S02 - Attachment 12 VHA Handbook 1160.01 Uniform Mental Health Services in VA Medical Centers and Clinics.pdf

Department of Veterans Affairs VHA HANDBOOK 1160.01 Veterans Health Administration Transmittal Sheet Washington, DC 20420 September 11, 2008

UNIFORM MENTAL HEALTH SERVICES IN VA MEDICAL

CENTERS AND CLINICS

1. REASON FOR ISSUE. This revised Veterans Health Administration (VHA) Handbook defines minimum clinical requirements for VHA Mental Health Services. It delineates the essential components of the mental health program that is to be implemented nationally, to ensure that all veterans, wherever they obtain care in VHA, have access to needed mental health services.

2. SUMMARY OF MAJOR CHANGES. This VHA Handbook incorporates the new standard requirements for VHA Mental Health Services nationwide. It also specifies those services that must be provided at each Department of Veterans Affairs (VA) Medical Center and each Community-Based Outpatient Clinic (CBOC).

3. RELATED DIRECTIVES. VHA Directive 1160 (to be published).

4. RESPONSIBLE OFFICE. The Office of Patient Care Services, Office of Mental Health

(116) is responsible for the contents of this VHA Handbook. Questions may be referred to (202)-461-7309.

5. RESCISSION. VHA Handbook 1160.01 dated June 11, 2008, is rescinded.

6. RECERTIFICATION. This VHA Handbook is scheduled for recertification on or before the last working date of September 2013.

Michael J. Kussman, MD, MS, MACP Under Secretary for Health

DISTRIBUTION CO: E-mailed 9/12/08 FLD: VISN, MA, DO, OC, OCRO, and 200 – E-mailed 9/12/08

T-1

September 11, 2008 VHA HANDBOOK 1160.01 i

CONTENTS

PARAGRAPH PAGE

1. Purpose

2. Background

3. Scope

4. Responsibilities

5. Specifications

6. Implementation

7. Structure and Governance of Mental Health Services

8. Community Mental Health

9. Gender-specific Care

10. 24 Hours a Day, 7 Days a Week (24/7) Care

11. Inpatient Care

12. Residential Rehabilitation and Treatment Programs (RRTP)

13. Ambulatory Mental Health Care

14. Care Transitions

15. Substance Use Disorders (SUD)

16. Seriously Mentally Ill (SMI)

17. Rehabilitation and Recovery-Oriented Services

18. Evidence-Based Treatments

19. Homeless Programs

20. Incarcerated Veterans

VHA HANDBOOK 1160.01 September 11, 2008 ii

CONTENTS (Continued)

PARAGRAPH PAGE

21. Integrating Mental Health into Medical Care Settings

22. Integrating Mental Health Services in the Care of Older Veterans

23. Specialized PTSD Services

24. Military Sexual Trauma (MST)

25. Suicide Prevention

26. Prevention and Management of Violence

27. Disaster Preparedness

28. Rural Mental Health Care

1. PURPOSE

This Veterans Health Administration (VHA) Handbook establishes minimum clinical requirements for VHA Mental Health Services. It delineates the essential components of the mental health program that is to be implemented nationally, to ensure that all veterans, wherever they obtain care in VHA, have access to needed mental health services. It also specifies those services that must be provided at each Department of Veterans Affairs (VA) Medical Center and each Community-Based Outpatient Clinic (CBOC). By building the requirements for services on specifications of what must be available to each veteran, no matter where in VHA that they receive care, it is designed to focus on the patient’s perspective, and on meeting the care needs for each veteran. NOTE: Throughout this Handbook, the term mental health services is meant to include services for the evaluation, diagnosis, treatment, and rehabilitation of both substance use disorders and other mental disorders.

2. BACKGROUND

a. VHA places a high priority on enhancing mental health services for returning Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans, as well as for those who served in prior eras. This Handbook and the requirements for mental health services within it are significant steps in the process that began with approval of the VHA Comprehensive Mental Health Strategic Plan in 2004, and the allocation of funding through the Mental Health Enhancement Initiative to support its implementation beginning in 2005. NOTE: Distribution of this Handbook will be followed by the distribution of the metrics that will be used to ensure the implementation of its requirements. When fully implemented, these requirements will complete the patient care recommendations of the Mental Health Strategic Plan, and its vision of a system providing ready access to comprehensive, evidence-based care.

b. The VHA Comprehensive Mental Health Strategic Plan and the requirements included in this Handbook have been developed to implement the goals of the President’s New Freedom Commission on Mental Health, including the principle that mental health care is an essential component of overall heath care. This means that services addressing substance use –related conditions must be integrated or coordinated with other components of mental health care, and that mental health services must be integrated or coordinated with other components of overall health care. Although this Handbook focuses specifically on mental health services, it does so within a comprehensive and integrated health care system.

c. Statutory and regulatory eligibility and enrollment criteria are different amongst the various programs discussed in this Handbook, which does not replace, change or supersede the existing statutory and regulatory criteria governing these programs. VHA employees are encouraged to become familiar with the statutory and regulatory eligibility and enrollment criteria for each of the programs discussed in this Handbook, and to consult their respective VHA program office or business office as needed.

