Background In recent years, the Trump Administration and Congress have grappled with how to address the substantial number of migrants from the Northern Triangle countries of El Salvador, Guatemala, and Honduras arriving to the U.S. Southwest border. Many observers have criticized what they label as "catch and release," a colloquial phrase used to describe the process by which apprehended asylum seekers who lack valid documentation are subsequently released into the U.S. interior while they await their immigration hearings. This occurs because of growing backlogs in the immigration court system leading to wait times for immigration hearings now often lasting two years or more, and a lack of appropriate detention space for families due to the limitations imposed by the Flores Settlement Agreement, which restricts the government's ability to detain alien minors. Such observers argue that many apprehended aliens who are released into the United States do not appear for their immigration hearings and become part of the unlawfully present alien population. In light of these circumstances, Department of Homeland Security (DHS) Alternatives to Detention (ATD) programs are generating increased congressional interest as a way to monitor and supervise foreign nationals who are released while awaiting their immigration hearings. Proponents of ATD programs cite their substantially lower daily costs compared with detention, the high compliance rates of ATD participants with immigration court proceedings, and what they characterize as a more humane approach of not detaining low-flight-risk foreign nationals, many of whom are asylum applicants (particularly family units). Critics contend that ATD programs provide opportunities for participants to abscond (e.g., evade removal proceedings and/or orders) and create incentives for migration by allowing people to live in the United States for extended periods while awaiting the resolution of their case. They also question the effectiveness of these types of monitoring programs as a removal tool (i.e., as a means to remove participants ordered removed from the United States). DHS, for its part, states that nothing compares to detention for ensuring compliance. However, existing capacity to hold aliens is limited. Immigration statistics indicate that while the total number of individuals apprehended at the Southwest border has generally declined over the past two decades, the demographic profile of those apprehended has shifted toward a population more likely to be subject to detention. Historically, most unauthorized aliens apprehended at the Southwest border have been adult Mexican males who are considered to be "economic" migrants because they are primarily motivated by the opportunity to work in the United States, and who can be more easily repatriated without requiring detention. However, over the past five years, apprehensions of aliens from the Northern Triangle countriesâmany of whom are reportedly fleeing violence and seeking asylum in the United Statesâhave exceeded those from Mexico. Since 2017, U.S. Customs and Border Protection (CBP) has reported a sharp increase in the number of apprehensions at the Southwest border, especially among members of family units and unaccompanied alien children (UAC). Together, persons in family units and UAC currently make up more than two-thirds of apprehensions. In May 2018, the number of apprehensions by the U.S. Border Patrol plus the number of aliens determined inadmissible by CBP's Office of Field Operations (OFO) totaled 22,000; in April 2019, that number was 100,569, a 357% increase. In contrast, the number of single adults who were apprehended or found inadmissible rose from 24,493 to 43,637, a 46% increase, during the same time period. Foreign nationals from the Northern Triangle are requesting asylum at high rates that are DHS officials say are overwhelming the ability of federal agencies to process their detention, adjudication, and removal. Laws Governing Aliens Arriving at the U.S. Border The U.S. Border Patrol is responsible for immigration enforcement at U.S. borders between ports of entry (POEs). CBP's Office of Field Operations (OFO) handles the same responsibilities at the POEs. Foreign nationals seeking to enter the United States may request admission legally at a POE. In some cases, aliens attempt to enter the United States illegally, typically between POEs on the southern border. If apprehended, they are processed and detained briefly by Border Patrol; placed into removal proceedings; and, depending on the availability of detention space, either transferred to the custody of Immigration and Customs Enforcement (ICE) or released into the United States. Removal proceedings take one of two forms (streamlined or standard) depending on how the alien attempted to enter the United States, his/her country of origin, whether he/she is an unaccompanied child or part of an arriving family unit, and whether he/she requests asylum. If the alien is determined by an immigration officer to be inadmissible to the United States because he/she lacks proper documentation or has committed fraud or willful misrepresentation in order to gain admission, the alien may be subject to a streamlined process known as expedited removal. Expedited removal allows for the alien to be ordered removed from the United States without any further hearings or review. UAC, however, are not subject to expedited removal. Instead, if they are subject to removal, they are placed in standard removal proceedings and transferred to the Department of Health and Human Services' (HHS') Office of Refugee Resettlement (ORR) pending those proceedings. Although most aliens arriving in the United States without valid documentation are subject to expedited removal, they may request asylum, a form of relief granted to foreign nationals physically present within the United States or arriving at the U.S. border who meet the definition of a refugee. During CBP's initial screening process, if the alien indicates an intention to apply for asylum or a fear of persecution in his/her home country, the alien is interviewed by an asylum officer from DHS's U.S. Citizenship and Immigration Services (USCIS) to determine whether she/he has a "credible fear of persecution." If the alien establishes a credible fear, she/he is placed into standard removal proceedings under Immigration and Nationality Act (INA) Â§240 and may pursue an asylum application at a hearing before an immigration judge. Those who receive a negative credible fear determination may request that an immigration judge review that finding. If the immigration judge overturns the negative credible fear finding, the alien is placed in standard removal proceedings; otherwise, the alien remains subject to expedited removal and is usually