maintain separate clinical records. Medical
facility staff cannot electronically access Vet Center clinical
records.
Recommendation: Designate a PTSD coordinator in each VA network;
Year recommendation initially made by Special Committee: 2001;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
GAO's analysis actions not completed: We agree with the Special
Committee that this recommendation is not met because VA has not
assigned PTSD coordinators in its networks.
Recommendation: Improve the continuum of care for PTSD;
Year recommendation initially made by Special Committee: 1985;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2006-2007;
GAO's analysis actions not completed: We agree with the Special
Committee that this recommendation is not met because VA has not
developed or implemented a plan of action to improve the continuum of
care for PTSD.
Recommendation: Develop a national PTSD education plan for VA;
Year recommendation initially made by Special Committee: 1985;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
GAO's analysis actions not completed: We agree with the Special
Committee that this recommendation is not met because VA has not
developed a comprehensive national education plan for VA staff.
Furthermore, our analysis shows that while VA has undertaken various
educational initiatives, these do not constitute a national approach as
recommended by the Special Committee.
Recommendation: Develop credentialing standards for VA clinicians
specializing in PTSD;
Year recommendation initially made by Special Committee: 2001;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
GAO's analysis actions not completed: We agree with the Special
Committee that this recommendation is not met because VA has not
developed credentialing standards for its clinicians specializing in
PTSD.
Recommendation: Utilize Vet Center appointments to satisfy VA
performance standards for PTSD follow-up care;
Year recommendation initially made by Special Committee: 2001;
VA's targeted time frame (fiscal year) for implementing planned actions
associated with recommendation: 2008 or later;
GAO's analysis actions not completed: We agree with the Special
Committee that this recommendation is not met because VA has not
modified its performance standard to allow Vet Center appointments to
satisfy the VA requirement for follow-up care.
Source: GAO analysis.
[End of table]
[End of section]
Appendix V: Comments from the Department of Veterans Affairs:
THE DEPUTY SECRETARY OF VETERANS AFFAIRS: WASHINGTON:
February 8, 2005:
Ms. Cynthia A. Bascetta:
Director:
Health Care Team:
U. S. Government Accountability Office: 441 G Street, NW:
Washington, DC 20548:
Dear Ms. Bascetta:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, VA HEALTH CARE: VA Should
Expedite the Implementation of Recommendations Needed to Improve Post-
Traumatic Stress Disorder Services, (GAO-05-287). As the report
acknowledges, VA is a world leader in treating post-traumatic stress
disorder (PTSD). Regrettably this fact is lost by GAO's uneven
depiction of the Department's achievements in PTSD services. To the
average reader, this report implies that VA services for veterans with
PTSD is woefully inadequate, and undermines the quality of VA care. VA
disagrees with GAO and does not concur with its conclusions and
recommendation.
Enclosure 1 discusses the Department's disagreement with GAO and
provides numerous points of clarification. Enclosure 2 is a copy of
VA's transmittal letter to Congress and excerpts detailing VA's actions
as related to the fourth annual report of the VA Special Committee on
PTSD. Enclosure 3 provides copies of letters signed by the Co-Chairs of
the Under Secretary's Special Committee on PTSD that outline support
for VA's implementation of the Committee's recommendations. VA believes
enclosure 2 and 3 are fundamental to the Department's comments and
should be included as part of VA's published response to GAO's draft
report. Due to the extremely short period to comment on GAO's draft
report, VA will provide a detailed refutation of this report when
responding to the final report.
Sincerely yours,
Signed by:
Gordon H. Mansfield:
Enclosures:
Enclosure 1:
THE DEPARTMENT OF VETERANS AFFAIRS (VA) COMMENTS TO GOVERNMENT
ACCOUNTABILITY OFFICE (GAO) FINAL REPORT:
VA HEALTH CARE: VA Should Expedite the Implementation of
Recommendations Needed to Improve Post-Traumatic Stress Disorder
Services (GAO-05-287):
To help ensure that VA has the capacity to diagnose and treat veterans
returning from the Iraq and Afghanistan conflicts, as well as to
maintain these services for other veterans, we recommend that the
Secretary of Veterans Affairs direct the Under Secretary for Health to
prioritize those recommendations needed to improve PTSD services and to
expedite VA's time frames for fully implementing those recommendations.