3. SCOPE

a. This Handbook defines requirements for the services that must be provided as clinically needed at VA medical centers and CBOCs. The services that must be provided in CBOCs differ according to the size of the clinics. In this Handbook, very large CBOCs are those that serve more than 10,000 unique veterans each year; large CBOCs are those that serve 5000-10,000 veterans; mid-sized CBOCs are those that serve 1,500-5,000 veterans; and small CBOCs are those that serve under 1,500 veterans.

(1) In this Handbook, the services that must be “available” are those that must be made accessible when clinically needed to patients receiving health care from VHA. They may be provided by appropriate facility staff, by telemental health, by referral to other VA facilities, or by sharing agreements, contracts, or non-VA fee basis care to the extent that the veteran is eligible.

(2) The services that must be “provided” are those that must be delivered when clinically needed to patients receiving health care at a facility by appropriate staff located at that facility, or by telemental health.

(3) Some services or other provisions are mentioned, with wording indicating such that they “may” be delivered, or that facilities are “encouraged” or “strongly encouraged” to provide them.

These indicate suggestions, not requirements.

b. It is not the purpose of this Handbook to describe all mental health programming that could be appropriate and effective. Sites are strongly encouraged to go beyond these specifications in developing their mental health programming, in accordance with their challenges, resources, and opportunities. As in the past, VISNs and facilities are strongly encouraged to engage in research and clinical innovation to develop new strategies of care.

Ongoing improvements in the VHA system depend on these approaches to developing best practices.

c. Program specifications are not described in detail, allowing opportunities for local choice, within the specifications, and for developing programs that address local variation in presenting problems. For example, some areas of the country have far more homeless veterans than do other areas, and their specific programming can be expected to vary accordingly.

d. Care must be provided with fidelity to these specifications. Fidelity includes attention to good program design, to delivery of evidence-based psychotherapy in ways that capture those therapy procedures, and to the provision of pharmacotherapy using evidence-based strategies for choosing medications, implementing treatment, monitoring both side effects and therapeutic outcomes, and modifying treatment when appropriate. Details that are not provided in this Handbook can be found in program documents and Clinical Practice Guidelines. NOTE:

Contact the VA Central Office, Office of Mental Health Services with questions or requests for technical assistance at: 202-461-7309.

e. Care must be delivered by qualified, trained, competent staff. In general, this Handbook does not specify the professions who must provide the services described, but there must be attention to ensuring that care is provided by those at an appropriate level of training and clinical privileging. All professional staff must have the administrative and clinical support(s) they require to allow them to work efficiently.

f. These specifications of the mental health services that must be available as needed to each veteran and those that must be provided as needed at each type of facility supplement other requirements for timely access and quality of care. Because VHA is responsible for mental health care to a defined population, it has responsibilities for ensuring ready access to care for new patients, as well as for the continuity and quality of care for established ones. At a time when large numbers of veterans are returning from deployment and combat, ensuring access to care for patients in need must be considered VA’s highest priority.

g. In order to ensure full coverage across a spectrum of needs, the specifications are laid out according to particular program areas. Individual veterans typically present with more than one mental health problem, and, typically, they also present with other health problems as well.

Services must not be set up in isolation. It is expected that there will be communication and coordination between services. Every program element described in this Handbook must be understood as an integrated component of overall health care.

4. RESPONSIBILITIES

a. Facility and Veterans Integrated Service Network (VISN) Mental Health Leadership. Facility and VISN Mental Health Leadership must work in collaboration with overall leadership at each level to ensure:

(1) There is integration or coordination between the care of substance use disorders and other mental health conditions for those veterans who experience both, and for integration or coordination between care for mental health conditions and other components of health care for all veterans.

(2) Every veteran seen in mental health services is assigned a principal mental health provider. When veterans are seeing more than one mental health provider and when they are involved in more than one program, the identity of the principal mental health provider must be made clear to the patient and identified in the medical record. The principal mental health provider must be identified on the patient tracking database for those patients who need case management.

b. The Principal Mental Health Provider

(1) The principal mental health provider must ensure that:

(a) Regular contact is maintained with the patient as clinically indicated as long as ongoing care is required.

(b) A psychiatrist reviews and reconciles each patient’s psychiatric medications on a regular basis.

(c) Coordination and development of the veteran’s treatment plan incorporates input from the veteran (and, when appropriate, the family with the veteran’s consent when the veteran possesses adequate decision-making capacity or with the veteran’s surrogate decision-maker’s consent when the veteran does not have adequate decision-making capacity).

(d) Implementation of the treatment plan is monitored and documented. This must include tracking progress in the care delivered, the outcomes achieved, and the goals attained.

(e) The treatment plan is revised, when necessary.

