Background Veterans with Mental Health Conditions About 2 million of the more than 6 million veterans who received VHA services in fiscal year 2018 had at least one diagnosed mental health condition, with MDD being the most prevalent diagnosis. About half of these approximate 2 million veterans had a single mental health condition while the remaining half had multiple mental health conditions (see fig. 1). In fiscal year 2018, the three most prevalent mental health conditions among veterans using VHA services were MDD (15 percent), PTSD (12 percent), and GAD (3 percent): MDD. This condition is the most prevalent and disabling form of depression. In addition to the immediate depression symptoms (such as persistently feeling sad or anxious, loss of interest in activities, and difficulty sleeping or oversleeping), MDD can result in poor quality of life overall and decreased productivity, and increased risk of suicide. PTSD. Those with PTSD have experienced symptoms that have persisted for more than 1 month after exposure to a traumatic event, although the onset of symptoms may be delayed for much longer, and cause significant distress or impairment in social, occupational, or other important areas of functioning. Symptoms may include recurrent, involuntary memories of the traumatic event and flashbacks in which the veteran feels or acts as if the traumatic event were recurring. PTSD is strongly associated with reduced quality of life and adverse physical health outcomes. GAD. Those with GAD feel continually worried or anxious about a range of events or activities in their daily lives and have difficulty controlling or stopping this worry. Along with feeling worried, those with GAD experience symptoms of tension such as restlessness, feeling on edge, being easily tired, difficulty concentrating, and sleep difficulties. Outpatient Mental Health Treatment Veterans with mental health conditions may be offered a variety of treatment options. Of the approximate 2 million veterans with at least one diagnosed mental health condition in fiscal year 2018, 45 percent received non-pharmacologic therapy, 27 percent received a combination of non-pharmacologic therapy and psychotropic medication, and 10 percent received psychotropic medication only. Non-pharmacologic therapy. Non-pharmacologic therapy, or psychotherapy, involves treating mental health conditions using psychological rather than medical means. There are many different types of therapy options, although not all may be available at every VAMC. Examples of non-pharmacologic therapies include cognitive behavioral therapy and prolonged exposure therapy. Some therapy options may be provided to individual veterans, while others are offered to groups of veterans. Psychotropic medications. Psychotropic medications are used to affect one’s mood, thought, or behaviors. Veterans can be prescribed one or more psychotropic medications, from one or more classes, to treat their diagnosed mental health conditions. For example, sertraline—a psychotropic medication commonly known by its brand name Zoloft®—is used by VHA providers to treat both depression and anxiety. Combining treatment. Providers may decide to offer both psychotropic medications and non-pharmacologic therapy, rather than prescribing or offering either option alone. Decisions to offer any of these treatment options are made by providers in various VAMC outpatient care settings. Primary care setting. In addition to addressing other health care needs, PCPs may order non-pharmacologic treatment, prescribe psychotropic medications, or combine both treatment options to address a veteran’s mental health conditions. Through the primary care-mental health integration (PC-MHI) model, which VAMCs began implementing in 2007, PCPs may also collaborate with mental health providers (e.g., psychologists, social workers, nurses) who are collocated within the primary care clinic before making treatment decisions. These collocated mental health providers can also offer non-pharmacologic therapy to veterans without requiring a separate visit outside of primary care. Specialty care setting. Mental health providers in a specialty care setting, such as psychiatrists, decide whether to provide any type of treatment for veterans who have been referred to them by providers in primary care for services specific to their mental health conditions. Veterans may also seek services from a mental health provider in specialty care without first obtaining a referral from primary care. Mental Health Treatment Planning Requirements VHA has established certain requirements for providers’ documentation of specialty mental health care treatment plans, and the Joint Commission periodically reviews the documentation of such plans to ensure that they align with the Commission’s standards. VHA. To ensure that providers develop appropriate approaches to treating veterans with mental health conditions and reevaluate such treatment approaches over time, VHA has established certain policies to govern the documentation of mental health treatment decisions by mental health providers in specialty care. For example, in 2008, VHA issued its mental health services handbook to define minimum clinical requirements for mental health services at VAMCs, requiring that providers in specialty care document mental health treatment plans in veterans’ electronic medical records. The mental health services handbook specifies that plans should include certain components such as documentation that different evidence-based treatment options were considered by mental health providers and that approaches to monitor the outcomes of care were developed. The Joint Commission. The Joint Commission is an independent, not-for-profit organization responsible for accrediting and certifying health care organizations and programs in the United States (including VAMCs) at least once every 3 years, and it has developed standards to use as the basis of its evaluative process. These standards focus on specific patient and organization functions that are essential to providing safe and high-quality care, including plans for treatment provided in mental health care settings. VAMC Resources and the Complexity of Veterans’ Mental Health Conditions Are among Factors That Contribute to Providers’ Treatment Decisions VAMC officials we interviewed reported various factors as contributing to providers’ decisions to prescribe psychotropic medications and offer non- pharmacologic therapy to veterans. Specifically, officials from multiple VAMCs cited each of the following factors as contributing to treatment decisions: VAMC resources, complexity of veterans’ mental health conditions, comfort level of providers with treating conditions or prescribing medications, veterans’ preferences, and logistics of receiving mental health treatment. See table 2 for the factors and supporting examples offered by VAMC officials during our site visits. In our review of documentation VAMC providers may use when making treatment decisions, we identified some additional factors. For example, providers’ use of clinical practice guidelines (CPG) established by VA and the Department of Defense may contribute to providers’ treatment decisions. Specifically, the CPG for mental health conditions that are highly prevalent among veterans, including MDD and PTSD, are a resource that all VAMC providers may use when making treatment decisions. For example, the CPG for the management of MDD recommends that providers offer either psychotropic medications or non- pharmacologic therapies (such as behavioral therapy) for the primary treatment of uncomplicated MDD. In contrast, the CPG for the management of PTSD recommends initial treatment for this condition to be a specific type of non-pharmacologic therapy (individual trauma- focused therapy), and when this therapy is not readily available or preferred, then treatments include prescribing psychotropic medications or offering another form of non-pharmacologic therapy. Though it is not mandatory for providers to follow the recommendations of the CPGs, which are based on the strength of evidence and also the potential benefits and harms of treatment options, every provider is responsible for evaluating the appropriateness of applying CPG recommendations in any particular clinical situation. Another factor we identified in our review of documentation was service agreements that VAMCs have in place to help coordinate mental health services across outpatient settings. All five of the VAMCs in our review have formal agreements to help coordinate mental health services across outpatient settings to help manage VAMC resources. These agreements indicate that, for example, providers in primary care can provide treatment for certain mental health conditions, such as uncomplicated depression, without referring veterans to mental health providers in specialty care (see text box). Service Agreements between Primary and Specialty Care for the Treatment of Mental Health Conditions in Selected VA Medical Centers (VAMC) All five of the VAMCs in our review have formal service agreements to help coordinate treatment across primary and specialty care settings for certain mental health conditions, such as uncomplicated depression: All service agreements from the VAMCs in our review indicated that providers in primary care can treat uncomplicated depression without referring veterans to a mental health provider in a specialty care setting. All service agreements indicated at what point mental health providers in specialty care should be involved to help treat veterans with uncomplicated depression—for example, if veterans failed to respond to treatment after trying two different psychotropic medications, or if symptoms worsen over time. In addition to uncomplicated depression, other mental health conditions (including anxiety, PTSD, schizophrenia, and bipolar disorder) were addressed in four of the five service agreements we reviewed. For example, the four service agreements indicated that veterans with bipolar disorder should be treated by mental health providers in specialty care. In light of these factors, providers we interviewed reported on the extent to which each of the most prevalent mental health conditions resulted in PCPs prescribing medication to veterans prior to or without being referred to specialty care. Specifically, more providers reported that psychotropic medications are commonly prescribed to veterans with MDD, PTSD, or GAD prior to referring them to specialty care compared to providers who reported that it is common to prescribe without referring veterans to specialty care at all. See figure 2 for the percentages of providers reporting that psychotropic medications are commonly prescribed to veterans with these three conditions prior to referring them to specialty care. Providers also reported on the extent to which it was common for any provider to offer non-pharmacologic therapy to veterans with these three conditions in lieu of, or in addition to, prescribing psychotropic medications. More providers reported that non-pharmacologic therapy is commonly offered in