Statement of NAMI on the Needs of Veterans with Severe Mental Illness
Statement submitted by NAMI to the Veterans Administration's Capital Asset Realignment for Enhanced Services (CARES) Commission, October 7, 2003
NAMI is a nonprofit, grassroots, self-help, support and advocacy organization of consumers, families, and friends of people with severe mental illnesses, such as schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, panic and other severe anxiety disorders, autism and pervasive developmental disorders, attention deficit/hyperactivity disorder, and other severe and persistent mental illnesses that affect the brain.
Founded in 1979, NAMI today works to achieve equitable services and treatment for more than 15 million Americans living with severe mental illnesses and their families. Hundreds of thousands of volunteers participate in more than one thousand local affiliates and fifty state organizations to provide education and support, combat stigma, support increased funding for research, and advocate for adequate health insurance, housing, rehabilitation, and jobs for people with mental illnesses and their families.
We are submitting this statement to express our grave concern regarding the loss, and potential elimination of more inpatient beds, for veterans with severe mental illness and potential policies to eliminate more hospital beds. Across the nation, the Veterans Administration has undertaken the elimination of critically needed services and supports for our most vulnerable veterans, and yet there has not been the appropriate increase in community-based treatments and programs needed to address the need of veterans across the country.
The VA should not make the same mistakes that so many states and communities have made over the past quarter century with respect to deinstitutionalization. Numerous studies have demonstrated that in several states, monies saved through the closing of state psychiatric hospitals were either never transferred into the community, or squandered on community-based services that lacked focus and accountability.
NAMI strongly supports treating veterans with severe mental illness in the community when the proper intensive community supports and treatments are available and easily accessible. However, we are still very concerned that those veterans who need inpatient care are increasingly unable to access needed treatment because of the limited inpatient beds, and the dramatic shift to an outpatient treatment system that is not adequately funded.
Services for veterans with mental illness should be available without waiting lists or other barriers to treatment and services. The VA must provide a comprehensive system of care and maintain the capacity to provide such services.
NEED FOR INPATIENT CAPACITY
The Independent Budget of the VA reports 454,598 veterans have a service-connected disability due to a mental illness. Of great concern to NAMI are the 130,211 veterans who are service-connected for psychosis—104,593 of them who were treated in the VHA in FY99 for schizophrenia, one of the most disabling brain disorders. NAMI feels strongly that the VA must do more to maintain capacity for veterans with severe and chronic mental illness.
In 2001, Congress passed the Department of Veterans Affairs Health Care Programs Enhancement Act (P.L.107-135). This law strengthened the VA’s capacity to serve veterans with mental illness, requiring improvements to the current system to ensure that veterans have access to necessary treatment and services. The law requires the VA to maintain capacity for serving veterans with mental illness and to replace lost capacity as well.
Currently, about 20 percent of veterans in the health care system are in need of mental health treatment and far below the expectations of the VA’s capacity law. While the VA reports that it has maintained capacity for veterans with severe mental illness, many advocates argue that it has not, citing higher numbers of veterans enrolled in the system, decreased staffing levels, and budgets that are not adjusted for inflation.
The Committee on the Care of Severely Chronically Mentally Ill Veterans (SCMI Committee) reports that during FY 2002, VHA spent only 77% of the amount that it spent in FY 1996 for care of veterans with serious mental illness—a decrease of $478 million annually. (This was based on data from the FY 2002 Report to Congress on Maintaining Capacity for Special Populations). This reduction has occurred despite mandates that the VHA focus on its high priority veterans, including veterans with serious mental illness.
In FY 2000, out of the 192,982 veterans who were treated for a severe mental illness, only 19.7% received treatment in an inpatient setting. Data shows that the number of veterans treated in an inpatient setting further declined in FY 2001. In fact, from FY 1994 to FY 2001, the number of veterans receiving inpatient treatment for severe mental illness has dropped from 58,062 to 35,888. We are very concerned that those veterans who need inpatient care and are unable to access the needed treatment because of the limited inpatient beds and the dramatic shift to outpatient treatment.