deported. Aliens may be detained or granted parole while in standard removal proceedings. During these proceedings, immigration judges within the Department of Justice's (DOJ's) Executive Office for Immigration Review (EOIR) conduct hearings to determine whether a foreign national is subject to removal or eligible for any relief or protection from removal. While immigration judges have the authority to make custody decisions, ICE makes the initial decision whether to detain or release the alien into the United States pending removal proceedings. Most asylum seekers who are members of family units are currently being released into U.S. communities to await their immigration hearings. Detention in the Immigration System The INA authorizes DHS to arrest, detain, remove, or release foreign nationals subject to removal. Enforcement and Removal Operations (ERO) is the office within ICE that is charged with detention and removal of aliens from the United States. Generally, aliens may be detained pending removal proceedings, but detention is discretionary if the alien is not subject to mandatory detention. Detention is mandatory for certain classes of aliens (e.g., those convicted of specified crimes) with no possibility of release except in limited circumstances. During the intake process, an ERO officer uses the ICE Risk Classification Assessment (RCA), a software tool that attempts to standardize custody decisions across all ERO offices, to evaluate whether a foreign national should be detained or released on a case-by-case basis. The factors used to make the detention decision include, but are not limited to, criminal history, alleged gang affiliation, previous compliance history, age (must be at least 18), community or family ties, status as a primary caregiver or provider to family members, medical conditions, or other humanitarian conditions. Typically, an alien may be released from ICE custody on an order of recognizance, bond, or parole on humanitarian grounds. For example, aliens initially screened for expedited removal who request asylum are generally subject to mandatory detention pending their credible fear determinations, and, if found to have a credible fear, pending their standard removal proceedings; however, DHS has the discretion to parole the alien into the United States pending those proceedings. Pursuant to a court settlement agreement, alien minors may be detained by ICE for only a limited period, and must be released to an adult sponsor or a non-secure, state licensed child welfare facility pending their removal proceedings. Due to these legal restrictions and a lack of appropriate facilities for family units, DHS typically releases family units with accompanying minors, if they are subject to removal, pending their removal proceedings because there are not enough licensed shelters available to detain the number of family units arriving at the Southwest border. Thus, if family units entering the United States request asylum and receive a positive credible fear determination, they typically will not be detained throughout their removal proceedings. In addition, as noted previously, UAC are generally transferred to the custody of ORR pending the outcome of their removal proceedings. Thus, like family units, UAC typically are released from DHS custody and placed in the non-detained docket during those proceedings. All aliens released from ICE custody into the U.S. interior are assigned to the non-detained docket and must report to ICE at least once a year. ICE's non-detained docket currently has approximately 3 million cases. Some portion of those in the non-detained docket are enrolled in an ATD monitoring program, but all aliens in the non-detained docket are awaiting a decision on whether they should be removed from the United States. The number of initial "book-ins" to an ICE detention facility (by ICE and CBP combined) has exceeded 300,000 annually in recent years, peaking in 2014 at 425,728, and reaching nearly 400,000 in FY2018. Even though there were nearly 400,000 admissions to detention in FY2018, the number of book-ins does not describe the population of aliens who are in a detention facility on any given day. Instead, the number of aliens in detention on a given day is determined by the number of book-ins, the length of stay in detention, and the number of beds authorized by Congress. In FY2019, the number of detention beds authorized by Congress was set at 45,274, up nearly 5,000 from the previous year, and more than 10,000 greater than FY2016. ICE reported that 54,082 aliens were currently detained on June 22, 2019. ICE Caseload Size and ATD Participants Figure 1 shows the ICE caseload, which consists of all detained and non-detained aliens that ICE must supervise as part of its docket management responsibilities. As mentioned above, non-detained aliens include those released from ICE custody on various types of orders, including orders of recognizance, parole, and bond, and those who were never detained. The ICE non-detained docket also includes aliens in state or federal law enforcement custody and at-large aliens with final orders of removal (e.g., fugitives). Those released from ICE custody are required to report to ERO at least once annually, but the frequency is at the discretion of ERO. The non-detained docket caseload is monitored as aliens move through immigration court proceedings until their cases close. Aliens in ATD have secured a legal means of release (i.e., bond or parole); participating in ATD is a condition of their release. As noted, ICE's full non-detained caseload was approximately 3 million foreign nationals on June 22, 2019. On that same date, ICE reported that there were 54,082 detained aliens, less than 2% of the entire ICE caseload. Included in the ICE non-detained caseload are 101,568 aliens, approximately 3% of all cases (See Figure 1 ), enrolled in ISAPIII. The goal of the ICE ATD program is to monitor and supervise certain aliens in removal proceedings more frequently relative to those released with annual supervision. Those in ATD are required to report to ERO annually as well, but they are also subject to varying degrees of supervision and monitoring at more frequent intervals on a case-by-case basis (see description of " Alternatives to Detention (ATD) Programs "). More broadly, DHS maintains that ATD programs should not be considered removal programs or a substitute for detention. Instead, according to DHS, these programs have enhanced ICE's ability to monitor more intensively a subset of foreign nationals released into communities. Alternatives to Detention (ATD) Programs Intensive Supervision Appearance Program III (ISAP III) ICE's Intensive Supervision Appearance Program III (ISAP III) is the third iteration of the ATD program started by the agency in 2004. It