(f) The principal therapist or principal mental health provider communicates with the veteran (and the veteran's authorized surrogate or family or friends when appropriate and when veterans with adequate decision-making capacity consent) about the treatment plan, and for addressing any of the veteran’s problems or concerns about their care. For veterans who are at high risk of losing decision-making capacity, such as patients with a diagnosis of schizophrenia or schizoaffective disorder, such communications needs to include discussions regarding future mental health care treatment (see information regarding Advance Care Planning Documents in VHA Handbook 1004.2).

(g) The treatment plan reflects the patient’s goals and preferences for care and that the veteran verbally consents to the treatment plan in accordance with VHA Handbook 1004.1, Informed Consent for Clinical Treatments and Procedures. If the principal mental health provider suspects that the veteran lacks the capacity to make a decision about the mental health treatment plan, the provider must ensure that the veteran’s decision making capacity is formally assessed and documented. For veterans who are determined to lack capacity, the provider must identify the authorized surrogate and document the surrogates’ verbal consent to the treatment plan.

(2) Each principal mental health provider must collaborate with the Suicide Prevention Coordinator (SPC) in each facility to support the identification of those who have survived suicide attempts and others at high risk, and to ensure that they are provided with increased monitoring and enhanced care.

5. SPECIFICATIONS

a. These specifications describe both general mental health services and a number of specific programs focusing on conditions or problems, such as: substance use disorders, Post-Traumatic Stress Disorder (PTSD), military sexual trauma (MST), homelessness, and psychosocial rehabilitation. Although facilities differ in the way they organize and administer these services, when facilities have distinct services or programs, they must develop service agreements defining when and how patients are transferred or co-managed between them (see current VHA policy regarding service agreements).

b. The specifications in this Handbook for enhanced access, evidence-based care, and recovery or rehabilitation must not be interpreted as deemphasizing respect for the needs of those who have been receiving supportive care. No longstanding supportive groups are to be discontinued without consideration of patient preference, planning for further treatment, and the need for an adequate process of termination or transfer.

(l) All veterans receiving mental health care need to be enrolled in a VA primary care clinic to receive primary care. When veterans are not already engaged in primary care in VHA, mental health providers need to assist them in arranging a first visit to primary care. Patients who decline primary care involvement must receive all required screening and preventive interventions in the mental health clinic.

(2) Mental health services must be recovery-oriented. According to the National Consensus Statement on Mental Health Recovery (found at:

http://mentalhealth.samhsa.gov/publications/allpubs/sma05-4129/ ): “Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of the person's choice while striving to achieve ... full potential.”

(a) The Consensus Statement lists ten fundamental components of recovery:

1. Self-direction,

2. Individualized and person-centered,

3. Empowerment,

4. Holistic,

5. Non-linear,

6. Strengths-based,

7. Peer support,

8. Respect,

9. Responsibility, and

10. Hope.

(b) As implemented in VHA recovery, it also includes:

1. Privacy,

2. Security,

3. Honor, and http://mentalhealth.samhsa.gov/publications/allpubs/sma05-4129/

4. Support for VA patient rights.

(3) All mental health care must be provided with cultural competence.

(a) All staff who are not veterans must have training about military and veterans’ culture in order to be able to understand the unique experiences and contributions of those who have served their country.

(b) All staff must receive cultural competence training addressing ethnic and minority issues.

(4) There must be a mental health treatment plan for all veterans receiving mental health services.

(a) The treatment plan must include the patient’s diagnosis or diagnoses and document consideration of each type of evidence-based intervention for each diagnosis.

(b) The treatment plan needs to include approaches to monitoring the outcomes (therapeutic benefits and adverse effects) of care, and milestones for reevaluation of interventions and of the plan itself.

(c) As appropriate, the plan needs to consider interventions intended to reduce symptoms, improve functioning, and prevent relapses or recurrences of episodes of illness.

(d) The plan needs to be recovery oriented, attentive to the veteran’s values and preferences, and evidence-based regarding what constitutes effective and safe treatments.

(e) The treatment plan needs to be developed with input from the patient, and when the veteran consents, appropriate family members. The veteran’s verbal consent to the treatment plan is required pursuant to VHA Handbook 1004.1.

6. IMPLEMENTATION

a. VA Central Office recognizes that local and regional issues may affect the implementation of these clinical requirements. NOTE: The Office of Mental Health services needs to be kept informed about such difficulties as they arise and evolve. Potential barriers to implementation can include:

(1) Space limitations within VA facilities;

(2) A relative lack of availability in certain regions of mental health clinicians who could be recruited to the VA;

(3) Difficulties in meeting information technology needs;

(4) The distances for patient travel;

(5) Limitations in the availability of community-based providers who could provide services using a sharing agreement, contract, or non-VA fee basis care to the extent that the veteran is eligible; and

(6) The time that may be required to develop contacts or other arrangements with local provider organizations.

b. Each VISN must request modifications or exceptions for each medical center and CBOC for those requirements that cannot be met in fiscal year (FY) 2008 and FY 2009 with available and projected resources.

c VISNs must submit requests for modifications and exceptions to these clinical requirements to the Office of Mental Health Services (116) for informational purposes and to the Deputy Under Secretary for Health for Operations and Management (10N) for approval. Any unresolved issues between the program office and (10N) must be presented to the Principal Deputy Under Secretary for Health for resolution. Requests are to include mark-ups to this document indicating the specifications of the package of services that will be delivered in each facility together with justifications for the modifications or exceptions, and, where relevant, requests for the additional resources that would enable implementation. These may include requests for medical care funds, medical facilities funds, informatics resources, legal support for contracting, or other resources.

d. Requests for modifications and exceptions need to include plans for ensuring the availability of all required services for veterans who need them, and, where relevant, timetables and milestones for implementation of the clinical requirements at relevant facilities.

