Veterans Disabled by Mental Illness
NAMI’s Position (taken from the NAMI Policy Platform)
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.
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.
1 Department of Veterans Affairs National Mental Health Performance Monitoring System for Fiscal Year 1998.
2 P. L. 104-262, the Veterans Eligibility Reform Act of 1996 requires the Department of Veterans Affairs (V A) to maintain its capacity to treat veterans requiring special treatment or rehabilitation, including those with spinal cord dysfunction, amputations, blindness, and mental illness.
3 "Minority Staff Review of V A Programs for Veterans with Special Needs," prepared for Senator Rockefeller, Ranking Member, Senate Committee on Veterans Affairs; July 1999.
5 NAMI's managed care principles were crafted specifically for state mental health systems. With minimal adjustments to VHA's terminology and operating procedures, they should by fully applicable:
- 5.5 Managed Care
- (5.5.1) The public sector must continue to be accountable for the delivery of treatment and services for persons with brain disorders even when contracting out the services to private sector managed care organizations.
- (5.5.2) NAMI advocates for research and services in response to these major brain disorders in persons of all ages: schizophrenia, bipolar disorder, major depression, obsessive-compulsive disorder, and panic disorder.
- (5.5.3) There must be continued eligibility within the public system for persons with brain disorders who are employed but cannot obtain health coverage through their employers.
- (5.5.4) State government must develop and maintain a comprehensive community-support system of treatment and services for the priority populations. Services must, at a minimum, be those required in a state mental health plan by PL 99-660. States must continue to maintain short- and long-range plans for those with brain disorders.
- (5.5.5) There must be meaningful participation of consumers and families at every stage of the redesign, implementation, evaluation, and monitoring of the managed care system.
- (5.5.6) All planning and delivery of services must be culturally sensitive to ethnically diverse populations and the communities in which they are located.
- (5.5.7) Public sector entities that contract with managed care organizations (MCOs) or other entities for the management and/or delivery solely of Medicaid-funded services for persons with brain disorders must exercise great caution lest they inadvertently divide the mental health system and cause dumping of persons with severely disabling brain disorders who are heavy users of costly services back onto a public system that is generally considered to be underfunded.
- (5.5.8) Public resources saved by managed care systems should be reallocated to expand services to the priority population.
- (5.5.9) Provider personnel, both administrators and treatment staff, must have an understanding of brain disorders. They must have training to work with the priority population--including training in the consumer and family perspective--and must accept accountability for the quality of services they provide.
- (5.5.10) All provider staff must be rigorously and appropriately credentialed by appropriate state agencies.
- (5.5.11) A comprehensive array of community-support services must be available for individuals who meet the priority-population definition and either have a Global Assessment Functioning (GAF) scale score of 50 or below or who are at risk of declining to this level. These services must include new-generation medications, inpatient treatment, residential support services, intensive case management, psychosocial rehabilitation, consumer-run services, and around-the-clock crisis services seven days a week. Outpatient services must be mobile.
- (5.5.12) MCOs must be held accountable by the public purchasers for linkages to housing with supportive services and employment services.
- (5.5.13) There must be consumer and family involvement in individual treatment planning including choice of provider, treatment delivery, and appropriate access to peer-support groups.
- (5.5.14) Appeal and grievance procedures must be in place that are user-friendly and time-sensitive to the life-threatening nature of psychotic episodes.
- (5.5.15) The public sector purchasers must report quarterly to the public the number of recipients who 1) fail to present for services; 2) are in jail or prison; 3) have been placed in a state hospital; and/or 4) have died.
- (5.5.16) Outcome measurement for people with brain disorders must be included in the contracts with managed care organizations and be required by the public sector purchaser on a regular basis. Outcomes should include relevant and scientifically sound measures of clinical status, general health status, functioning, quality of life (such as housing status, employment status, treatment compliance, substance abuse, involvement with the criminal justice system, and involvement with meaningful activities), and subjective measures from patients and family members, of satisfaction with care."