Do Not Concur - The Department of Veterans Affairs does not concur with
either GAO's report or the recommendation. VA does not believe GAO's
findings and conclusions accurately portray the actual provision of
post-traumatic stress disorder (PTSD) services to veterans by VA over
the past 20 years nor VA's ability to provide future services to
veterans. To the average reader, this report will leave the impression
that VA services to veterans with PTSD is woefully inadequate, which is
completely wrong.
VA believes it is imperative to make the following significant
observations on GAO's draft report.
* On page three, GAO states, "VA's delay in fully implementing the
recommendations raises questions about VA's capacity to identify and
treat veterans returning from military combat who may be at risk for
developing PTSD, while maintaining PTSD services for veterans currently
receiving them." This is an egregious misrepresentation of VA's ability
to provide care to returning Operation Iraqi/Operation Enduring Freedom
(OIF/OEF) servicemembers, and is not supported by GAO's findings. In
fact, VA provided PTSD services to approximately 6,400 OIF/OEF veterans
to date. This is a small percentage of the total of more than 244,000
veterans treated for PTSD in the VA health care system, and indicates
that VA does indeed have sufficient capacity to provide care to
veterans with PTSD.
Enclosure 1:
THE DEPARTMENT OF VETERANS AFFAIRS (VA) COMMENTS TO GOVERNMENT
ACCOUNTABILITY OFFICE (GAO) FINAL REPORT:
VA HEALTH CARE. VA Should Expedite the Implementation of
Recommendations Needed to Improve Post-Traumatic Stress Disorder
Services (GAO-05-287):
* GAO acknowledges VA as a world leader in the treatment of PTSD. The
co-chairs of the Under Secretary for Health's Special Committee on PTSD
reviewed VA's draft mental health strategic plan and concurred that the
Special Committee's recommendations were fully addressed in the
comprehensive strategic plan. The co-chairs also concurred that the
implementation time frames outlined in the mental health strategic plan
were appropriate.
* GAO failed to include in its report the Secretary's letter to members
of Congress, dated October 18, 2004, which explained the Department's
response to the recommendations of the Special Committee. These
responses are crucial to understanding the Department's constructive
actions toward the Special Committee and to its recommendations.
Enclosure 2 is a copy of the Secretary's letter and extracts from its
enclosure to Ranking Democratic Member Evans so that it may be included
as part of the Department's published response to this draft report.
* GAO's report gives the impression that VA is ignoring the provision
of PTSD services.
GAO's report discounts the progress made on each of the Special
Committee recommendations and ignores the relevant information provided
by Dr. Mark Shelhorse, Acting Chief Consultant, Mental Health Strategic
Healthcare Group. Other VA experts also share documentation that
represents progress towards meeting recommendations of the Special
Committee. VA recommends that GAO reexamine its findings in the light
of the support provided to VA efforts by the co-chairs of the Special
Committee in letters dated February 3, 2005. The co-chairs are firm in
their belief that the report "portrays an unfair and one-sided image of
the agency...." (Enclosure 3 provides copies of the co-chair letters to
be included as part of the Department's published response to GAO's
draft report.)
Enclosure 3:
DEPARTMENT OF VETERANS AFFAIRS: Veterans Health Administration:
Washington DC 20420:
February 3, 2005:
In Reply Refer To:
Cynthia A. Bascetta:
Director, Health Care - Veterans' Health & Benefits Issues: United
States Government Accountability Office: Washington, DC 20548:
Dear Ms. Bascetta:
We would like to express our discomfort with the negative tone of the
Government Accountability office report on Post Traumatic Stress
Disorder (PTSD) as presented in the exit conference on January 28,
2005, and in the draft report. Recognizing, treating, and assisting
veterans with PTSD is one of Veterans Health Administration's (VHA)
highest priorities. The Under Secretary for Health and the agency are
invested and engaged in implementing the President's New Freedom
Commission on Mental Health Recommendations, and have developed a
National Mental Health Strategic Plan (MHSP) to lead us to those goals.