addition to psychotropic medications compared to providers who reported that it is common to offer therapy instead of medication. See figure 3 for the percentages of providers reporting that non-pharmacologic therapy is commonly offered in addition to psychotropic medications. See appendix I for additional information about mental health treatment practices, including the prescribing of psychotropic medications and offering non-pharmacologic therapy to veterans in a random, nongeneralizable selection of medical records from the VAMCs in our review. See appendix II for information on the use of psychotropic medications or non-pharmacologic therapy by VHA providers to treat veterans with certain mental health conditions, nationally, in fiscal year 2018. VHA Has Not Developed Guidance that Communicates Its Expectation That Mental Health Treatment Plans Be Easily Identifiable VHA has not developed and disseminated guidance that specifies its expectation that mental health providers in specialty care document treatment plans in an easily identifiable way within veterans’ medical records. According to VHA officials responsible for overseeing mental health services, mental health providers should be documenting treatment plans in notes that are easily identifiable and separate from other health information, rather than embedding the plans in progress notes where they may combined with other information related to veterans’ medical histories and current health conditions. In our nongeneralizable review of 80 medical records for veterans who were seen by providers in specialty care and prescribed a psychotropic medication, we found that a majority (50) had a mental health treatment plan recorded in a progress note. We viewed several examples where the treatment plan was not the only information recorded within the progress note, making it difficult to readily identify the mental health treatment plan itself. A VHA official responsible for overseeing mental health services told us it is important for a mental health provider in specialty care to document each veteran’s treatment plan in such a manner so that the provider, or any other providers who may become involved in the veteran’s treatment, can readily refer to the plan as they evaluate progress. This may be particularly important during transitions between inpatient and outpatient care settings, or when adding providers to a veteran’s care team. Providers need to be able to readily access veterans’ mental health treatment plans to ensure that treatment is being provided as ordered, understand why certain treatments were decided against, and assess whether treatment changes are needed. The same VHA official told us that he encourages this practice to support VAMC compliance with the Joint Commission’s standards for mental health treatment plans. However, relevant VHA guidance documents for mental health providers do not specify this expectation: VHA mental health services handbook. The VHA mental health services handbook, published in 2008, requires that mental health providers in specialty care document treatment plans that include certain components. However, it does not specify where providers should document such plans within veterans’ medical records. VHA memo. A 2012 VHA memo promotes the use of a software program by mental health providers in specialty care that, according to VHA officials, facilitates the documentation of treatment plans in notes that are easily identifiable and separate from other information. However, the memo did not specifically state that documenting treatment plans in easily identifiable and separate locations from other information is the goal of using the software program, nor does the memo require providers to use the software. VHA health records handbook. This handbook, published in 2015, provides basic health information procedures for managing veterans’ health records and specifies that all outpatient providers must include treatment plans in progress notes. It does not explicitly reflect VHA’s expectation for mental health providers in specialty care to document mental health treatment plans in an easily identifiable way. Further, the health records handbook specifies that progress notes must also include other types of information, including the history of the veteran’s medical problem, the provider’s assessment of the problem, any tests or consults ordered, and instructions given to the veteran. VHA officials did not provide a rationale as to why they have not developed guidance that clearly directs mental health providers in specialty care to document treatment plans in an easily identifiable way within veterans’ medical records. They noted that VHA has relied upon the VAMCs to develop local processes for documenting specialty mental health treatment plans in an easily identifiable way when providers decide not to use the software program that VHA promoted in its 2012 memo. According to VHA officials, VHA is developing a new memo to communicate its expectation that mental health providers in specialty care document treatment plans in an easily identifiable way within veterans’ medical records. However, as of March 2019, VHA officials had not finalized this memo or indicated when the memo will be disseminated. Standards for internal control in the federal government require that agencies document responsibilities through policies and define objectives in terms that are understood at all levels. These standards also require that agencies communicate necessary information throughout all agency reporting lines to achieve the agencies’ objectives. Absent VHA guidance that clearly identifies its expectation for documenting specialty mental health treatment plans, providers may incorrectly record treatment plans in veteran’s electronic medical records such that they are not easily identifiable. As a result, there is a risk that a provider may be unable to readily access important information about a veteran’s mental health treatment, including the use of psychotropic medication or non- pharmacologic therapy, during changes in a veteran’s care. VHA may learn of the extent of this risk through efforts to collect information resulting from the Joint Commission’s accreditation survey process. Specifically, VHA uses various conference calls to discuss the Joint Commission accreditation survey process and results: According to a VHA official, VHA has weekly and quarterly conference calls with VISNs to, in part, help them prepare their VAMCs for future surveys and, as a result, VHA may learn about different types of citations that apply to multiple VAMCs. This, in turn, may allow VHA to identify concerns that may need to be addressed system-wide, including those related to mental health treatment planning. The Joint Commission provides VHA with an annual summary of data on common citations issued to VAMCs. According to the Joint Commission officials, the Commission provides VHA with this information through a conference call, which may also include a discussion of the underlying causes for any trends in system-wide citations. VHA officials may be able to use this information to address any systemic problems related to the documentation of specialty mental health treatment plans in an easily identifiable way within veterans’ medical records. According to a VHA official, VHA has not identified the documentation of specialty mental health treatment plans as an area for improvement across VAMCs. This issue was not included in the November and December 2018 conference calls with the VISNs, nor was it included in the 2018 annual summary of data that the Joint Commission provided to VHA. VHA Has Not Monitored Providers’ Documentation of Required Treatment Option Considerations in Mental Health Treatment Plans VHA has not developed or implemented an approach for monitoring whether mental health providers in specialty care are documenting their consideration of different evidence-based treatment options in mental health treatment plans as required by VHA’s mental health services handbook. In our review of a nongeneralizable sample of 80 medical records for veterans who were seen by such providers and prescribed a psychotropic medication, we found that none of the veterans had treatment plans that documented consideration of different evidence- based treatment options for the veterans’ mental health conditions. VHA relies on the Joint Commission to assess mental health treatment plans as part of the organization’s accreditation process for each VAMC, according to VHA officials. However, VHA does not obtain information resulting from the Joint Commission’s accreditation process that specifically relates to whether mental health providers are documenting consideration of different treatment options in their mental health treatment plans as required. The Joint Commission’s accreditation standards related to mental health treatment plans align with some, but not all, of VHA’s mental health services handbook’s required treatment plan components. For example, the standards align with VHA’s requirement that mental health providers in specialty care must document how they plan to track outcomes and re-evaluate treatment when needed. However, they do not call for the Joint Commission’s accreditation survey to assess whether specialty mental health treatment plans include providers’ consideration of different treatment options, and, according to organization officials, this is not something they look for when conducting their reviews. VHA’s mental health services handbook calls for monitoring through the use of metrics to ensure implementation of the handbook’s requirements, including those related to the documentation of the mental health treatment plan components by mental health providers in specialty care. Additionally, standards for internal control in the federal government require that agencies establish appropriate performance measures for defined objectives, perform ongoing monitoring activities, and remediate identified deficiencies on a timely basis. VHA’s lack of monitoring may contribute to inadequate documentation of the treatment options considered by mental health providers in specialty care in accordance with the mental health services handbook’s requirements. As a result, VHA cannot ensure that mental health providers in specialty care are appropriately considering all available evidence-based treatment options to provide the best care for veterans. This monitoring may be accomplished, for example, by establishing metrics and monitoring performance against such metrics, as called for by VHA’s mental health services handbook. Without metrics or other approaches to monitoring, VHA officials may not be identifying and addressing any systemic problems related to consideration of different evidence-based treatment options. VHA Has Taken Steps to Improve Veterans’ Treatment through the Psychotropic Drug Safety Initiative VHA has reported improvement in the safe and effective prescribing of certain psychotropic medications used to treat veterans with mental health conditions since the 2013 start of its Psychotropic Drug