7. STRUCTURE AND GOVERNANCE OF MENTAL HEALTH SERVICES

a. Each VISN must include a mental health professional as a member of its principal decision-making body. Each facility must include such leadership in its governance.

b. Where there are mental health service lines, or equivalents, recruitment of leadership must be compliant with current VHA policy, which specifies that all mental health leadership positions must be advertised for all of the core mental health professions (Psychiatry, Psychology, Social Work, and Nursing), and that selection must be equitable among candidates.

Evaluation of candidates and selection of leadership needs to consider all relevant factors.

c. Mental health programs must not function as isolated entities. Regardless of the structure of mental health services and of their leadership, there must be mechanisms for ensuring that leadership has coordinated input from all of the mental health professions that serve patients in relevant facilities, and from each of the specialized programs. Mental health leadership has the responsibility to build a coherent program; much like the Chief of Medicine coordinates the activities of a diverse group of specialists.

(1) Within each medical center, each of the core mental heath professions needs to be represented by a designated leader in that profession who takes responsibility for the professional practice of that discipline and has responsibilities for mentoring and professional development of staff in that profession. This person needs to have responsibilities for, or direct input into, hiring decisions and performance evaluations.

(2) Each VA medical center must establish and maintain a Mental Health Executive Council that includes representation from core mental health professional disciplines and specialty VA mental health programs with administrative support from the medical center. NOTE: Facilities are encouraged to include representation from Readjustment Counseling Centers (Vet Centers) in this Council. The facility Director may decide whether other professions (e.g., Recreation Therapists, Occupational Therapists, Chaplains, as well as representatives from the Integrated Ethics program, and others) are also to be represented.

(a) Reporting

1. Where there is a mental health service line or equivalent, the Mental Health Executive Council reports to its leadership.

2. Where the core disciplines function more independently, the Mental Health Executive Council reports to the Chief of Staff.

(b) Responsibilities. The Mental Health Executive Council is responsible for:

1. Proposing strategies to improve care and consulting with management on methods for improvement and innovation in treatment programs.

2. Working to coordinate communication among and between various departments and specialty mental health programs.

3. Reviewing the mental health impact of facility-wide policies that include, but are not limited to policies on:

a. Patient rights, privileges, and responsibilities;

b. Restraints and seclusion;

c. Management of suicidal behavior; and

d. Management of mental health emergencies.

d. Leadership of mental health services in medical centers needs to have professional oversight of the delivery of mental health care in associated CBOCs. However, this oversight cannot diminish or replace formal lines for reporting for staff at the clinic, or for decision-making about allocation of clinic resources. There must be mechanisms for ensuring communication between the leadership of mental health services and that of the associated CBOCs, such that their mental health delivery needs, activities, and evaluation outcomes are appropriately considered in the governance and decision-making processes for those facilities.

NOTE: This requirement for oversight and communication is intended to ensure the ability of the CBOC to respond to patients’ mental health needs, regardless of the processes used to address them. It applies whether or not the CBOC has specific mental health staffing.

8. COMMUNITY MENTAL HEALTH

a. Each VISN and each medical center must appoint mental health staff responsible for liaison with State, county, and local mental health systems and with community providers, ensuring coordination of VA activities with those of other public mental health and health systems. Such activities include:

(1) Informing State, county, and local mental health providers about VA services.

(2) Working through or with existing programs providing liaison with State National Guard programs, and with Vet Centers in their outreach to Post Deployment Health Re-Assessment (PDHRA) events.

(3) Maintaining awareness of community-based public and private mental health assets, particularly with respect to veterans and their families.

(4) Developing models for coordinating services for veterans and families (e.g., sharing agreements, collocation of staff, providing telemental health).

(a) Coordination of telemental health programs needs to be overseen by the Office of Care Coordination.

(b) Sharing agreements with the Department of Defense (DOD) and the military services must be coordinated through the office designated for that function.