is the only ATD program currently operated by ERO. To be eligible for this program, participants must be 18 years of age or older and at some stage of their removal proceedings. The most recent publicly available data show that there were 101,568 active participants enrolled in ISAP III, which is a 283% increase over the 26,625 enrollees in FY2015. Those enrolled in ISAP III are supervised largely by BI, Inc., a private company that provides ICE with case management and technology services in an attempt to ensure non-detained aliens' compliance with release conditions, attendance at court hearings, and removal. ERO ATD officers determine case management and supervision methods on a case-by-case basis. Case management can include a combination of face-to-face and telephonic meetings, unannounced visits to an alien's home, scheduled office visits by the participant with a case manager, and court and meeting alerts. Technology services may include telephonic reporting (TR), GPS monitoring (via ankle bracelets), or a relatively new smartphone application (SmartLINK) that allows enrolled aliens to check in with their case workers using facial recognition software to confirm their identity at the same time that their location is monitored by the GPS capabilities of the smartphone. As of June 22, 2019, approximately 42% of active participants in the ISAP III program used telephonic reporting, 46% used GPS monitoring, and 12% used SmartLINK. According to a 2014 Government Accountability Office (GAO) report, enrollees in ICE ATD programs are closely supervised at the beginning of their participation. If they are compliant with the terms of their plans in the first 30 days, the level of supervision may be lowered. Various compliance benchmarks are tracked in order to make decisions about whether supervision should be reduced or increased. If a final order of removal is issued, supervision usually increases until resolution of the case. ICE typically ends an alien's participation in the program when they are removed, depart voluntarily, or are granted relief from removal through either a temporary or permanent immigration benefit. Who is in the ISAP III program?58 Statistics obtained from ERO show that of the 87,384 enrollees in ISAP III on August 31, 2018, approximately 61% were female and 56% were members of family units (at least one adult with at least one child). Approximately 61% of participants were between the ages of 18 and 34, another 38% were 35-54, and 2% were 55 and older. Seventy-one percent of ISAP III enrollees were from the Northern Triangle countries of Guatemala, Honduras, and El Salvador ( Figure 2 ). Participants from Mexico made up 17% of the total, and the remaining 12% were from all other countries ( Figure 2 ). Ninety percent had no record of a criminal conviction ( Figure 3 ). Although all foreign nationals in ISAP III are in removal proceedings, most (86%) did not yet have a final order of removal on the date that these data were made available. Fourteen percent had a final order of removal; 19% of these aliens had appealed their removal order. Evaluating ATD In 2014, GAO evaluated ISAP III's predecessor program, ISAP II, during the FY2011 to FY2013 period. This iteration of the program had two supervision options, "full service" and "technology only," thus the results of the GAO evaluation of ISAP II have limited utility for better understanding the effectiveness of ISAP III (which has not been similarly evaluated). The GAO evaluation of ISAP II noted that ICE had established two program performance measures to assess the effectiveness of the program: ensuring compliance with court appearance requirements and securing removals from the United States. However, GAO stated that limitations in data collection interfered with its ability to assess overall program performance. GAO found high rates of compliance with court appearances among full service ISAP II enrollees in the FY2011-FY2013 time period: 99% of participants appeared at their court hearings, dropping to 95% if it was their final removal hearing. Similar data was not collected for participants enrolled in the technology-only component, which amounted to 39% of the total participants in 2013. GAO subsequently reported that ICE, through its contractor, began collecting court compliance data for approximately 88% of the total participants, who were managed by either ICE or the contractor. According to ICE officials, as reported by GAO, ICE added a performance measure based on removals in 2011 because "the court appearance rate had consistently surpassed 99 percent and the program needed to establish another goal to demonstrate improvement over time." GAO found that ICE met its ISAP II program goal for the number of removals for FY2012 and FY2013. For each of these years, the removal goal was a 3% increase in the number of removals from the previous fiscal year. In FY2012, the removal goal was 2,815, and ICE met it by removing 2,841 program participants from the United States. In FY2013, the removal goal was increased to 2,899, and ICE removed 2,901 program participants from the United States. Even though GAO was able to report on ISAP II removal and court compliance performance measures, it determined that data collection limitations hampered its ability to fully evaluate ISAP II's performance. For example, as described above, data collection on court appearance rates was inconsistent and incomplete for over one-third of program participants. ICE's performance measures were based on data collected at the time of an alien's termination from ISAP II, but ICE could not determine whether the alien complied with all of the terms of his/her release while participating in the program or absconded, due to incomplete record keeping and limited resources to maintain contact. GAO concluded that these performance measures and rates provided an incomplete picture of enrollees who were terminated from ISAP II prior to receiving final disposition of immigration proceedings, making it impossible to know how many were removed, departed voluntarily, or absconded. The Family Case Management Program (FCMP) The Family Case Management Program (FCMP), which operated from January 2016 until June 2017, was an ATD pilot program for families with vulnerabilities not compatible with detention. An ICE review of the program published in March 2017 showed that although the rates of compliance for the FCMP were consistent with other ICE monitoring options, FCMP daily costs per family unit were higher than ISAP III. The program was discontinued. The FCMP prioritized families with young children or pregnant or nursing women, individuals with medical or mental health considerations (including trauma), and victims of domestic violence. The program was designed to increase compliance