Decisions to close a psychiatric service at one or more centers have frequently resulted in unintended hardships for veterans trying to remain compliant with their outpatient regimen of appointments and medications. Results are predictable: more frequent relapses and homelessness.
The VHA needs to be held accountable for its inability to ensure that savings derived from the closure of inpatient psychiatric beds is transferred into community-based treatment services.
From NAMI’s perspective, it is obvious that this significant decrease in inpatient care has not resulted in a sufficient transfer of resources to community-based treatment and supports for veterans with severe mental illnesses. In VISN efforts to reduce overall costs, many VISN administrators have closed long-term psychiatric beds without adequately shifting these resources into outpatient settings. The most recent report to the VA Under Secretary for Health from the SCMI committee states that; "VHA has been alarmingly inconsistent in building and providing an adequate continuum of care for veterans who are seriously mentally ill."
If several hospitals are scheduled to close, NAMI is very concerned about the hardships that veterans with serious mental illness will have to endure if they are forced to travel long distances to obtain needed treatment. Many individuals have severe disabilities that prevent them from driving on busy roads. They will lose the doctors and other caregivers that veterans with mental illness entrust their lives with. They are obviously concerned about an uncertain future.
One veteran said this to us about the likelihood of a hospital closing. "This place is like family to me. The other patients mean so much to me and I try to help in any way I can. To take this place away from us would be shameful because I know right now if asked, I would go back and give to this nation as I did before."
NAMI feels strongly that the VA must do more to maintain capacity for veterans with severe and chronic mental illness. The lack of access to treatment and community supports for veterans with severe mental illness is one of the greatest unmet needs in the VHA.
NEED FOR COMPREHENSIVE COMMUNITY SERVICES
NAMI remains truly concerned that meaningful community-based capacity is not being developed to treat chronically mentally ill veterans in their communities—including the VHA’s lack of mental illness services available in community based outpatient clinics (CBOCs). Many of the CBOCs were instituted in areas where VA health services were not easily accessible allowing many more veterans access to needed health care. However, out of the VHA’s CBOCs that are operated, only about 40% of these facilities offer treatment services for veterans with severe mental illness. This is a disturbing statistic given that 20% of VHA outpatient visits were for mental health purposes.
Over the years, the VA has shifted care from the inpatient settings to CBOCs. CBOCs are instituted in areas where VA health services are not easily accessible, and allow veterans to access care closer to their homes. However, many of the CBOCs offer only minimal treatment services for veterans with severe mental illnesses, and many others offer no mental health treatment services at all.
NAMI believes that veterans should receive the same full range of integrated services within the hospital and upon discharge to the community that are received by other people with brain disorders. NAMI calls for veterans hospitals and veterans outpatient treatment programs to be held to the same standards of performance as all other hospitals and outpatient treatment programs.
In NAMI’s view, an appropriate community-based continuum of care for veterans should include the availability and accessibility of:
- Physician services
- State-of-the-art medications
- Family education and involvement
- Inpatient and outpatient care
- Residential treatment
- Supported housing
- Assertive community treatment (mental health intensive case management teams – (MHICM)
- Psychosocial rehabilitation
- Peer support
- Vocational and employment services
- Integrated treatment for co-occurring mental illness and substance abuse
The services a veteran requires from this continuum of care at any given time are determined by the fluctuating needs of his or her current clinical condition and should be established in conjunction with his or her treatment team. All services should be available without waiting lists or other barriers to accessing needed treatment and services. To be a comprehensive system of care the VHA must have the capacity to provide such services.
NAMI strongly recommends that the VHA establish one-stop comprehensive community care settings and programs so that veterans receive appropriate care and, moreover, in response to hospital closings, have the ability to access needed services and supports.
NEED FOR IMPROVING MENTAL HEALTH INTENSIVE CASE MANAGEMENT
Related to our position on hospital closures and community services is Mental Health Intensive Case Management (MHICM). The VHA issued a directive in October 2000 for MHICM. MHICM is based on the Substance Abuse and Mental Health Services Administration’s (SAMHSA) standards for assertive community treatment (ACT), which NAMI believes are proven, evidence-based approaches for treating individuals with the most severe and persistent mental illnesses.