(5) Addressing issues regarding involuntary mental health treatment that occur under State laws and sometimes across state lines.

b. When responsibilities for care within a State are divided between two or more VISNs, the VISNs need to coordinate their State liaison activities.

c. VISNs must designate a mental health professional, usually one of the facilities’ SPCs, to serve on each State’s council or workgroup on suicide prevention.

d. Each VISN and each medical center must designate at least one mental health professional to serve as public spokespersons for specific mental health issues. These individuals must work collaboratively with public affairs, communications offices, and leadership at the local, regional, and national levels. NOTE: Media training is encouraged.

e. Each facility must designate at least one individual to serve as a liaison with Vet Centers in the area (if any), to ensure care coordination and continuity of care for veterans served through both systems.

f. Facilities need to develop processes and procedures for promoting collaborations between mental health providers and VA Chaplains. Mental health services are encouraged to work with Chaplaincy to develop interactions with community clergy, including training to facilitate collaboration, appropriate referral, and coordination of services.

g. VISNs and facilities must collaborate with Vet Centers in outreach to returning veterans.

Outreach activities can include presentations at National Guard or Reserve sites and PDHRA events.

(1) Outreach to OEF and OIF veterans has several goals:

(a) Informing recently discharged veterans of the nature of VA benefits including, but not limited to health care benefits;

(b) Screening veterans for signs and symptoms of mental health conditions; and

(c) Supporting engagement in clinical services as needed.

(2) Outreach can involve veterans’ families, as well as the veterans themselves, consistent with VA’s legal authority.

h. Facilities are strongly encouraged to implement and maintain a local mental health Consumer-Advocate Liaison Council to facilitate input from stakeholders on the structure and operations of mental health services.

(1) Mental health Consumer-Advocate Liaison Councils are composed of consumers and family members of consumers, and may include other stakeholders including, but not restricted to:

(a) Veteran Service Organizations (VSOs),

(b) Representatives from the National Alliance for the Mentally Ill (NAMI), Depression and Bipolar Support Alliance (DBSA), and other mental health advocacy groups active within the local community; and

(c) Local community employment and housing representatives;

(2) If a facility has a Mental Health Consumer-Advocate Liaison Council, at least one VA mental health staff member must be designated to serve as a liaison to the Council to facilitate communication with the leadership of the facility’s mental health program.

(3) The Federal Advisory Committee Act (FACA) may be applicable to the Consumer- Advocate Liaison Council. Facilities must consult with Regional Counsel to ensure compliance with FACA, if applicable.

9. GENDER-SPECIFIC CARE

a. Mental health services need to be provided to those who need them in a manner that recognizes that gender-specific issues can be important components of care.

(1) Facilities are strongly encouraged, when clinically indicated, to give veterans (women and men) being treated for MST the option of being assigned a same-sex mental health provider, or opposite-sex provider if the trauma involved a same-sex perpetrator.

(2) Facilities are strongly encouraged to give patients treated for other mental health conditions the option of a consultation from a same-sex provider regarding gender-specific issues. NOTE: Facilities are encouraged to offer men and women treated for other mental health conditions the option of a consultation or treatment from an opposite-sex mental health provider, when clinically appropriate.

b. All VA facilities must accommodate and support women and men with safety, privacy, dignity, and respect.

c. All inpatient and residential care facilities must provide separate and secured sleeping accommodations for women. Mixed gender units must ensure safe and secure sleeping and bathroom arrangements, including, but not limited to door locks and proximity to staff.

10. 24 HOUR A DAY, 7 DAYS A WEEK (24/7) CARE

a. VHA policy requires that all VHA Emergency Departments (EDs) have mental health coverage by an independent, licensed mental health provider (i.e., a psychiatrist, psychologist, social worker, or advanced practice nurse) either on site or on call, on a 24/7 basis. For "Level 1A" facilities (those facilities that have higher utilization, higher risk patients, specialized intensive care units, and research, educational, and clinical missions), mental health coverage must at a minimum be on-site (based in the ED) from 7 am to 11 pm. At other times, it may be on-site or on-call. For other facilities, coverage may be either on-site or on-call at all times. On-call coverage requires a telephone response within 20 minutes and the ability to implement on-site evaluations within a period of time to be established on a facility-by-facility basis.

Psychiatric residents and psychology postdoctoral fellows, where available, may provide ED coverage. If that coverage is on site, then a psychiatry or psychology supervising attending must also be present in the ED. Psychiatry residents or psychology fellows who are on call and respond to requests for ED consultation are expected to contact their supervising practitioners while the patient is still in the ED in order to discuss the case and to develop and recommend a plan of management.

b. All medical centers with emergency departments must have resources to allow extended observations or evaluations for up to 23 hours when clinically necessary. This may be accomplished through accommodations such as observation beds in the EDs, or, when consistent with State law and accreditation standards, through arrangements with inpatient units. These may be especially important to allow observations and evaluations of patients presenting in states of intoxication.

c. Urgent care centers must have mental health coverage during their times of operation.

"Level 1a" complexity sites must have mental health coverage from a licensed independent mental health provider available on-site during their times of operation at least from 7 am to 11 pm with on-call coverage at other times. For other facilities, urgent care centers must have mental health coverage during their times of operation that may be on-site or on-call.

d. Providers in EDs and Urgent Care Centers, as well those in mental health care settings must be aware of relevant State laws for involuntary hospitalization, and consult Regional Counsel as needed.