with immigration obligations through a comprehensive case management strategy supported by established community-based organizations (CBOs). A private contractor, GEO Care, Inc., entered into agreements with local CBOs that provided case management and other services. The program operated as follows. Each family was assigned to a case manager and offered three sets of services. First, participants were offered "initial stabilization" services, such as referrals for legal assistance, medical and food assistance, and English language training, based on the premise that stable families are more likely to comply with immigration requirements. Second, participants were required to attend legal orientation programs, which included presentations about immigration proceedings, obligations of participants, and legal representation. These programs were also designed to orient enrollees in understanding basic U.S. laws covering issues such as child supervision, domestic violence, and driving while intoxicated. Third, the program was specifically intended to reinforce information pertinent to aliens' cases through frequent reporting requirements, typically monthly office and home visits with case managers and monthly appointments with ERO. Ongoing relationships with case workers were developed to build trust in the immigration system and set clear expectations of the legal process, as well as to provide planning assistance for the eventuality of return, removal, or an immigration benefit that would offer relief from removal. Individualized and interactive oversight of cases and a flexible monitoring plan (similar to ISAP III) were implemented to provide a range of supervision optionsâsupervision was typically high while families stabilized their situations, and lower (conducted by ERO only) once they were considered stabilized. Who was enrolled in the FCMP? The program enrolled 952 heads of households with 1,211 children, for a total of 2,163 individuals in five metropolitan areas around the country. According to a 2018 ICE internal close-out report, most of the families in the program (92%) were headed by women; and most of the participants (95%) were from the Northern Triangle countriesâEl Salvador (44%), Honduras (32%), and Guatemala (19%) ( Figure 4 ). Overall, 55% of the program participants were children under the age of 18; 21% of children were under age 6. Twenty-one percent of program participants were between the ages of 26 and 35, 13% were 18-25, 9% were 36-45, and 2% were 46 or older ( Figure 5 ). All participants enrolled in the FCMP were individually assessed for vulnerabilities and needs. Seventy-three percent had experienced some kind of trauma, 11% were victims of domestic violence, 6% were pregnant, 6% were nursing, and 4% had mental health concerns ( Figure 6 ). Evaluating FCMP ICE conducted an evaluation of the FCMP that focused on three metrics: attendance at ERO appointments, attendance at appointments with community-based organizations, and attendance at court hearings. Data on compliance of the relatively small number of families that completed the program prior to its termination reported it to be high across all locations, with 99% attendance at immigration court proceedings and 99% compliance with ICE monitoring requirements. About 4% of program participants absconded during the life of the program. In total, 65 families left the program: 7 were removed from the United States by ICE, 8 left the country on their own, 9 were granted some form of immigration relief, and 41 absconded. The rest of the families remained in the program; however, because of its short duration the ICE evaluation of the FCMP is limitedâthe majority of the participants were still in immigration proceedings when it was terminated. It is unknown what the program's success rates would have been if participants were allowed to remain in the program through the final outcome of their cases. When ICE discontinued the program in June 2017, the agency stated that rates of compliance for the FCMP were consistent with its other ATD program (i.e., ISAP III).Â In addition to compliance rates, another important factor in evaluating the program is its cost. The FCMP cost approximately $38.47 per family per day in FY2016, versus approximately $4.40 per person per day for ISAP III. By comparison, family detention costs an estimated $237.60 per day and adult detention in the same cities that the FCMP operated in cost $79.57 on average per day in FY2016. The FCMP is more expensive than ISAP III due to the comprehensive case management and services available to its participants, the more vulnerable family populations targeted, and the smaller caseload per case manager (which allowed for more time with each participant household). For example, FCMP case managers were expected to have a high level of experience, used outreach (not just referrals) to connect participants with community resources, had Spanish language ability or accessed interpretation services, and developed individualized plans for families, including children. The evaluation indicated that FCMP families made use of the services offered to them: the most common referrals made by case workers were for legal services, medical attention, and food aid. The Consolidated Appropriations Act, 2019 ( P.L. 116-6 ) includes $30.5 million to resume the FCMP. The conference report states that the FCMP "can help improve compliance with immigration court obligations by helping families access community-based support of basic housing, healthcare, legal and educational needs." The conference report also directs ICE to prioritize the use of ATD programs, including the FCMP, for families. In addition, the report instructs ICE to brief the relevant committees, within 90 days of the date of enactment, on a plan for a program within the FCMP managed by nonprofit organizations that have experience in connecting families with community-based services. The ICE ERO Detention Management website mentions a new program, Extended Case Management Services (ECMS). It states, "as instructed by Congress, ICE recently incorporated many of the Family Case Management Program (FCMP) principles into its traditional ATD program. These principles were incorporated into the current ATD ISAP III through a contract modification and are known as Extended Case Management Services (ECMS). These same services are available through the ECMS modification as they were available under FCMP with two distinct differences: ECMS is available in a higher number of locations and available at a fraction of the cost. While ECMS is a new program, ICE continues to identify and enroll eligible participants." As of June 22, 2019, ICE reported that 57 family units and 59 adults are enrolled in ECMS. Why have alternatives to detention? Supporters of ATD