This plan includes PTSD. We have cross-walked our recommendations with
the MHSP with the help of the Mental Health Strategic Healthcare Group
(MHSIIG) and all recommendations are addressed within the body of that
plan. We have also agreed with the Under Secretary for Health that 7 of
the 24 recommendations are complete. We do not understand why the
report continues to portray those 7 as incomplete.
The report fails to address the many efforts undertaken by the agency
and the members of the PTSD Advisory Group to improve the care
delivered to Veterans with PTSD. This includes:
* A clinical practice Guideline for PTSD;
* The Research efforts of The National Center for PTSD;
* The development of an Iraqi War guide for Clinicians;
* A national Clinical Reminder to prompt Clinicians to assess OIF/OEF
Veterans for PTSD, Depression, and Substance abuse;
* A National system of 144 Specialized PTSD Programs in all states;
* A National System of 207 Community Readjustment Counseling Centers
(RCS);
* The Treatment in 2003 of over 200,000 Veterans with PTSD;
* Establishing a Mental Illness Research and Education Center in 2004
in Durham, NC directed to evaluate post deployment veterans;
* The development of l7 individual educational initiatives for staff,
patients, and families;
* The 2005 planning for a joint VHA/DoD PTSD 101 Course forproviders
and programs focusing on PTSD in special groups (women veterans, older
adults, medically ill, etc.);
* The March Planning for a joint VHA/DoD conference centered on
improving care to the returning war veteran;
* VHA placing Social Workers in Military Treatment Facilities to assist
soldiers in the transition to VHA;
* The addition of 50 Global war on Terrorism (GWOT) counselors to
Readjustment Counseling Service to assist with counseling;
* The current expansion of VHAs four Traumatic Brain Injury Centers to
Polytrauma Centers including Services for Mental Health;
* VHAs ongoing efforts with DoD through Seamless Transition Task Force
to improve the care we deliver to this population.
We are concerned that anyone reading your report will not be aware of
these actions taken by the agency, many of which were contributed to by
the members of the PTSD Advisory Committee. To not include these
efforts not only portrays an unfair and one-sided image of the agency
but discounts the work of the dedicated employees and members of the
Advisory Committee.
VHA is the World Leader in the treatment of PTSD and we will continue
to work with the system to assure that that status is maintained and
improved.
Respectfully,
Signed by:
Philip Hamme, MSW:
Co-Chair, PTSD Advisory Committee:
[End of section]
Appendix VI: GAO Contact and Staff Acknowledgments:
GAO Contact:
Marcia A. Mann (202) 512-9526:
Acknowledgments:
In addition to the contact named above, key contributors to this report
were Mary Ann Curran, Linda Diggs, Martha Fisher, Lori Fritz, Alice L.
London, Janet Overton, and Marion Slachta.
FOOTNOTES
[1] Servicemembers include active duty members of the Army, Marines,
Air Force, and Navy and members of the Reserves and National Guard.
[2] Based on data under the broad definition of PTSD provided in
Charles W. Hoge, MD et. al., "Combat Duty in Iraq and Afghanistan,
Mental Health Problems, and Barriers to Care," The New England Journal
of Medicine, 351 (2004):13-22.
[3] VA was the Veterans' Administration in 1984.
[4] Department of Veterans Affairs Under Secretary for Health's Special
Committee on Post-traumatic Stress Disorder, Fourth Annual Report of
the Department of Veterans Affairs: Under Secretary for Health's
Special Committee on Post-traumatic Stress Disorder: 2004.
[5] We focused on the recommendations related to clinical care and
education because implementation of these recommendations most directly
affects the provision of PTSD services. We excluded 2 clinical care and
education recommendations because one relates to VA's role during a
national emergency and the Special Committee stated that the other
requires a legislative change in order for VA to fully implement the
recommendation. See app. II for a table summarizing each of the 24
Special Committee recommendations included in our review.
[6] Fourth Annual Report of the Department of Veterans Affairs: Under
Secretary for Health's Special Committee on Post-traumatic Stress
Disorder: 2004, pg. 5.
[7] The Special Committee did not issue a report in every year.
[8] We reviewed a draft of VA's mental health strategic plan dated July
2004.
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