Safety Initiative (PDSI). To date, PDSI has consisted of three phases, with each phase focusing on different classes or types of psychotropic medications, age groups, or mental health conditions and substance use disorders. PDSI is currently in phase 3 and VHA is in the process of planning for a new phase 4, scheduled to begin in July 2019. For each phase, VHA developed a set of performance metrics from which each VAMC was required to select a designated number as a focus for implementing prescribing-related quality improvement efforts (referred to as the VAMC’s priority metrics). See table 3. VHA reported improvements in the majority of the performance metrics from the past PDSI phases. Specifically, VHA reported nationwide improvements in 16 of the 20 metrics that it developed for phase 1, and all 14 of the metrics that it developed for phase 2. For example, upon the completion of phase 1, VHA found that there was a nationwide 5.4 percentage point decrease (indicating improvement on this metric) in the percentage of veterans with PTSD who received one or more outpatient prescriptions for a benzodiazepine (a type of antianxiety medication). VHA reported that the change in benzodiazepine prescribing, among other improvements in treating veterans with PTSD, was particularly noteworthy given that the number of veterans diagnosed with this mental health condition increased over the duration of phase 1. Further, upon the completion of phase 2, VHA found that there was a nationwide 1.7 percentage point decrease (indicating improvement on this metric) in the percentage of veterans 75 or older with an outpatient prescription for a benzodiazepine or sedative hypnotic medication. During each PDSI phase, VHA works with VISNs and VAMCs to support their quality improvement efforts related to their priority metrics. For example, VHA provides feedback and technical assistance to VISNs and VAMCs for developing and implementing quality improvement strategies for their priority metrics, which must be updated and submitted to VHA semiannually; convenes a bi-monthly PDSI conference call for VISN and VAMC staff and providers involved in PDSI, which serves as a forum for providing training to participants, discussing best practices, and facilitating collaboration among VAMCs that may have chosen the same priority metrics; develops a semi-annual feedback report for each VISN that includes, among other content, the most recent quarterly score on the priority performance metrics for each VAMC within the network, according to a VHA official; and provides VISNs and VAMCs access to a PDSI clinical management dashboard to use to identify veterans who may benefit from changes to their psychotropic medication prescriptions. These lists can be filtered by the care setting in which the patient is seen, such as the primary or specialty care settings. Although VISNs and VAMCs are not always required (but are encouraged) to continue quality improvement efforts related to VAMCs’ priority metrics from past PDSI phases, VHA continues to monitor VAMC performance on all metrics from each PDSI phase. Specifically, a VHA official told us that VHA monitors performance by calculating quarterly VAMC scores on all performance metrics, which are published on the PDSI clinical management dashboard. VHA also disseminates these scores to the VISNs in the semiannual feedback reports. In these feedback reports, VHA highlights any metric—from the current or a past phase—for which a VAMC within that VISN has regressed. A VHA official stated that if a VAMC regresses significantly in any area, VHA would work with that medical center to determine the cause and take action to reverse the trend as needed. See appendix III for information on PDSI’s planned focus on reducing the co-prescribing of benzodiazepines and opioids as well as the initiative’s collaboration with VHA’s Academic Detailing program, which has developed its own campaign related to stimulant prescribing. VHA Has Included Psychotropic Medications in Multiple Efforts to Examine Suicide Risk among Veterans Since 2012, VHA has included psychotropic medications in multiple efforts to examine suicide risk among veterans, including two programs and three research studies. These efforts include: Recovery Engagement and Coordination for Health – Veterans Enhanced Treatment (REACH VET) Program. VHA includes psychotropic medications as part of its effort to examine veterans who may be at risk of suicide through its REACH VET program. Specifically, REACH VET uses prior research findings to conduct predictive modeling on data collected from VHA’s electronic medical records to identify veterans who are within the top tier (0.1 percent) of predicted suicide risk. These veterans may also be at increased risk of other adverse outcomes, such as overdoses, violence, and mental health hospitalization. Of note, five of the 61 variables used in REACH VET’s predictive model relate to the prescription of specific psychotropic medications (e.g., alprazolam), and three relate to the prescription of specific psychotropic classes (e.g., antidepressants). Other variables used in the model include demographic characteristics, past suicide attempts, measures of VHA care utilization, and certain diagnoses such as substance use disorder, MDD, and chronic pain. REACH VET coordinators staffed at VAMCs are responsible for notifying the appropriate mental health provider or PCP that a veteran has been identified as being at high risk for suicide, based on a high-risk list of veterans generated monthly by REACH VET’s predictive model. As shown in Figure 4, veterans identified as being at high risk for suicide may then receive targeted outreach from their mental health providers or PCPs if those providers conclude that outreach is warranted based on their review of the veterans’ medical records, according to VHA officials. This outreach may result in changes to the veteran’s treatment as agreed upon by the provider and veteran. VHA reported that within the first year of nationwide implementation, February 2017 through February 2018, the program identified close to 30,000 veterans at high risk for suicide. Behavioral Health Autopsy Program. VHA also includes psychotropic medications in its Behavioral Health Autopsy Program. This program examines information about veteran deaths by suicide that are reported to VAMC providers and suicide prevention coordinators. When informed that a veteran has died by suicide, suicide prevention coordinators are to electronically report, among other things, whether the veteran had (1) been prescribed psychotropic and other medications, for the treatment of a mental health condition within the previous year, and (2) adhered to the medications. Other sources of information collected through the program may include coroners’ and medical examiners’ reports, death certificates, and information provided by family members and significant others. Data are reported to and analyzed by VHA’s VISN 2 Center of Excellence for Suicide Prevention. One recommendation in the program’s 2017 annual report called for more efforts to study issues related to medication management, such as veterans’ medication adherence, overmedication, and frequent and abrupt medication changes. In the past, recommendations from the program have been used to inform VHA suicide prevention policies, programs, and educational efforts, according to VHA officials. For example, officials shared that the program informed the development of a tool kit for providers to use to help address veterans’ sleep issues after analyses found that sleep patterns were often altered for veterans prior to their death by suicide. Lithium for Suicidal Behaviors in Mood Disorders study. As of March 2019, VHA is in the process of conducting a randomized clinical trial that examines the effect of a specific psychotropic medication (lithium) on reducing suicide risk for veterans with MDD or bipolar disorder who either survived a recent suicide attempt or were hospitalized to prevent one. VHA plans to enroll 1,600 veterans in the study from 28 VAMCs and provide them with the appropriate treatment options as determined by their respective providers, as well as provide some additional care coordination. Additionally, half of the participants will receive lithium, and half of the participants will receive a placebo. The study’s investigators told us that, to their knowledge, this study is the first effort to test lithium’s efficacy for reducing suicide risk in a randomized clinical trial setting. Investigators also told us that, because all participants will receive medications already proven safe and effective for the treatment of their conditions, it is not considered unethical to withhold lithium, a yet untested medication for treating suicide risk, from half of participants. VHA investigators told us they hope to use the results of this clinical trial to inform future treatment options for patients with MDD or bipolar disorder and who are at risk of suicide. Drugs and Suicide Risk study. Between January 2017 and October 2018, VHA officials and collaborators at the University of Chicago and Columbia University analyzed 513 medications, which included psychotropic medications, prescribed between 2003 and 2014 for association with increased or decreased risk of suicidal events in VHA patients. According to the study’s investigators, they expect to be able to identify specific psychotropic medications that are found to be associated with the largest increases and decreases in suicide risk. VHA officials told us that as of March 2019, the research manuscript was under review for publication in a peer-reviewed journal. Using Big Data and Precision Medicine to Assess and Manage Suicide Risk in U.S. Veterans study. As of March 2019, VHA officials, in collaboration with the Department of Energy, were in the process of developing a new model to predict suicidal behavior among veterans by combining data on genetic and non-genetic risk factors, such as demographics, medical conditions, and stressful life events; psychotropic medications are also included as a risk factor, according to VHA officials. The researchers are expected to combine data from VHA electronic medical records with data from a VHA Office of Research and Development program that collects genetic information from veterans to develop the new algorithm. VHA officials we interviewed noted some broad challenges not exclusive to VHA that may affect efforts for any researcher in examining suicide risk and the use of psychotropic medications: Multiple risk factors. All VHA officials that we spoke with discussed the need for efforts examining psychotropic medications and suicide risk to account for other suicide risk factors beyond the use of these types of medication. Such factors may include having a substance use disorder or other mental health diagnoses; homelessness; chronic (non-mental health) medical conditions; age; and psychosocial factors, such as recent loss of a significant other or a history of abuse or violence. Methodological considerations. Most VHA officials that we spoke with mentioned