(1) Facilities with locked and secure mental health inpatient units must be prepared when it is feasible to accept involuntary admissions resulting from civil commitments for those veterans for whom VHA provides health care services.

(2) All other facilities must have agreements with appropriate agencies or hospitals to allow them to arrange involuntary hospitalization when it is appropriate.

(3) Requirements for facilities to accept involuntary hospitalizations resulting from civil commitments do not apply when another agency of Federal, State, or local government has the duty to give the care or services in an institution of such government.

e. All telephone triage programs must have the capacity to evaluate mental health problems by having:

(1) Staff, training, and protocols to allow responders to screen for mental health conditions and to know when to contact the mental health provider on-call for an evaluation of the screening findings.

(2) A mental health provider on-call to provide back-up decision-support when needed.

(3) Procedures to facilitate access to the national suicide prevention hotline when appropriate.

f. All CBOCs and facilities without EDs or 24/7 urgent care must have predetermined plans for responding to mental health emergencies when they occur during times of operation. They must:

(1) Identify at least one accessible VA or community-based ED where veterans are directed to seek emergent care when necessary,

(2) Develop contracts, sharing agreements or other appropriate arrangements with them for sharing information, and

(3) Develop financial arrangements for payment for authorized emergency services and necessary subsequent care.

g. Patients in ED or urgent care settings must be evaluated to establish the urgency of care.

When indicated, interventions must be initiated immediately, with follow-up as appropriate.

Follow-up for mental health conditions determined to be non-urgent must be within 14 days.

11. INPATIENT CARE

a. Inpatient care must be available to all veterans who require hospital admissions for a mental disorder, either in the VA medical center where they are treated, a nearby facility, or by contract, sharing agreement, or non-VA fee-basis referral to a community facility to the extent that the veteran is eligible.

b. Secured (locked) inpatient mental health units must be available for these veterans when symptoms or conditions require them. Secured inpatient units in VA medical centers must be prepared when it is feasible to accept involuntary hospitalizations resulting from civil commitments for veterans for whom VHA provides health care services.

(1) Requirements for facilities to accept involuntary hospitalizations resulting from civil commitments do not apply when another agency of Federal, State, or local government has the duty to give the care or services in an institution of such government.

(2) Facilities must consult regional counsel, as needed, to ensure that local policies are consistent with Federal, State, and other applicable laws.

c. Inpatient units must promote a positive therapeutic and least restrictive environment and strive to be restraint- free.

d. Acute hospitalization must be available without delay for those who require urgent or emergent admissions.

e. Staff on inpatient units must function as care teams with close coordination of their activities to ensure continuity of care, safety, and effective treatment for all patients.

f. All patients on inpatient units must be evaluated as clinically indicated for warning signs of self-destructive and dangerous behaviors, including risks of suicide and violence. When such symptoms or warning signs are observed, the care team must act immediately to optimize safety.

g. All inpatient units must be surveyed at least quarterly with the Environment of Care checklist at: http://vaww.ncps.med.va.gov/Dialogue/pslog/view.asp?eid=280 . NOTE: This is an internal VA web site not available to the public. Safety problems need to be remedied or mitigated prior to the next quarterly review. Requests for exceptions must be approved by the VISN Director and the VA Office of Mental Health Services.

h. Acute inpatient psychiatry units need to be staffed at a level that ensures that all patients are safe in the environment of care. One on one (1:1) care may be necessary for patients with a high risk for suicide.

i. Privacy and a safe environment for all patients are required in all inpatient mental health programs, as well as access to gender-specific staff when clinically indicated.

http://vaww.ncps.med.va.gov/Dialogue/pslog/view.asp?eid=280

j. Inpatient, as well as outpatient care, must be guided by principles of psychosocial rehabilitation with an expectation of recovery. Specifically:

(1) The veteran or the veteran’s authorized surrogate and, with the veteran's consent, family members must be encouraged to participate in inpatient treatment planning and discharge planning to the fullest extent possible. NOTE: Involuntarily committed patients are to be presumed to have decision-making capacity, unless a formal assessment has determined they lack capacity for a specific treatment decision.

(2) Staff evaluations of inpatients must include attention to the veteran’s goals, activities directed toward improved functioning, involvement in community activities, and other indices of functioning and role performance.

(3) Treatment goals for inpatients need to be congruent with those expectations for functioning, including discharge to a less restrictive level of care.

k. Discharge planning needs to include:

(1) Consideration of referral to Mental Health Intensive Case Management (MHICM) programs or utilization of other recovery-oriented resources, such as Psychosocial Rehabilitation and Recovery Centers (PRRC) (see subpar. 17.b); and

(2) Communication and coordination with primary care.

