NAMI’s Position (taken from the NAMI Policy Platform)
Veterans Health Administration Losing Capacity
The U.S. Department of Veterans Affairs’ Veterans Health Administration reports a patient census for FY 1998 of 649,814 veterans receiving specialized VA mental health services.1 Despite a requirement in law that veterans with "severe chronic mental illness" are a protected category of VHA’s patient census for whom capacity must be maintained2, decentralized decision making has severely cut back services to such veterans. There is ample evidence that services to these veterans have become fragmented and sporadic due to a five-year budget freeze, reorganization that radically decentralized authority, substantial reductions in staff, reallocation of resources among Veterans Integrated Service Networks (VISNs), a deliberate shift from in-patient to out-patient focus, and contracting out for services.3
As the Nation’s Voice on Mental Illness, NAMI advocates a comprehensive continuum of care–evidence-based and clinically appropriate--for all persons suffering from severe and persistent mental illnesses, which are brain disorders. NAMI’s advocacy certainly embraces veterans.
NAMI demands a comprehensive continuum of care for persons suffering from a severe and persistent mental illness--a brain disorder. This includes availability and accessibility of physician services, state of the art medications, family education and involvement, inpatient care, outpatient care, residential treatment, supported housing, assertive community treatment teams, psychosocial rehabilitation services, peer support, vocational and employment services, representative payee assistance, housing assistance, integrated treatment for co-morbid substance abuse disorders, and effective referral for co-morbid medical and surgical conditions.
Which of the elements from this continuum--or combination thereof--an individual consumer requires at any given time is indicated by the fluctuating needs of the consumer depending on his/her current clinical condition, and is determined in conjunction with his or her treatment team. All elements should be available without waiting lists or other barriers to access. A system, particularly one that is deliberately converting itself from in-patient to outpatient bases, must be modeled with the flexibility and capacity to make this so. Only then can it be correctly designated a "comprehensive system of care."
NAMI is concerned that the elements of the de-centralized twenty-two "little V As"--as many have named the Veterans Integrated Service Networks (VISNs)--combine to ill serve the 26% of the VHA patient census that VA calls the "severely chronically mentally ill veterans". These VISN elements are grounded in severed links to Washington oversight and sign-off, and often hampered by compartmentalized budgeting which strains pharmacy/formulary protocols. VISNs’ program components include Medical Centers (MCs), Community Based Outpatient Clinics (CBOCs), Intensive Psychiatric Community Care (IPCCs), and perhaps Mental Illness Research, Education and Clinical Centers (MIRECCs). Vet Centers (which don't properly belong to the VISNs) are also present within each VISN’s catchment area.
V A's Undersecretary for Health and chief VISN administrative officer have each promulgated directives that re favorable to the interests of vets with severe chronic mental illness. The implementation of these directives varies across a broad spectrum of compliance among the 22 VISNs. Some have done quite well, well enough to merit commendation from NAMI—VISN 10. Others have been so non-compliant as to be written up in reports by the Inspector General, Congress's General Accounting Office, and in a staff study commissioned by the ranking member on the Senate Veterans Affairs Committee, Senator Rockefeller.4
This wide diversity from VISN to VISN is seen similarly with the new structures put in place as part of the V A de-institutionalization initiative. There are CBOCs that do exemplary work following and treating vets with mental illness; there are others that have no psychiatric services whatsoever. Even some of the Veterans Centers have integrated at least effective outreach if not full psychiatric services, including pharmacy; others don't even have a pamphlet.
Decisions to close a psychiatric service at one or more MCs within a VISN, and consolidate them at other MCs in the VISN selected to retain a psychiatric service, have frequently resulted in (we trust unintended) hardships for veterans trying to remain compliant to their outpatient regimen of appointments and medications. Results are predictable--far more frequent relapse and homelessness.
The special services for those diagnosed with Post Traumatic Stress Disorder (PTSD), and for those suffering from alcohol or other substance addictive disorders have also been cut to the point of virtual extinction in some VISNs. The Rockefeller report last year called attention prominently to these severe cuts in services for addictive disorders and post-traumatic stress disorder.
NAMI has sufficient policy and supportive materials setting forth minimally acceptable standards for public mental health systems. Nearly all of these are applicable to the Department of Veterans Affairs in the transition its Veterans Health Administration has undergone. The sixteen managed care principles enunciated in NAMI’s Policy Platform5 set benchmarks which V A must be challenged to attain.
There are concerns with the V A budget and program implementation around research issues and resources, as well as around service delivery. NAMI has consistently called for an increase in the proportion of the V A research budget that supports mental illness research, arguing that it should match the proportion of the V A patient census—26%--, which is comprised by vets with mental illness.
NAMI Policy Goals
Achieve full funding of VHA’s Mental Illness Research Education and Clinical Centers (MIRECCs) as NAMI’s research funding issue.
Promote multiplication of V A’s Intensive Psychiatric Community Care (IPCC) programs, their version of PACT.
Monitor national pharmacy/formulary policies and procedures, and local formularies and prescribing protocols put forth by a particular VISN or MC.
Secure active oversight of VHA’s mental health treatment system by VHA’s Medical Inspector, V A’s Inspector General, and the General Accounting Office, through Members of Congress.
Insure that members of both congressional authorizing committees and appropriations subcommittees are continually informed about capacity and access reductions.
Highlight VISNs doing well on mental health services; commend them for it. Tout best practices; put them in testimony. Ask Members to put remarks in the Congressional Record.
Identify the poorly performing VISNs and assist with strategies to intervene.
Develop collaborative policy-specific activities with the advocacy programs of the Disabled American Veterans, American Legion, Paralyzed Veterans of America, and National Coalition for Homeless Veterans.
For more information about this issue, please call Andrew Sperling at 703/516-7222 or Kim Encarnation at 703/312-7895. All media representatives, please call NAMI’s communications staff at 703/516-7963.