some methodological considerations that must be considered when designing a research study to examine this relationship. For example, an official told us that measuring veterans’ medication adherence is important to track, but is difficult to do as VHA generally only has data on whether medications were dispensed to veterans, not whether medications were actually taken. Ethics. Some VHA officials that we spoke with noted that certain ethical considerations may limit the methodological options available to researchers, such as randomized clinical trials. For example, it would be unethical to withhold medications that have been proven as safe and effective from veterans who may clinically benefit from receiving such treatments, such as from veterans in a control group. In the face of these challenges, VHA officials also noted some advantages VHA researchers, in particular, may experience in examining the use of psychotropic medications and suicide risk: a large patient population with more than 2 million veterans who have at least one mental health condition, and a corresponding electronic medical records database, providing sufficient data and sample sizes needed to test hypotheses; internal funding streams dedicated to research activities examining issues related to suicide prevention, such as funds available through three of VA’s Office of Research and Development’s four central research services; and research centers with researchers who have specific expertise about issues related to suicide prevention and the treatment of serious mental health conditions. Conclusions Veterans diagnosed with mental health conditions rely on providers in VAMCs across the country to make treatment decisions that are safe and effective, including whether to treat highly prevalent and serious conditions such as MDD and PTSD with psychotropic medications, non- pharmacologic therapy, or a combination of both. In recent years, VHA has taken steps aimed at improving the safety and effectiveness of prescribing decisions for certain psychotropic medications and noted important improvements resulting from these efforts. However, VHA’s oversight related to treatment planning needs improvement. VHA has yet to disseminate guidance that clearly reflects its expectation that mental health providers in specialty care document mental health treatment plans in a readily identifiable manner in veterans’ medical records. Additionally, VHA does not monitor whether mental health providers are considering evidence-based treatment options in treatment plans, as VHA requires in its mental health services handbook. As a result, VHA cannot ensure that providers are considering and documenting all appropriate treatment options, adequately evaluating patient care, and making treatment modifications as necessary, among other issues. Furthermore, the lack of monitoring may impede VHA’s ability to identify important factors that contribute to providers’ treatment decisions, which could in turn allow VHA to identify more systemic barriers to safe and effective treatment, such as needed training. In addition, being able to readily identify how veterans are being treated for mental health conditions may allow VHA to enhance its research efforts related to suicide risk. VHA has noted several advantages it has in conducting research involving the role of psychotropic medications in suicide risk among veterans, including that VHA researchers have access to a large patient population with at least one mental health condition. Monitoring veterans’ use of psychotropic medications and non- pharmacologic therapies and related outcomes may further enhance this capacity for research on suicide risk. Recommendations for Executive Action We are making the following two recommendations to VA: The Veterans Health Administration should disseminate guidance for VISNs and VAMCs that more clearly reflects its expectation that mental health providers in specialty care should record mental health treatment plans within veterans’ medical records in an easily identifiable way. (Recommendation 1) The Veterans Health Administration should develop and implement an approach for monitoring treatment plans for veterans with mental health conditions to ensure that such plans include documentation that different evidence-based treatment options were considered. (Recommendation 2) Agency Comments We provided a draft of this report to VA for review and comment. In its written comments, which are reproduced in Appendix IV, VA concurred with our recommendations. VA agreed that the recommendations would promote adherence to mental health treatment planning requirements. VA stated that it is developing guidance to help ensure that mental health providers in specialty care record mental health treatment plans in separate, easily identifiable documents within veterans’ medical records. VA also stated that it will develop and implement a process for monitoring whether such plans include documentation that providers considered different evidence-based treatment options. We will monitor VA’s efforts to address our recommendations. As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies to the appropriate congressional committee and the Secretary of Veterans Affairs. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or at DraperD@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix V. Appendix I: Mental Health Treatment Practices for Veterans in a Nongeneralizable Sample of Selected Medical Centers We reviewed a nongeneralizable, randomly selected sample of 75 veterans’ medical records from five Department of Veterans Affairs (VA) medical centers (VAMC)—25 for each of the three most prevalent conditions diagnosed among veterans—who had at least one primary care visit in fiscal year 2017 and were prescribed a new psychotropic medication. About half (37) of the 75 medical records we reviewed indicated the veteran was prescribed a new psychotropic medication prior to or without being referred to a mental health provider in specialty care. See table 4. We reviewed a separate, nongeneralizable, randomly selected sample of an additional 75 veterans’ medical records from the five VAMCs—25 for each of the three most prevalent conditions diagnosed among veterans— who were newly diagnosed within that year. Over half (44) of the 75 medical records we reviewed indicated whether the veteran was offered non-pharmacologic therapy in lieu of or in addition to being prescribed a psychotropic medication. See table 5. Appendix II: Information on the Treatment of Veterans with Certain Mental Health Conditions, Nationally, in Fiscal Year 2018 We analyzed national data obtained from VHA on the types of treatments received by veterans with a diagnosis of a single mental health condition who had encounters with VHA providers for that diagnosis in fiscal year 2018, including the three most prevalent mental health conditions diagnosed among veterans. See Figure 5 for the percentages of veterans with these three conditions or another mental health condition who received (1) non-pharmacologic therapy (psychotherapy), (2) at least one medication from a psychotropic medication class, (3) a combination of the two, or (4) neither psychotropic medication nor non-pharmacologic therapy in fiscal year 2018. We also analyzed national encounter data obtained from VHA for veterans with one of the three most prevalent mental health conditions and who received psychotropic medications in a VA medical center (VAMC) in fiscal year 2018. We found that for all three conditions, the largest percentage of veterans who received at least one psychotropic medication from one class were seen in the primary care setting only. The percentages of veterans with medications from two or three classes— typically veterans who had more complex mental health conditions, according to a VHA official—were larger for veterans seen by specialty care providers, compared to the percentages of veterans with medications from multiple classes seen in primary care only. See Figure 6. Appendix III: PDSI’s Planned Focus on Medication Tapering and Collaboration with VHA’s Academic Detailing Program The Veterans Health Administration (VHA) has taken steps to improve the safe and effective prescribing of certain psychotropic medications used to treat veterans with mental health conditions through the Psychotropic Drug Safety Initiative (PDSI). PDSI has consisted of three phases since 2013, when the initiative began. Each phase has focused on making improvements related to the prescribing of different classes or types of psychotropic medications, or treating different age groups or mental health conditions and substance use disorders. PDSI is currently in phase 3, and VHA is in the process of planning for phase 4. According to a VHA official, PDSI phase 4 (expected to begin in July 2019) will, in part, increase the role of mental health providers in the monitoring and management of the co-prescribing of benzodiazepines (a type of antianxiety medication) and opioids. This includes tapering the use of these medications among this high-risk veteran population to a reduced dose or discontinuation entirely when the harms associated with their concurrent use outweigh the benefits. The same official told us that, to date, VHA has primarily focused on monitoring the concurrent use of these medications—which the Department of Veterans Affairs’ and the Department of Defense’s clinical practice guideline (CPG) for opioid therapy strongly recommends against—through the Opioid Safety Initiative and in the primary care setting (see text box). Veterans Health Administration’s (VHA) Efforts to Taper Veterans Co-Prescribed Benzodiazepines and Opioids Efforts focused on the establishment of safe and effective tapering programs in the primary care setting: VHA launched the Opioid Safety Initiative in 2013 to ensure that veterans are prescribed and use opioid pain medications in a safe and effective manner. This initiative seeks to establish safe and effective tapering programs for veterans who are co-prescribed opioids and benzodiazepines, among other goals. A VHA official told us that the initiative primarily focuses on monitoring and managing the concurrent use of these medications in the primary care setting. Efforts conducted on an individualized, gradual basis: The Department of Veterans Affairs’ and Department of Defense’s clinical practice guideline (CPG) for opioid therapy strongly recommends that tapering of opioids be done on an individualized basis, weighing the benefits and risks to each veteran as well as the veteran’s characteristics and needs. The CPG also notes that the sudden stopping of benzodiazepines should be avoided, since doing so can lead to seizures or death. Department of Veterans Affairs and Department of Defense, Clinical Practice Guideline for Opioid Therapy. To help achieve PDSI’s goal of improving the prescribing of certain psychotropic medications, VHA officials leading PDSI collaborate with VHA’s Academic Detailing program. Academic detailers, who are Veterans Integrated Service Networks (VISN) or Department of Veterans Affairs (VA) medical center (VAMC) clinical pharmacy specialists, disseminate resources and provide one-on-one educational outreach to providers to help them improve their psychotropic medication prescribing practices. Pharmacy staff, including staff involved in academic detailing, from four VISNs told us that they provide education related to PDSI. The Academic Detailing program has also implemented a campaign to improve the appropriate prescribing and monitoring of stimulants (see text box). Veterans Health Administration’s (VHA) Academic Detailing Program Prescription Stimulants Campaign According to a VHA official, in February 2018, the Academic Detailing program implemented a campaign to improve the treatment of patients receiving prescription stimulant therapy for adult attention-deficit / hyperactivity disorder. A VHA official told us that Veterans Integrated Service Networks (VISNs) or Department of Veterans Affairs (VA) medical centers (VAMCs) may choose, but are not required, to participate in this campaign. The stimulant campaign dashboard includes VAMC scores on 13 quality indicators related to (1) prescribing stimulants for off-label use, (2) assessing co-morbidities, (3) monitoring patients, and (4) managing medication. For example One quality indicator measures the percentage of veterans co-prescribed a stimulant and a benzodiazepine, and Another quality indicator measures the percentage of veterans co-prescribed a stimulant and an opioid. Academic detailers (VISN or VAMC clinical pharmacy specialists) may use the dashboard to identify providers who may benefit from changes to their stimulant prescribing practices. A VHA official reported that between February 2018 and the end of fiscal year 2018, academic detailers made 37 staff interactions with providers related to the national academic detailing program’s stimulant campaign. As of October 2018 (the most recent data available), 37,223 veterans with at least one diagnosed mental health condition had an active prescription for at least one stimulant, according to a VHA official. Among these veterans, 2,360 had a co-occurring cardiac condition.Sudden death, stroke, or other cardiac events have been reported with stimulants. The U.S. Food and Drug Administration has stated that stimulants should generally not be used in patients with serious heart problems or for whom an increase in blood pressure or heart rate would be problematic. See U.S. Food and Drug Administration, FDA Drug Safety Review Communication: Safety Review Update of Medications Used to Treat Attention-Deficit / Hyperactivity Disorder (ADHD) in Adults, accessed March 1, 2019, https://www.fda.gov/Drugs/DrugSafety/ucm279858.htm. Appendix IV: Comments from the Department of Veterans Affairs Appendix V: GAO Contact and Staff Acknowledgments GAO Contact Staff Acknowledgments In addition to the contact named above, Hernán Bozzolo (Assistant Director), Kaitlin Asaly (Analyst-in-Charge), Jennie F. Apter, Karen Belli, Topher Hoffmann, and Rebecca Rust Williamson made key contributions to this report. Also contributing were Rich Lipinski, Diona Martyn, Vikki Porter, and Jennifer Whitworth.


Background Veterans with SUDs In fiscal year 2018, VHA data show that 518,570 veterans received any treatment (specialty or non-specialty services) from VHA’s health care systems for a diagnosed SUD, a 9.5 percent increase from fiscal year 2016 (see figure 1). Because these data include non-specialty services, the data do not indicate the extent to which the veteran received SUD services. For example, a provider briefly discussing the SUD of a veteran in long-term recovery during a primary care visit would be included in SUD treatment data. VHA data show that the majority of veterans who received any treatment from VHA’s health care systems for a diagnosed SUD had an alcohol use disorder. Veterans received any treatment from VHA for a diagnosed SUD at a higher rate than the general population. Data from the 2017 National Survey on Drug Use and Health indicate that 1.5 percent of individuals aged 18 or older nationwide received any SUD treatment in the past year. In comparison, 8 percent of veterans getting health care provided or purchased by VHA received any treatment for a diagnosed SUD in fiscal year 2017, including individuals who received specialty SUD services as well as individuals who received non-specialty services in, for example, primary care or general mental health clinics. Specialty SUD Services VHA’s health care systems provide specialty SUD services in three settings increasing in intensity (see figure 2): Outpatient services. Individual and group therapy, either in person or via telehealth, among other services. VHA also offers intensive outpatient programs, which provide services for 3 or more hours per day, 3 days a week at a minimum. Residential rehabilitation treatment programs. Medically monitored, high-intensity care in a 24-hour supervised environment specifically dedicated to treating SUDs. These programs may also provide social services for community reintegration and treatment for other medical conditions during a veteran’s stay. Inpatient services. Acute in-hospital care, which may include detoxification services. Medication-Assisted Treatment for Opioid Use Disorder For veterans with opioid use disorder—a subset of SUDs—VHA’s health care systems provide medication-assisted treatment. Medication- assisted treatment combines behavioral therapy and the use of certain medications, including methadone and buprenorphine. Medication- assisted treatment has proven to be clinically effective in reducing the need for inpatient detoxification services for individuals with opioid use disorder, according to SAMHSA. Methadone. This medication suppresses withdrawal symptoms during detoxification. It also controls the craving for opioids in maintenance therapy, which is ongoing therapy meant to prevent relapse and increase treatment retention. Methadone is a controlled substance and, when used to treat opioid use disorder, may generally be administered or dispensed only within a certified opioid treatment program to help prevent diversion. Buprenorphine. This medication eliminates opioid withdrawal symptoms, including drug cravings, and it may do so without producing the euphoria or dangerous side effects of other opioids. It can be used for detoxification and maintenance therapy. Buprenorphine is also a controlled substance, and when used to treat opioid use disorder, may be administered or dispensed within an opioid treatment program, or prescribed or dispensed by a qualifying provider who has received a waiver to do so. Providers who receive this waiver are limited in the number of patients they may treat for opioid use disorder. In addition to medication-assisted treatment, VHA has initiatives aimed at preventing opioid-related overdose deaths. For example, VHA’s Opioid Overdose Education and Naloxone Distribution program includes education and training regarding opioid overdose prevention as well as naloxone distribution. Naloxone is a medication that can reverse opioid overdoses. Care in the Community Veterans may receive services from community providers via local contracts or community care. For local contracts, individual VA medical centers establish contracts with local community providers. For example, a VA medical center may develop a contract with a community residential rehabilitation treatment program provider to set aside a number of beds specifically for veterans. For community care, veterans may be eligible if, for example, VHA does not offer the care or service the veteran requires or VHA cannot provide the care or services consistent with its access standards. In general, community care services must be authorized in advance of when veterans access the care. Prior to June 6, 2019, eligible veterans could receive community care via one of multiple VHA community care programs. In 2018, the VA MISSION Act required VA to implement a permanent community care program that consolidated several community care programs. On June 6, 2019, the consolidated community care program, the Veterans Community Care Program, went into effect. Number of Veterans Receiving, and Expenditures for, VHA Specialty SUD Services Have Remained Unchanged in Recent Years; Community Care SUD Services Have Increased Number of Veterans Receiving Specialty SUD Services in VHA’s Health Care Systems and Related Expenditures Were Relatively Unchanged Between Fiscal Years 2014 and 2018 Among the 518,570 veterans who received SUD services in fiscal year 2018, VHA provided specialty SUD services to 152,482 veterans in fiscal year 2018. This number has increased slightly but remained relatively unchanged since fiscal year 2014, as shown in table 1 below. These veterans received care in VHA’s health care systems—that is, in VA medical centers or in one of the medical centers’ affiliated outpatient clinics and other medical facilities. During the same time period, VHA expenditures for these specialty SUD services increased from $552 million in fiscal year 2014 to $601 million in fiscal year 2018. Total specialty SUD expenditures per capita increased from $3,691 to $3,941 from fiscal years 2014 through 2018. Adjusted for inflation, however, per capita expenditures remained relatively unchanged between fiscal years 2014 and 2018. Most Veterans Received Specialty SUD Services in Outpatient Settings; Medication-Assisted Treatment Has Increased for Opioid Use Disorders in Recent Years Our analysis of VHA data shows that veterans received specialty SUD services from VHA’s health care systems in multiple settings from fiscal years 2014 through 2018, with most veterans receiving these services in outpatient settings. Veterans may receive specialty SUD services across multiple settings within a year. Below, we provide information on utilization and expenditures for specialty SUD services in outpatient and residential treatment programs and for medication-assisted treatment for veterans with opioid use disorder. Specialty Outpatient Settings In fiscal year 2018, nearly all veterans who received specialty SUD services from VHA’s health care systems received this care in outpatient settings at some point during the year. Of those veterans who received outpatient specialty SUD services, 17 percent received intensive outpatient specialty SUD services, with little change from previous years. Expenditures for outpatient specialty SUD services increased from fiscal years 2014 through 2018, as shown in table 2 below. During this time period, outpatient specialty SUD expenditures per capita increased from $2,176 to $2,348. Adjusted for inflation, per capita expenditures grew 1.5 percent between fiscal years 2014 and 2018. In addition, we found little change in the number of full-time employee equivalents that actively provided outpatient specialty SUD services from fiscal years 2015 through 2018. VHA did not provide specialty outpatient wait-time data because, according to VHA officials, the data do not reliably capture veterans’ wait times to receive SUD services in outpatient settings. VHA officials explained