programs cite several reasons for their use. First, the number of foreign nationals currently being taken into custody far exceeds the capacity of existing detention facilities. As noted above, in FY2018 the number of book-ins to ICE facilities was nearly 400,000. As of July 12, 2018, ICE's detention capacity was approximately 45,700 beds; of these, approximately 2,500 were for family units housed in family residential centers. Second, many foreign nationals who are in removal proceedings are not considered security or public safety threats, nor are they an enforcement priority as outlined in guidance to DHS personnel regarding immigration enforcement. Third, some foreign nationals who are found deportable or inadmissible may not be removed because their countries of citizenship refuse to confirm an individual's identity and nationality, issue travel documents, or otherwise accept their physical return. A U.S. Supreme Court ruling from 2001, Zadvydas v. Davis , limits the federal government's authority to indefinitely detain aliens who have been ordered removed and who have no significant likelihood of removal in the reasonably foreseeable future. Those who promote using ATD programs also cite the relatively low cost compared with detention. ICE spent an average of $137 per adult per day in detention nationwide in FY2018. The cost of enrolling foreign nationals in the ISAP III program depends on the method of management, but the average daily cost per participant in FY2018 (through July 2018) was $4.16. GAO utilized two methods of determining the cost of ATD (ISAP II) relative to detention in FY2013 (at that time, the average daily cost of ISAP II was $10.55, while daily detention was an average of $158). First, given the average daily costs of ATD and detention, and the average length of time an alien spent in detention awaiting an immigration judge's final decision, GAO found that the cost of maintaining an enrollee in ISAP II would surpass the costs of detention only if the enrollee were in the program for 1,229 days, which would be 846 days longer than the average number of days a participant typically spent in it. Second, given the average cost of ATD and detention, and the average length of time an alien spent in detention regardless of whether a final decision on her/his case was rendered, GAO determined an individual would have to spend, on average, 435 days in ISAP II before they exceeded the cost of the average length of detention (29 days in FY2013). There are also arguments against using ATD programs. Of primary concern is that the programs, in comparison to detention, create opportunities for aliens in removal proceedings to abscond and become part of the unauthorized population who are not allowed to lawfully live or work in the United States. Because immigration judges must prioritize detained cases, ATD enrollees must often wait several years before their cases are heard, during which time they may abscond. They may also fall out of contact with ERO for other reasons. For example, an alien may move within the United States and fail to provide updated contact information to ERO. If they do not receive communication from ICE or the immigration court system, they could miss court dates that have changed in the interim. If they fail to show up for a removal hearing, for example, they can be ordered removed in absentia , which would render them inadmissible for a certain period (at least 5 years if they are an arriving alien, and at least 10 years for all other aliens) and ineligible for certain forms of relief from removal for 10 years. Another concern is that asylum-seeking families are often placed into ATD, and this creates incentives for others to travel to the United States with children, request asylum, and receive similar conditions of release into the United States. DHS has expressed concern over adults using children as a "human shields" to avoid detention after illegally entering the United States. Those without bona fide family relationships may travel with children and file fraudulent claims or do harm to children. Recent reports of children being "recycled"âcrossing into the United States with an adult or a family, only to be returned across the border to travel with another migrantâhas prompted DHS to take biometric data, such as fingerprints, from children. Additional arguments against using ATD programs include that reliable measures of their effectiveness are limited, as discussed above in " Evaluating ATD " and "Evaluating FCMP," and for the FCMP pilot, that the feasibility of scaling up a small pilot program to accommodate the large number of families requesting asylum remains an open question.


Background In response to the 2014 access crisis, VA launched the MyVA initiative, which was designed to transform the health care experience of veterans. In concert with the MyVA initiative, VA introduced the MyVA Access Declarations in April 2016 with the goal of improving access by providing veterans more control as to how they receive their health care. The MyVA Access Declarations was a list of nine “access declarations” that were intended to serve as the foundational principles for improving and ensuring access to care. Two of these “access declarations” required providing timely primary and mental health care and included same-day services. VHA Policies on Same- Day Services VHA had policies in place for same-day services in primary and mental health care clinics for several years prior to the same-day-services initiative. In primary care, the 2014 Patient-Aligned Care Team (PACT) handbook required all primary care providers and registered nurses to ensure they provide same-day access (unless it is too late in the day as determined by the individual facility) for face-to-face encounters, telephone encounters and, when required by VHA guidance or policy, other types of encounters. The PACT handbook was supplemented by a 2015 VHA memo on unscheduled patient walk-ins. The memo states that if an unscheduled patient presents at a PACT clinic with a clinical concern, the patient cannot be turned away without evaluation by a clinical member of the team, regardless of clinic hours, resource availability, or eligibility/enrollment status. VHA also had previously developed policies stating that veterans are entitled to timely access to mental health care. Specifically, a 2007 VHA memo required that all veterans requesting or referred for mental health care or substance abuse treatment receive an initial evaluation within 24 hours. VHA’s 2015 Uniform Mental Health Services handbook also noted that all new patients requesting or referred for mental health care services must receive an initial evaluation within 24 hours and a more comprehensive diagnostic and treatment planning evaluation within 30 