12. RESIDENTIAL REHABILITATION AND TREATMENT PROGRAMS (RRTP)

NOTE: Mental Health Residential Rehabilitation Treatment Programs (MH RRTP) provide residential rehabilitative and clinical treatment for veterans who have a wide range of problems, illnesses, or rehabilitative care needs. These can be medical, psychiatric, vocational, educational, and social and could be related to Substance Use Disorder (SUD), homelessness and other conditions or problems. The term MH RRTP is used to refer to those facilities currently designated as Psychosocial Residential Rehabilitation Treatment Programs (PRRTPs), Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Programs (PTSD-RRTPs), Substance Abuse Residential Rehabilitation Treatment Programs (SARRTPs), and Compensated Work Therapy (CWT)-Transitional Residence (TRs), as well as Domiciliaries, also designated as Domiciliary Residential Rehabilitation Treatment Programs (DRRTPs), and Domiciliary Care for Homeless Veterans (DCHVs). Although these programs have different histories and different eligibility policies, the clinical policies and clinical practices are identical.

a. Given their distinct mission to serve veterans with multiple and severe deficits, MH RRTPs must not be used as a substitute for community housing or as VA lodging or Hoptel facilities. Additionally, VA lodging or Hoptel facilities do not provide the necessary structure, programming, support, and are not an appropriate alternative or replacement for an MH RRTP

b. Each veteran who requires domiciliary care or residential rehabilitation and treatment programs must have timely access to these residential care programs as medically necessary to meet the veteran's need for specialized, residential, intensive mental health treatment, and rehabilitation services.

c. Each medical center must provide access to MH RRTP services for veterans who require this type of care. This requirement can be met:

(1) On a local basis through the availability of MH RRTP at the facility,

(2) On a regional basis through service agreements with other VA facilities, or

(3) By sharing agreements, contracts, or non-VA fee basis care to the extent the veteran is eligible, in community facilities.

d. Each VISN must have residential care programs able to meet the needs of women veterans and veterans with a Serious Mental Illness (SMI), PTSD, MST, SUD, Homelessness, and Dual Diagnoses either through special programs or specific tracks in general residential care programs.

However, the needs for some types of sub-specialty care (e.g., women with PTSD or veterans with PTSD and SUD) may be limited, and regional or national resources may be needed.

e. Mental health services must be provided as needed to female veterans at a level equivalent to their male counterparts at each facility. MH RRTP clinicians must possess training and competencies to meet the unique mental health needs of women veterans.

f. MH RRTPs must be Commission on Accreditation of Rehabilitation Facilities (CARF)-accredited in Behavioral Health Residential Standards.

g. Facilities must ensure that waits for admission to a MH RRTP do not delay the implementation of care by instituting processes that include:

(1) Ongoing monitoring and case management of referred patients.

(2) Provision of treatment as needed to ensure stabilization of target conditions and management of comorbidities. NOTE: This may include inpatient care.

(3) Utilizing waiting periods to provide pre-group preparation to enhance the experience and benefits of group treatment. Pre-group preparation can be provided on an outpatient basis provided veterans are in a safe and secure environment.

h. Whenever veterans awaiting admission to an RRTP have an urgent need for mental health care, appropriate mental health services must be provided.

i. Whenever there is a gap of greater than 2 weeks for any veteran accepted into an MH RRTP, providers must maintain clinical contact with the veteran until the time of admission, and address any urgent mental health care needs that arise.

j. When the referral to the MH RRTP involves a transfer between facilities, the referring facility must maintain full responsibility for the patient until the time of admission.

Responsibility for travel arrangements and transfer expenses must be determined in accordance with current VHA inter-facility transfer policy.

k. The use of cohort-based or closed group modalities can enhance the levels of trust and cohesiveness between group members, especially when highly-sensitive topics are discussed.

However, they can also introduce delays in admission and the start of treatment. Use of cohort-based or closed groups is authorized in a VHA facility only when the care system within the facility is designed to ensure that they do not lead to any veteran being turned away from care.

(1) When VHA facilities utilize cohort or closed group treatment, the facility must ensure that this does not limit access to needed care. This may require immediate provision of all required treatment that can be provided for veterans outside of the closed group in ambulatory, inpatient, or other residential care settings as appropriate.

(2) Pre-group preparation can be provided when needed on outpatient basis provided veterans are in a safe and secure environment or in open beds in a MH RRTP.

l. Facilities must ensure that discharge planning, including an aftercare plan, occurs for all veterans leaving an MH RRTP and that these veterans are provided services based on a plan of care addressing clinical needs at time of discharge.

m. Facilities must ensure full compliance with MH RRTP Safe Medication Management (SMM) procedures. NOTE: VHA Handbook 1108.3 Self Medication Program does not apply to MH RRTPs.

n. Facilities must ensure safety and security of all MH RRTPs. Facilities must ensure that each MH RRTP is in compliance with VA and accrediting body standards for safety and security.

o. MH RRTPs require 24/7, on site-supervision. At least one staff member must be physically present on the unit at all times that veterans are present on the unit. The only exception to this requirement is for mental health rehabilitation and treatment services provided in CWT-TR. Because residents in these facilities are more stable and functional than those in other MH RRTPs, a peer “house manager” may supervise the residence in lieu of staff.