that veterans may receive non-specialty SUD services in various outpatient settings, including primary care and general mental health clinics. Therefore, developing a wait-time measure for specialty SUD services would not accurately capture whether veterans are waiting for SUD services not previously provided or services that would continue ongoing treatment begun in a primary care or general mental health clinic. As a result, we did not analyze outpatient wait-time data. In prior work, we have made recommendations to VHA on ways it can improve its outpatient wait-time data (see sidebar). Specialty Residential Rehabilitation Treatment Programs As of fiscal year 2018, VHA had residential rehabilitation treatment programs available for veterans with complex and long-term mental health needs at 113 facilities, and 67 of these programs were dedicated to SUD treatment. The number of residential rehabilitation treatment programs dedicated to SUD treatment increased from fiscal years 2014 through 2018, as did the number of beds available. Figure 3 shows the location of all 67 residential rehabilitation treatment programs specifically dedicated to SUDs with the corresponding number of beds in fiscal year 2018. See appendix III for more information on residential rehabilitation treatment programs dedicated to SUD treatment. The number of veterans participating in VHA’s specialty SUD residential rehabilitation treatment programs (that is, those dedicated to SUD treatment) remained relatively stable from fiscal years 2014 through 2018, as shown in table 3. Of the veterans who received specialty SUD services in fiscal year 2018, approximately 10 percent participated in one of VHA’s 67 residential rehabilitation treatment programs dedicated to SUD treatment, similar to previous years. Meanwhile, expenditures for VHA’s residential rehabilitation treatment programs dedicated to SUD decreased from fiscal years 2014 through 2016, but increased in fiscal years 2017 and 2018. Similarly, specialty SUD residential expenditures per capita decreased from $15,386 in fiscal year 2014 to $12,526 in fiscal year 2016 and increased again to $16,031 in fiscal year 2018. After adjusting for inflation, specialty SUD residential expenditures per capita in 2018 were about 2 percent less than what they were in 2014. From fiscal years 2014 to 2018, veterans’ average length of stay for VHA’s specialty residential rehabilitation treatment programs specifically dedicated to SUD generally decreased, while wait times varied across programs. Across VHA’s residential rehabilitation treatment programs dedicated to SUD treatment, veterans’ average length of stay generally decreased from fiscal years 2014 to 2018, from nearly 40 days to nearly 36 days. VHA officials said that average length of stay may have decreased as a result of multiple factors, such as programs with longer lengths of stay adjusting their treatment approaches. The median wait times to enter residential rehabilitation treatment programs dedicated to SUD treatment varied considerably, ranging from 0 days to 56 days across the programs in fiscal year 2018, although not all residential rehabilitation treatment programs had sufficient—and therefore reliable— data on wait times. Specifically, out of the 67 residential rehabilitation treatment programs dedicated to SUD, VHA officials identified 12 that did not have sufficient wait-time data, which we excluded from our analysis. VHA officials noted that some specialty residential rehabilitation treatment programs do not have sufficient wait-time data because the facilities do not consistently code whether a patient’s visit included a screening for admission to the program. As such, VHA cannot tell when patients were initially screened for admission. In fiscal year 2019, officials implemented changes to address the lack of reliable data from some facilities. However, it is too early to tell if the new changes will address the data reliability issues in wait-time data for residential rehabilitation treatment programs. Medication-Assisted Treatment for Opioid Use Disorder VHA health care systems offer veterans medication-assisted treatment for opioid use disorder in a variety of settings, including outpatient specialty SUD settings and residential rehabilitation treatment programs dedicated to SUD treatment, as well as in non-specialty settings, such as primary care and general mental health clinics. Our analysis of VHA data shows the number and proportion of veterans with an opioid use disorder who received medication-assisted treatment from VHA’s health care systems has risen in recent years, as shown in table 4. In fiscal year 2018, 23,798 veterans received medication-assisted treatment, which was 33.6 percent of veterans diagnosed with an opioid use disorder. Veterans with an opioid use disorder may receive medication-assisted treatment through VHA at a lower rate than individuals who received care through private insurance. According to a study by the Department of Health and Human Services, 50.6 percent of individuals diagnosed with an opioid use disorder and enrolled in private insurance received medication-assisted treatment in 2014 to 2015. Some veterans may also have private insurance and may have received their medication-assisted treatment through that private insurance. In fiscal year 2018, 9,132 (38 percent) of the veterans who received medication-assisted treatment received their care at one of VHA’s 33 opioid treatment programs, which is the only setting where methadone can be administered to treat opioid use disorder. Expenditures for these opioid treatment programs increased from $35.9 million in fiscal year 2014 to $39.1 million in fiscal year 2018. In fiscal year 2018, VHA had 2,036 providers with a waiver to prescribe buprenorphine, a 17.6 percent increase from fiscal year 2017. According to VHA officials, VHA has encouraged its providers—including those who are not specialists in treating SUDs, such as primary care providers—to obtain the waiver required to prescribe buprenorphine to treat opioid use disorder. In fiscal year 2018, there were about 29 VHA providers with a waiver to prescribe buprenorphine for every 1,000 veterans with opioid use disorder, a 14 percent increase from fiscal year 2017. Naloxone Distribution VHA’s naloxone kit distribution increased exponentially from 646 in fiscal year 2014 to 97,531 kits in fiscal year 2018. A total of 204,557 naloxone kits have been distributed through fiscal year 2018. VHA health care systems distributed naloxone kits to VA staff, including VA first responders and VA police officers, and veterans with opioid use disorder. Factors contributing to the increase may include: In 2014, VHA implemented the Opioid Overdose Education and Naloxone Distribution initiative to decrease opioid-related overdose deaths among veterans, with one of its key components focused on encouraging naloxone kit distribution. Since the program’s implementation, all VHA health care systems dispense naloxone kits. The Comprehensive Addiction and Recovery Act of 2016 directed VHA to maximize the availability of naloxone to veterans and to ensure that veterans who are considered at risk for opioid overdose have access to naloxone and training on its proper administration. More Veterans Have Received SUD Services through Community Care in Recent Years; VHA Seeks to Collect Reliable Data on Usage by Community Care Settings Veterans Health Administration (VHA) Community Care Wait Times GAO has a body of work highlighting challenges VHA has with the reliability of its wait-time data. See below for recent reports about this issue. We have highlighted the importance of reliable community care wait-time data in a testimony regarding VHA’s efforts to address our previous recommendations on these issues. See GAO, Veterans Health Care: Opportunities Remain to Improve Appointment Scheduling within VA and through Community Care, GAO-19-687T (Washington, D.C.: July 24, 2019). We have designated our past recommendations related to community care wait-time data as priorities for the agency. See GAO, Priority Open Recommendations: Department of Veterans Affairs, GAO-19- 358SP (Washington, D.C.: Mar. 28, 2019). We have previously made recommendations to VHA to capture the necessary information and improve the reliability of wait-time data for community care. These recommendations remain outstanding as of October 2019. See GAO, Veterans Choice Program: Improvements Needed to Address Access- Related Challenges as VA Plans Consolidation of its Community Care Programs, GAO-18-281 (Washington, D.C.: June 4, 2018). Through its community care programs, VHA purchased SUD services (specialty and non-specialty) for 20,873 veterans in fiscal year 2018, a significant increase since fiscal year 2014 (see table 5). VHA officials noted that veterans can receive community care in addition to, or instead of, care at a VHA facility; therefore, the number of veterans served through community care cannot be combined with the number who received services within VHA to provide an overall number of veterans receiving care. Expenditures for these SUD services purchased by VHA also increased over time, from nearly $6 million in fiscal year 2014 to over $80 million in fiscal year 2018. Between fiscal years 2014 and 2018, on a per capita basis, SUD services purchased by VHA increased from $3,021 to $3,852. Per capita expenditures adjusted for inflation also increased during this time period. These increases coincided with the establishment of the Veterans Choice Program in early fiscal year 2015, which expanded eligibility for community care. Wait-time data for SUD services purchased through community care were not available because of data reliability issues, VHA officials told us. See sidebar for more information on our previous recommendations to VHA regarding community care wait-time data. While VHA is able to report on the overall number of veterans receiving SUD services through community care, data limitations prevent VHA officials from reliably determining whether veterans received this care in residential or outpatient settings. These issues are as follows: Residential rehabilitation treatment programs. VHA uses billing codes on paid claims to track the settings in which veterans receive community care; however, according to agency officials, there is no specific billing code for a residential setting. VHA officials told us that community residential rehabilitation treatment programs may record treatment provided using inpatient or outpatient billing codes—or a combination of the two—in submitting claims to VHA. As a result, VHA is unable to use claims data to reliably identify veterans who received residential rehabilitation treatment through community care. Outpatient settings. Because some residential care data are coded using outpatient billing codes, outpatient data may contain residential services counted as outpatient services. As a result, VHA is unable to reliably identify veterans who received SUD services in community care outpatient settings. Currently, VHA is taking steps to address these coding