days. Additionally, since 2008, VHA has required the integration of primary care and certain mental health care services at VA medical centers serving a veteran population greater than 5,000. This care model, known as Primary Care–Mental Health Integration (PC-MHI), integrates mental health staff into each primary care PACT clinic, allowing veterans to receive services for depression, anxiety, post-traumatic stress disorder, and substance use without needing to obtain a separate referral to providers in the mental health care clinic. According to VHA guidance, PC-MHI has been shown to improve access to same-day mental health care and reduce no-show rates to appointments. Oversight of VHA Access to Care Efforts VHA’s veterans access to care office was created in 2016 as the national oversight office for VHA access-to-care issues. Additionally, each VISN is responsible for overseeing the VA medical centers within their designated regions. This oversight includes oversight of access issues and the implementation of initiatives such as the same-day service initiative. VA medical center directors are responsible for ensuring local policies are in place for the effective operation of their primary and mental health care clinics, including affiliated CBOCs. VHA Used a Five- Pronged Approach to Design Its Same-Day Service Initiative; Selected VA Medical Centers Relied on Previous Approaches to Implement It VHA Used a Five-Pronged Approach to Design and Set Up the Same-Day- Services Initiative VHA used a five-pronged approach to design its same-day services initiative: VHA (1) defined same-day services, (2) developed guidance, (3) updated its mental health policies, (4) offered training, and (5) assessed VA medical center readiness to implement the initiative. VHA defined same-day services. As an initial step, VHA leadership developed the following definitions of same-day services in primary and mental health care: Same-day services in primary care: “When a veteran requires primary care services right away, during regular business hours, he or she will receive services the same day at a VA medical center. If a veteran calls after normal business hours, he or she will receive care the next business day.” Same-day services in mental health: “If a veteran is in crisis or has another need for mental health care right away, he or she will receive immediate attention from a health care professional at a VA medical center.” VHA also identified a variety of ways in which veterans can receive same- day services, including: (1) providing a face-to-face visit; (2) returning a phone call; (3) arranging a telehealth or video care visit; (4) responding to a secure email; or (5) scheduling a future appointment. VHA developed guidance for the same-day service initiative. To help VA medical centers implement its definition of same-day services, in April 2016, VHA developed written guidance—the MyVA Access Implementation Guidebook. The guidebook provides a variety of solutions to help VA medical centers meet the intent of the same-day service initiative. The guidebook includes specific solutions for VA medical centers struggling to provide same-day services in primary or mental health care for veterans with urgent care needs: Implementing open access in primary and mental health care: Open access aims to balance the supply of (for example, available appointments) and demand for (for example, the number of patients assigned to a provider and annual visits per patient) services to increase patient access. Achieving open access requires implementing specific strategies including achieving full staffing, planning for contingencies such as clinical staff absences or vacancies and managing the number of times patients see a provider each year, among other strategies. Implementing primary care-mental health integration: In order to complete the implementation of PC-MHI across the VA system, the guidebook suggests facilities address staffing vacancies, develop a PC-MHI implementation plan, and choose an open access scheduling model (for example, full open access where there are no scheduled appointments and patients are seen on a first come, first served basis), among other things. Utilizing same-day referrals to mental health for suicide prevention: This solution reiterates many of the mental health policy changes that VHA introduced in conjunction with the same-day service initiative such as implementing an initial screening evaluation, developing a process for same-day care for established patients with an urgent need, and deploying open access scheduling, among other things. The guidebook states that all of the solutions were chosen because they were used successfully at other VA medical centers; can be quickly implemented; and have a high impact on veterans’ access to care. The guidebook also notes that flexibility is a key element when choosing solutions and explains that VA medical centers should select and modify solutions as needed. The guidebook does not make any of the solutions mandatory; however, several of the mental health solutions were introduced to facilities through separate VHA memos and are required. VHA updated mental health policies. VHA updated certain mental health policies to facilitate the implementation of the same-day services initiative. Specifically, in April 2016 VA issued a memo updating its mental health policy to require that any veteran new to mental health services requesting or referred for care in person be seen the same day by a licensed independent provider to screen for and address immediate care needs. This was a change from the previous timeframe of 24 hours for an initial evaluation. The memo also created new processes for VA medical centers to assess same-day services in mental health care clinics, including a medical chart review and a one-time review of standard operating procedures to ensure that the new guidelines are being followed. VHA also distributed other memos that either sought to clarify existing guidance or expand same-day services into other areas of mental health care, such as substance abuse. Additionally, VHA provided a memo to VA network directors and mental health leads about scheduling models for mental health care that all VA medical centers needed to implement for the same-day service initiative. VHA provided training on the same-day-services initiative. VHA provided voluntary training for same-day services some of which discussed the solutions from the guidebook and the updated mental health policy. The trainings began in February 2016 for primary care and in May 2016 for mental health. The trainings consisted of national telephone calls (often with slide presentations) that any VA medical center staff member could join, and the presentation materials were posted to VHA’s internal website. The