At our medical center (part of VISN 6) we have numerous vacancies for psychiatrists, nurse practitioners & physician's assistants which makes it double difficult to see new MH patients in a timely manner. We are losing several more within the next couple of months.

MH staff provide an Orientation to MH services group twice weekly and obtain a self assessment from the Veterans at the end of the group. The Veterans do talk 1:1 with a therapist to determine safety/suicide risk. Then an appointment is made for the Veteran to see a psychiatrist which takes an average of 5-6 months for the first appointment.

The orientation group has been counted to meet the 14 day requirement which also improves Performance Measure scores, but there is a significantly bigger problem here. Our schedulers have been told to ask the patient his Desired Date (DD) for an appointment, find the next available appointment, disregard patient's DD and enter a date that is within a 14 day window of the next available appointment.

What's wrong with this picture? Anything FRAUDUENT about this practice? ... gaming the system? Our leadership is experts in the gaming arts. At our medical center, unless there is a cancellation, new patients are waiting an average of 5-6 months to be seen by a psychiatrist. That was the practice until recently when there was a hue & cry in the media about "gaming" the scheduling system. Now schedulers are entering the actual patient DD even though the first available appointment is 6 months away.

All of a sudden our numbers have gone from "meeting the measure 98-100%" of the time to having in excess of 600 appointments scheduled that are > 14 days from DD.

Another way to game the system is to open a clinic for a psychiatrist who is in orientation and have him spend a month of his time doing nothing but seeing new MH patients (intake clinic). This will help get the backlog down, but it does nothing for the continuity of care as this new patient will not follow up with this clinician but will be given a follow up appointment with a provider they have never seen and will spend part of the next appointment time getting the new provider "up to speed" on his/her issues.

Our leadership is definitely creative. I dare say the manipulating of data/numbers so that Performance Measures are met and Management get their bonuses has been going on for years!!

It's the Congress that's gaming the system by not providing money for sufficient qualified providers and for clinical rooms that would allow pts to be seen in a timely manner.  Surveys and other poorly collected data can not be depended on to give an accurate picture.  These 2 sentences are true not just for VA Mental Health Services but for all VA scheduling and most VA Medical & Specialty Services. 

Among other hats, I am also a VA Scheduler and consider the line by line VISTA scheduling package cumbersome and inadequate.  It certainly is ineffective for collecting accurate data on patients' Desired Dates(DD).  It depends too much on the scheduler.  Instead there should be some way the pts themselves can enter their desired date.  The scheduler has too many other things to worry about and should not be saddle with the duty of determining when the pt really wants to be seen.  If the scheduler enters the wrong DD in trying to find an available date, they may be too rushed to start completely over (starting over is the only way to get back to the DD entry.) It is unrealistic to expect all the thousands of VA schedulers to get the DD correct most of the time.  If you had to use the VISTA scheduling package you would understand.

The problem of treating PTSD vets is made worse because the present mental health DSM-IV-TR coding for PTSD doens't discriminate between very ill vets with PTSD who need more intensive and urgent care from those that have PTSD and who need some help but not as urgently as the ill folks. This problem of taking up the slack is intensified as those who are very ill are not seen in a timely manner-said to because of lack of resources. This is made worse since soldiers and vets don't want to be stigmatized with the diagnoses of PTSD. PTSD is also has financial rewards and the system makes it harder to get the diagnoses instead of anxiety disorder, nos or adjustment disorder.

The VA makes an effort with mental health staff increases but the measurement of access is often initial contact and assessment not treatment. We are to target two 'check boxes': 1)  Did the vet get an appointent within 14 days and 2) was there an assessment of suicide risk.    How long from contact to treatment is not measured.  The problem varies with diagnosis but scarcity of providers is central.