issues. VHA officials told us they are developing a payment code that will bundle together common residential program services, which will allow VHA to identify veterans receiving residential rehabilitation treatment for SUDs through community care. Officials explained that using this code for residential SUD services will allow VHA to better distinguish between residential and outpatient community care because residential care will no longer need to be identified using outpatient codes. In contrast to its community care programs, VHA does not centrally track SUD services provided via local contracts. Rather, the individual medical centers that established the contracts with local community providers are responsible for tracking and documenting SUD services provided to veterans. In fiscal year 2019, VHA began conducting market assessments, a broader agency initiative to better understand the supply and demand of all services at all VA medical centers, including both what is available within VHA as well as what is available in the local communities. We reviewed one of the data collection instruments the agency is using as a part of this work and found that it should allow VHA to identify, among other things, the number of community residential rehabilitation treatment beds contracted by individual medical centers to serve veterans with SUDs, as well as the number of veterans who received SUD services through local contracts or community care for SUDs. Agency officials said that they expect the market assessments to be completed in 2020. Veterans’ Usage Differed Between Urban and Rural Areas for Some Specialty SUD Services; VHA Is Taking Steps to Address Access Issues in Rural Areas Although overall use of SUD services was similar among veterans in rural and urban areas, VHA data show the utilization rates of some specialty SUD services differed. The literature and agency documents we reviewed and VHA officials consistently cited several issues, such as recruiting SUD providers and accessing necessary prescriptions for SUDs, which affect the use of services by veterans with SUDs in rural areas. According to agency documents and officials, VHA is taking steps to address these issues. Overall Use of SUD Services Was Similar for Veterans in Rural Areas Compared to Urban Areas, but Use of Some Specialty SUD Services Differed in Fiscal Years 2014 through 2018 Overall, veterans’ use of SUD services was similar in rural areas compared to urban areas, but use of some specialty services differed. Our analysis of VHA data shows that across VHA’s 140 health care systems, there was relatively little difference in the overall utilization of SUD services (specialty and non-specialty) in rural and urban areas from fiscal years 2016 through 2018. In fiscal year 2018, for example, 7.5 percent of veterans in rural areas received any SUD services compared with 8.8 percent of veterans in urban areas. However, VHA data also show there were some types of specialty services, such as intensive outpatient specialty services, residential rehabilitation treatment programs, and medication-assisted treatment for opioid use disorder, that rural veterans with SUDs tended to use more or less of than their urban counterparts. Intensive Outpatient Specialty SUD Services Among veterans receiving specialty SUD services across all 140 VHA health care systems, those veterans in rural locations used intensive outpatient specialty SUD services at a slightly higher rate (19 percent) than veterans in urban locations (17 percent) in fiscal year 2018. While veterans’ utilization of these specialty SUD services has decreased in both rural and urban locations in recent years, the decreases have been larger in rural areas. In rural locations, the percentage of veterans using intensive outpatient specialty SUD services decreased from 25 percent in fiscal year 2015 to 19 percent in fiscal year 2018. In comparison, in urban areas, the percentage of veterans using these services decreased from 18 percent to 17 percent during this same time period. Officials from VHA health care systems in three urban locations and two rural locations we spoke with indicated that they offered intensive outpatient specialty SUD services in conjunction with either residential or outpatient services. According to officials from the rural VHA health care system that did not offer this service, the location did not have sufficient staff to provide the additional hours of intensive outpatient specialty SUD treatment each week. Specialty Residential Rehabilitation Treatment Programs Veterans in rural locations using specialty SUD services participated in residential rehabilitation treatment programs dedicated to SUD treatment at a higher rate (17 percent) than veterans using these services in urban locations (10 percent) across all 140 VHA health care systems in fiscal year 2018. From fiscal years 2014 through 2018, there was a slight increase in the percentage of rural veterans using specialty SUD services who participated in residential rehabilitation treatment programs dedicated to SUD treatment, from 13 percent to 17 percent. VHA officials told us rural communities often face difficulties with transportation that may make residential programs more feasible than accessing intensive outpatient specialty SUD services, which are at least 3 days per week, at VHA health care systems. All six of the VHA health care systems we interviewed offered residential rehabilitation treatment programs. VHA reported the agency is currently conducting market assessments that may help determine gaps in services for veterans with SUDs, including residential rehabilitation treatment, once the assessments are complete. Medication-Assisted Treatment for Opioid Use Disorder Across all 140 VHA health care systems, veterans with an opioid use disorder received medication-assisted treatment (in specialty and non- specialty settings) at a higher rate in urban locations (34 percent) than in rural locations (27 percent) in fiscal year 2018. We also found differences in the availability of medication-assisted treatment services between rural and urban areas: Methadone. The only setting in which methadone may be used to treat an opioid use disorder is an opioid treatment program. All of VHA’s opioid treatment programs are located in urban areas. Only one of the six selected VHA health care systems in our review had an opioid treatment program. Officials from the other five VHA health care systems we spoke with told us they typically referred out to community providers if a veteran needed methadone. Regional VHA officials indicated that some locations, especially rural ones, may not have the number of veterans with opioid use disorder needed to justify the resources required to run an opioid treatment program. Buprenorphine. The number of waivered providers per 1,000 veterans with opioid use disorder was slightly higher in rural areas (29.9 providers) than in urban areas (28.7 providers) in fiscal year 2018. Non-specialist rural providers, such as primary care providers, may feel a greater responsibility to obtain a waiver because there are fewer specialists for them to refer their patients to, according to VHA health care system officials. Despite the similar rates of waivered providers in rural and urban areas, as previously mentioned, rural veterans with opioid use disorder use medication-assisted treatment at a lower rate. VHA Taking Steps to Address Provider Shortage and Access Issues in Rural Areas for Veterans with SUDs VHA requires that all rural and urban health care systems offer the same range of SUD services (specialty or non-specialty). However, rural areas have historically faced difficulties delivering all types of health care, including SUD services, according to literature, agency documents, and VHA health care system officials we spoke with. VHA is taking steps to address several issues that affect the delivery of health care services generally, and SUD services in particular, in rural areas. Shortage of Qualified Providers Officials from three of the six VHA health care systems we interviewed noted a shortage of SUD specialists in their area, including addiction therapists and providers with a waiver to prescribe buprenorphine. According to one study and agency documents we reviewed, veterans may reside in mental health professional shortage areas at a higher rate than the general population, therefore they may have less access to providers qualified to offer medication-assisted treatment or other mental health treatment. One study found that efforts to improve access for veterans in rural areas by purchasing care from community providers may have limited effect, because these areas are relatively underserved generally. Officials from two of the three VHA health care systems in rural areas we selected expressed difficulty hiring and retaining providers to provide SUD services. Because of the shortages, recruiting and retaining providers to deliver care to rural veterans is critical. Based on the literature reviewed and half of VHA health care system officials interviewed, rural communities struggle with recruiting and retaining providers, including SUD providers. Some rural areas report provider shortages with ongoing, long-term vacancies. To respond to these provider shortages and hiring and retaining challenges, VHA has implemented new initiatives and practices to increase the supply of rural health professionals. A VHA official noted that these efforts include rural health training and education initiatives to provide rural health experience to health professions trainees, including those who provide SUD services. The agency also plans to use expanded recruitment tools, like greater access to an education debt reduction program, improved flexibility for bonuses for recruitment, relocation, and retention, as well as piloting a scholarship program authorized under the VA MISSION Act of 2018 to hire mental health professionals. However, recruiting health professionals in rural areas, including mental health providers and social workers, remains an issue for VHA and the community at large, and VHA officials noted that data are not yet available to understand the long-term effect of the newly trained providers on the availability of SUD services. Availability and Use of Telehealth Services for the Delivery of SUD Services Officials from two VHA health care systems we interviewed noted that providing services, such as medication-assisted treatment, through telehealth technology is difficult, especially when the SUD service requires monitoring for medication compliance. However, a VHA official told us the use of telehealth services overall has grown exponentially at VHA’s health care systems and goes beyond traditional video conference capabilities to include advanced technology that can be attached to computers or videoconference equipment like an exam camera to allow for an interactive examination. The official added that the provision of SUD services using telehealth can be supported by medical personnel located at the closest VA facility to complete necessary tests, such as