telephone trainings generally occurred twice a month in primary care and every week in mental health care. VHA assessed VA medical center same-day service readiness. Beginning in January 2017, VHA provided technical assistance around same-day services to VA medical centers. VHA reviewed several aspects of same-day services, including how VA medical centers were able to provide same-day services and identified any approaches that may have needed improvement. Generally, low-performing VA medical centers received continuous on-site support; moderate performing VA medical centers received a combination of virtual and on-site support; and, high performing VA medical centers primarily received virtual support. To determine the progress that VA medical centers were making in providing same-day services, VHA conducted surveys that required medical center directors to self-certify—and, in some cases, VISN directors to validate—that their VA medical centers (including affiliated CBOCs) were able to provide same-day services. In the event that a VISN director could not validate medical center survey information, VHA followed up with the medical center and VISN director to create an action plan to mitigate any issues that were delaying validation. These surveys were conducted in 2016 and 2017; focused on either primary care, mental health care or both; and varied in the information collected to determine how VA medical centers were providing same-day services (See Table 2 for information on the same-day-services readiness assessment surveys used by VHA). According to VHA, all VA medical centers were offering same-day services in primary and mental health care by December 2016. In January 2018, VHA announced that same-day services in primary and mental health care had been achieved in all VA medical centers and CBOCs (more than 1,000 facilities). Selected VA Medical Centers Generally Relied on Previous Approaches to Implement the Same- Day-Services Initiative Officials we spoke with from all six VA medical centers in our review told us they were providing same-day services in primary and mental health care prior to the same-day service initiative, an assertion supported by VHA survey data. For example, in a VHA survey conducted in May 2016, around the same time as the launch of the same-day service initiative, 142 out of 165 officials (86 percent) that responded to the survey said that their medical centers offered same-day appointments “always” or “very frequently” in primary care for urgent concerns. We found that the VA medical centers in our review used a variety of approaches in providing same-day services in primary and mental health care, most of which were in existence before the initiative. As noted earlier, VHA did not require the implementation of any specific solutions in the guidebook and afforded VA medical centers the flexibility to choose appropriate local solutions for the same-day service initiative. Many VA medical centers used this flexibility to continue providing same-day services as they had prior to the initiative often because that is what their resources allowed them to do or, in the case of mental health, because it was built into the foundation of their service line. VHA officials noted that mental health services—particularly PC-MHI—were built around same- day services so VHA’s guidance was familiar to them. The approaches used by the selected VA medical centers included using “float providers” who had not already been assigned specific patients to assist those who requested same-day services; carving out specific appointment times in the schedule for walk-ins; overbooking appointments in providers’ schedules, and offering walk-in clinics. VHA suggested that certain solutions should be prioritized if VA medical centers were struggling to provide same-day services and, in particular for mental health, created new requirements around same-day services. However, officials at selected VA medical centers noted that some of the suggested solutions in the guidebook—particularly open access—and requirements in updated mental health policies were difficult to implement because of longstanding challenges with staffing, space, or competing VHA policies. For example, VHA’s guidebook suggests the implementation of open access in primary and mental health care in such situations. However, officials at four of the six VA medical centers we visited noted that open access was difficult to implement because of the long-standing challenges mentioned above. In addition, VHA updated its mental health policy to include that any veteran new to mental health services requesting or referred for care in person be seen the same day by a licensed independent provider to screen for and address immediate care needs. However, one medical center official noted that they had designed their mental health clinic processes around registered nurses, who are responsible for completing the initial assessments of new patients. The official added that the medical center did not have licensed independent providers readily available at certain facilities to help complete the assessments in a timely manner. Officials at all six medical centers we visited noted that implementation was also sometimes challenging as veterans’ expectations shifted with the same-day-services initiative, with veterans’ expecting more immediate access to care from physicians for a variety of conditions. For example, one medical center official noted that veterans are presenting for care and wanting to see a provider because it is these veterans’ understanding that they could get care immediately for any condition including chronic, less urgent issues. Additional officials at the same facility echoed this concern and noted that they are not certain that this was the policy’s intent. Another medical center official noted that several medical center officials asked VHA to change the name “same-day service” because it gives the impression that veterans would always be able to see their provider immediately. This official added that there is some confusion for both staff and veterans about what are same-day services. Additionally, according to one veterans service organization official that we spoke with, a small number of veterans reported that the availability of same-day services varied by facility (VA medical center versus CBOC) and location (urban versus rural). Another medical center official noted that same-day services are not sustainable if the definition is immediate care by a provider for any condition, especially non-urgent issues. VHA officials told us that the same-day service initiative was a response to the 2014 access crisis and they wanted facilities to use the resources available to them rather than waiting on new policies and strategies. They stated that