However, professional staff must be available when needed on an emergency basis.

p. Each MH RRTP must be staffed by an interdisciplinary clinical team or teams of health care professionals and paraprofessionals. Attention to the veteran’s medical, social, and psychological needs must be ensured through adequate medical staff, social workers, and psychologists. Appropriate supporting administrative and clerical staff must be provided to allow for efficient operation.

q. In most MH RRTPs, staffing includes full-time staff assigned directly to the program and part-time staff from other inpatient or outpatient units providing treatment and rehabilitation services.

r. Special attention must be given to meeting the unique needs of women veterans, especially in the areas of SMI, sexual trauma, homelessness, and interpersonal violence.

s. All MH RRTPs must be sensitive to the special needs of veterans, and to the needs of specific populations, including, but not limited to: the homeless; ethnic minorities; women;

geriatric patients; those with SUD, PTSD, and other psychiatric comorbidities; infectious disease; Spinal Cord Injury (SCI); and Traumatic Brain Injury (TBI).

t. Based on the MH RRTP's mission and patient demographics, MH RRTP staff must have competencies to meet the individual needs of special populations.

u. Evidenced-based psychosocial treatment interventions must be provided when they are needed clinically in each MH RRTP. NOTE: MH RRTPs are strongly encouraged to include Seeking Safety, motivational interviewing, motivational incentives for recovery-related behaviors, and supported employment.

v. All MH RRTPs must have staffing with the training and expertise needed to provide interventions, designed to benefit the veteran, that include residents’ families when these are included in the treatment plan.

13. AMBULATORY MENTAL HEALTH CARE

NOTE: Evaluations and treatment for mental health conditions can be provided in mental health care services, through primary care and other medical care settings, or by arrangements with non-VA community services.

a. All new patients requesting or referred for mental health services must receive an initial evaluation within 24 hours, and a more comprehensive diagnostic and treatment planning evaluation within 14 days.

(1) The primary goal of the initial 24-hour evaluation is to identify patients with urgent care needs, and to trigger hospitalization or the immediate initiation of outpatient care when needed.

(2) The initial 24 hour evaluation can be conducted by primary care, other referring licensed independent providers, or by licensed independent mental health providers.

b. Waiting times for all services for established patients must be less than 30 days from the desired date of appointment.

c. Telemental Health services require a qualified professional at the facility and support staff at the distal end who can arrange appropriate time and space for the veteran, and staff who can provide technical support as needed.

(1) Use of Telemental Health to support the delivery of services is allowed and encouraged as a mechanism for meeting requirements throughout this document. Nevertheless, it is important to recognize that there may be limits to the services that can be provided using this technology.

These may include certain highly interactive and “high-touch” evaluations or interventions.

(2) Sufficient band width is required for satisfactory communication. The Mental Health Service needs to consult with the medical center and VISN Information Technology Offices to determine specific requirements to have satisfactory clinical video conferencing capabilities.

d. Psychotherapy groups can be closed or cohort-based, or they can continually be open to new members. There are a number of arguments in favor of closed groups. However, waiting for the formation of a new group can lead to delays in the institution of treatment. Accordingly, closed or cohort-based groups are allowable in VHA facilities only when the facility’s care system ensures that they do not lead to the denial of care for any veteran, and that waiting for the start of a new psychotherapy group does not lead to delays in the implementation of care

(1) Whenever veterans have an urgent need for mental health care, appropriate mental health services must be provided.

(2) Patients awaiting the start of a therapy group must be monitored on an ongoing basis.

Their care needs must be evaluated, and alternative treatments must be implemented when needed, for example:

(a) When patients are a danger to themselves or others,

(b) When they are experiencing increasing degrees of impairment, or

(c) When they are suffering from severe symptoms.

(3) Waiting periods need to be utilized to provide pre-group preparation to enhance the experience and benefits of group treatment. Whenever patients need to wait for the start of a group, they must be offered an appropriate form of interim treatment.

e. VA medical centers must provide general and specialty mental health services when those receiving care from the medical centers need them.

(1) General mental health services include:

(a) Diagnostic and treatment planning evaluations for the full range of mental health problems;

(b) Treatment services using evidence-based pharmacotherapy, or evidence-based psychotherapy for patients with mental health conditions and substance use disorders;

(c) Patient education;

(d) Family education when it is associated with benefits to the veterans;

(e) Referrals as needed to inpatient and residential care programs; and

(f) Consultation about special emphasis problems including PTSD and MST.

(2) Specialty mental health services include:

(a) Consultation and treatment services for the full range of mental health conditions;

(b) Evidence-based psychotherapy;

(c) MHICM;

(d) Psychosocial Rehabilitation Services, including: PRRCs, family psycho-education, family education, skills training, peer support, and CWT and supported employment;

(e) PTSD teams or specialists;

(f) MST special clinics;

(g) Homeless programs; and

(h) Specialty substance abuse treatment services.

f. Clinics in medical centers must offer a full range of services during evening hours at least 1 day per week. Additional evening, early morning, or weekend hours need to be offered when they are required to meet the needs of the facility's patient population.

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