urine screening, when the service is provided at a VHA location. VHA officials from one health care system we spoke with and literature noted that providing medication-assisted treatment via telehealth technologies requires a cultural change within the profession. Officials from one VHA health care system we spoke with told us that delivering medication-assisted treatment using technology is risky. For example, buprenorphine is a controlled substance with a risk of misuse. This official added that many providers may not be open to the idea of delivering this level of treatment using telehealth. One study we reviewed confirmed that acceptance within the profession appears to be the main barrier to the successful implementation of telehealth services. However, VHA’s budget and strategic plan show continued support for the use of telehealth for SUD treatment. Studies have shown that telephone services, a type of telehealth service, potentially have the same outcomes as in-person services. Officials from all six VHA health care systems we selected mentioned they had mental health telehealth services available to facilitate the delivery of care to veterans in both urban and rural areas for SUD services. To ensure adequate access to care, VHA has multiple telehealth initiatives underway. For example, between fiscal years 2017 and 2019, VHA allocated $28.5 million for mental health telehealth hubs at 11 sites. In another instance, VHA allocated more than $750,000 for rural facilities in fiscal years 2018 and 2019 toward a nationwide initiative to improve participation in a program that establishes video connections in the homes of rural veterans to receive mental health treatment, including for SUDs, with psychotherapy and psychopharmacology. While VHA has initiatives underway, the success of these efforts is contingent on rural areas having broadband and internet connectivity, which remains a challenge, according to agency documents and officials. Access to Necessary Prescriptions VHA’s Clinical Practice Guidelines for SUDs recommends methadone and buprenorphine, among others drugs, to treat opioid use disorder. However, accessing these drugs in rural areas can be challenging, according to literature we reviewed and VHA officials we spoke with. For example, one national study found that opioid treatment programs providing methadone are generally absent from the treatment options in rural areas. Within VHA, all of the opioid treatment programs are in urban areas. In addition, in rural areas generally, a small percentage of providers nationwide have received waivers to prescribe buprenorphine. VHA officials told us they are steadily expanding the availability of medication-assisted treatment for veterans with opioid use disorder. VHA had an interdisciplinary team of VA staff from a single facility within each region receive training on implementing medication-assisted treatment for opioid use disorder. These teams were responsible for spreading information to other facilities. Thus far, VHA reported it has trained over 300 providers using this model. In a separate initiative, a VHA official reported that its Office of Rural Health provided over $300,000 in fiscal year 2019 for a pilot program that trains primary care and mental health providers in the Iowa City VHA health care system on how to provide medication-assisted treatment for opioid use disorder. Transportation The availability of transportation is vital for veterans receiving medication- assisted treatment due to the necessity for frequent travel to the VHA health care systems for treatment. When using methadone for opioid use disorder treatment, the medication generally needs to be administered through an opioid treatment program at a specific location on a daily basis. In addition, during the initial stages of buprenorphine treatment, patients must also come into a facility frequently. Veterans living in rural areas who need this level of care may have to travel long distances every day to receive this medication. Distance and lack of transportation impede access to care, including SUD services, for rural veterans. Specifically, the literature we reviewed noted distance, time, and access to transportation as barriers to care. Veterans may lack access to transportation or are no longer able to drive because of age, health status, or driving restrictions. Some rely on family, friends or vans available through community service organizations; however, they may have other difficulties like reaching pick-up locations or the organization not having vans that are wheelchair-equipped. Officials from all six VHA health care systems we selected noted the lack of transportation as a barrier to accessing SUD services. Officials from two rural locations of the six selected VHA health care systems mentioned that volunteers, including a local veteran service organization, assist with getting veterans from their homes to their appointments; however, they added that these services operate on an abbreviated schedule and veterans are sometimes subjected to riding in the vehicle for long periods of time (2 hours each way). Over the last 10 years, a VHA official told us that the agency has allocated between $10 and $12.9 million for its Veterans Transportation Service for new vehicles, drivers, and mobility managers to assist with rural transportation needs. Additional VHA Plans to Address Rural Health Issues for SUD Services The VA MISSION Act of 2018 includes provisions that specifically address the need to improve veterans’ access to health care in areas with shortages of health care providers, including those providing SUD and mental health services. Based on this legislation, in June 2019, VHA published a plan organized in three areas: increasing personnel, using technology to connect veterans to care through public and private partnerships, and expanding VHA’s infrastructure through the building or acquiring of space to address the problem of underserved facilities. For example, VHA has a pilot program with 11 Walmart sites and 15-20 additional sites planned with Philips Healthcare, the Veterans of Foreign Wars, and the American Legion to enable veterans who lack the necessary technology in their home and live far from a VHA facility to receive remote health care at a convenient location. VHA’s plan indicates that while all VHA health care systems can use any of the strategies covered under this legislation, they will provide specific additional technical assistance for underserved facilities, monitor the effectiveness of these strategies, and share the findings of this work throughout the broader VHA system. Agency Comments We provided a draft of this report to VA for review and comment. VA provided written comments, which are reprinted in appendix IV, and technical comments, which we incorporated as appropriate. VA’s comments note that the agency generally reports obligations and that the agency is unable to confirm some of our financial data. However, the data provided by VA during the course of this engagement were regarding expenditures, and thus we report them as such. VA’s comments also provide information on additional efforts to expand mental health telehealth and ways the agency recruits providers in rural areas. We are sending copies of this report to the appropriate congressional committees, the Secretary of Veterans Affairs, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or at deniganmacauleym@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix V. Appendix I: Map of 140 Veterans Health Administration Health Care Systems, Fiscal Year 2018 Figure 4, an interactive graphic, shows the location and rurality of the Veterans Health Administration’s health care systems, as well as information on veterans treated by these health care systems. For an accessible version of the data used in this map, see https://www.gao.gov/products/GAO-20-35. Appendix II: Site Selection Methodology and Selected Health Care System Characteristics To describe any differences between veterans’ use of substance use disorder (SUD) services in rural and urban areas and the issues affecting access to those services in rural areas, we selected six Veterans Health Administration (VHA) health care systems and interviewed officials regarding their SUD services and issues serving veterans with SUDs. Because opioid use disorders may pose a greater risk to veterans than the general population, we selected the six VHA health care systems from among those with the highest percentages of veterans with an opioid use disorder diagnosis in fiscal year 2018. We also selected these six health care systems to achieve variation in representation among VHA’s five geographic regions and to include both urban and rural locations. See table 6. Appendix III: Veterans Health Administration Substance Use Disorder Residential Rehabilitation Treatment Programs The Veterans Health Administration had 67 residential rehabilitation treatment programs dedicated to substance use disorder treatment in fiscal year 2018. See table 7. Appendix IV: Comments from the Department of Veterans Affairs Appendix V: GAO Contact and Staff Acknowledgments GAO Contact Mary Denigan-Macauley, (202) 512-7114 or deniganmacauleym@gao.gov. Staff Acknowledgments In addition to the contact named above, Lori Achman, Assistant Director; Hannah Marston Minter and Carolina Morgan, Analysts-in-Charge; Sam Amrhein; Amy Andresen; Shaunessye D. Curry; and John Tamariz made key contributions to this report. Also contributing were Giselle Hicks, Diona Martyn, Ethiene Salgado-Rodriguez, and Emily Wilson Schwark. Related GAO Products Veterans Health Care: Opportunities Remain to Improve Appointment Scheduling within VA and through Community Care, GAO-19-687T. Washington, D.C.: July 24, 2019. VA Health Care: Estimating Resources Needed to Provide Community Care, GAO-19-478. Washington, D.C.: June 12, 2019. Drug Policy: Assessing Treatment Expansion Efforts and Drug Control Strategies and Programs, GAO-19-535T. Washington, D.C.: May 9, 2019. Priority Open Recommendations: Department of Veterans Affairs, GAO-19-358SP. Washington, D.C.: March 28, 2019. Behavioral Health: Research on Health Care Costs of Untreated Conditions is Limited, GAO-19-274. Washington, D.C.: Feb. 28, 2019. Veterans Choice Program: Improvements Needed to Address Access- Related Challenges as VA Plans Consolidation of its Community Care Programs, GAO-18-281. Washington, D.C.: June 4, 2018. VA Health Care: Progress Made Towards Improving Opioid Safety, but Further Efforts to Assess Progress and Reduce Risk Are Needed, GAO-18-380. Washington, D.C.: May 29, 2018. Opioid Use Disorders: HHS Needs Measures to Assess the Effectiveness of Efforts to Expand Access to Medication-Assisted Treatment, GAO-18-44. Washington, D.C.: October 31, 2017. Opioid Addiction: Laws, Regulations, and Other Factors Can Affect Medication-Assisted Treatment Access, GAO-16-833. Washington, D.C.: September 27, 2016. VA Health Care: Reliability of Reported Outpatient Medical Appointment Wait Times and Scheduling Oversight Need Improvement, GAO-13-130. Washington, D.C.: December 21, 2012.