FY 1998 Compensation and Pension data show that almost 40,000 veterans with severe mental illness are in need of intensive community case management services. Further VHA data shows that assertive community treatment is cost-effective as well as effective in treating severe mental illness. However, a FY 1998 survey by the Committee on Care of Severely Chronically Mentally Ill (SCMI) Veterans showed that just over 8,000 veterans are currently receiving some form of intensive case management, and that only 2,000 veterans were in treatment programs that met the SAMHSA standards. The SCMI committee has also reported that intensive case management teams are operating at minimal staffing and some are facing further staff reductions.
MHICM is based on principles and practice of assertive community treatment with some adaptations of practice to accommodate VHA’s integrated health care system.
MHICM is intended for veterans who are having trouble living on their own in the community. Veterans with primary diagnoses of psychiatric disorders, such as schizophrenia, bipolar disorder, major depression, and other debilitating mental illnesses, use MHICM.
NAMI strongly supports treating veterans with severe mental illness in the community when the proper intensive community supports and treatment are available and easily accessible.
NAMI strongly recommends that the necessary funds are appropriated to provide the essential number of new intensive case management teams and to fully staff existing teams so that our nation’s most vulnerable veterans receive appropriate and coordinated care.
Savings from cuts in inpatient psychiatric beds should be reinvested in intensive case management services and in providing mental illness treatment in community based outpatient clinics that serve veterans with severe mental illnesses.
NEED FOR PEER TO PEER SUPPORT
The Vet to Vet is a self-help program of veterans helping veterans overcome both mental illness and substance abuse. The program was created in 2002. Veterans have been informally helping each other gain realistic levels of recovery for years. The VA decided to officially train and develop peer educational support meetings inside the VA Errera Community Care Center and evaluate these self-help meetings. These meetings would be an adjunct to the care that was already being provided by the Errera Community Care Center. They would not take the place of mental health care given by the center.
The Vet to Vet program is part of an educational framework of learning about mental illness moving to a common understanding about these disorders.
The Vet to Vet program attempts to find solutions through education and the VA should facilitate and fund these programs in order to improve and increase mental health services through community education and service.
NEED TO EXPAND SERVICES TO HOMELESS VETERANS
Severe mental illness and co-occurring substance abuse problems contribute significantly to homelessness among veterans. Studies have shown that nearly one-third (approximately 250,000) of homeless individuals have served in our country’s armed services. Moreover, approximately 43% of homeless veterans have a diagnosis of severe and persistent mental illness, and 69% have a substance abuse disorder.
NAMI is pleased with initiatives at the VA that have supported residential options for homeless veterans with mental illness through the "Homeless Providers Grant and Per Diem Program" and the new "Loan Guarantee for Multifamily Transitional Housing for Homeless Veterans Program".
NAMI urges that these initiatives be expanded to offer clinical outreach, case management and support services in communities with high concentrations of homeless mentally ill veterans.
Housing is the cornerstone of recovery from mental illness and a life of greater independence and dignity. Decent, safe and affordable housing plays a critically important role in promoting recovery, access to treatment and a stable life in the community. NAMI believes that no single program or model can meet the needs of every individual living with severe mental illness.
NAMI feels strongly that a range of options are needed for consumers based on their own circumstances – from supported housing to congregate living to tenant-based vouchers to homeownership.
Representatives of NAMI’s Veterans Committee inform us that veterans with severe mental illness are fearful of the "systems in place" which would lead to the loss of benefits, so there is a built-in lack of trust. If the major illness is schizophrenia, then paranoia goes hand in hand with it, and if their perception is that they are going to be punished for getting better, then their perception becomes a reality.
We suggest that the benefits for severe mental illnesses be more closely aligned with "physical medicine."
As the national organization representing families of veterans who have served our country honorably and have serious illnesses that are no-fault and treatable, NAMI believes veterans with mental illness should receive a full range of integrated services on an inpatient and outpatient basis along the entire continuum of care.
Thank you for allowing us to share the views of the National Alliance for the Mentally Ill to the CARES commission. We would be pleased to work with you to address the needs and interests of veterans with serious mental illnesses.