their main concern was that veterans’ needs were met, not necessarily how they were met. As such, VHA officials told us that they found VA medical centers’ implementation of same-day services acceptable. The VHA officials added that the guidebook is still the foundational document for same-day services. VHA officials told us that it is important for VA medical centers to educate patients on the appropriate use of same-day services. They added that in fiscal year 2019 they are (1) developing a more precise definition of same-day services; (2) developing a website to better explain the purpose of the initiative; and (3) requiring on-demand trainings to provide a clearer explanation about what same day services are available and what staff roles and responsibilities are, among other things. The training is expected to be completed no later than the first quarter of fiscal year 2020. VHA Has Not Documented Objectives or Developed Performance Goals and Related Measures to Assess the Impact of Same- Day Services on Veterans’ Access to Care VHA is limited in its efforts to assess the impact of same-day services due to its lack of documented objectives, developed performance goals and related performance measures. Our previous work has shown the benefit of fully connected objectives and performance goals with measurable targets. Objectives state the longer term desired impact or outcome to be achieved, while performance goals communicate the target the agency seeks to achieve within a certain timeframe. Performance measures are indicators of the progress the agency is making towards a goal or target within a particular time frame. VHA officials told us that the overall objectives of same-day services are to improve veterans’ access to care and customer service while having minimal impact on medical centers’ existing workflows. However, VHA has not documented these objectives—for example, in a directive. In addition, VHA has not developed and documented performance goals that, with associated performance measures, would facilitate monitoring of progress towards the desired outcome of the same-day services initiative. VHA officials stated that the same-day-services initiative was developed quickly in response to the 2014 access crisis, and noted that at the time, their focus was “to get something out quickly” instead of taking time to standardize the initiative around specific policies and procedures, which could include documenting objectives and developing performance goals. VHA officials acknowledged that their decision to focus on quickly implementing the initiative without documenting objectives and developing performance goals and associated performance measures makes assessing the impact of the same-day services initiative more challenging. VHA has taken some steps to collect data on same-day services. For example, VHA officials stated that they primarily rely on two measures to assess the impact of the same-day services initiative: patient experience scores and the number of same-day appointments. However, without performance goals these measures do not provide VHA with a means to monitor progress and provide limited information on same-day services’ impact. Patient experience score: VHA uses the Survey of Healthcare Experiences for Patients (SHEP) to measure veterans’ perceptions of their experience at VA medical centers. For same-day services, VHA monitors responses to two questions. According to VHA officials, the key measure is based on the survey question that asks “in the last 6 months, when you contacted this provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?” While SHEP scores provide some data related to customer service and access to care, VHA has not developed performance goals that sets targets for these or other aspects of the same-day services initiative that would benefit from monitoring. Such goals would better enable VHA to identify gaps in performance and plan any needed improvements; ensure balance between agency priorities, such as customer service and access; and identify unintended effects, such as disruption to clinic workflows. For example, officials at one medical center told us that focusing on customer service creates issues with respect to routine care in that veterans’ definition of customer service is based on what makes them happy, while providers are focused on providing the best treatment. Officials added that these two definitions do not always align. In addition, officials at another medical center stated that implementing same-day services impacted their providers’ schedules and the resulting changes to their processes created chaos. Number of same-day appointments: VHA measures the number of same-day appointments, which, according to a VHA official, are identified in VHA data as appointments completed on the same day they are created in VHA’s scheduling system. According to a VHA training document, VA completed 12 million same-day appointments in fiscal year 2018. However, without performance goals with clear targets for same-day appointments, an official from one VISN said she was unclear how many same-day appointments medical centers should be scheduling. Additionally, same-day services performance goals may afford VHA the opportunity to monitor other key measures—such as those that capture services that do not require an appointment—which could provide VHA with important information on the impact of same-day services on access to care. Moreover, performance goals and additional performance measures may help prevent unintended consequences, such as an over-emphasis on same-day appointments as the way to provide same-day services, which VHA officials stated they are working to curb. For example, officials at two selected medical centers also noted that measuring the number or proportion of same-day appointments does not capture all the ways medical centers provide same-day services. Officials at two other selected medical centers noted they can meet veterans’ same-day needs through multiple avenues, such as a registered nurse providing patient education or by renewing a prescription, that do not require an appointment and therefore, would not be counted in the number of same-day appointments. VHA officials stated that the impact of the same-day services on access to care is difficult to measure and additional measures would help properly measure the impact. VHA’s lack of documented objectives and developed performance goals and related measures is inconsistent with our prior work on effective management practices and federal internal control standards. Specifically, we have previously reported that performance measures benefit from certain key practices, such as breaking down of broad long- term objectives into specific near-term performance goals with measurable targets and time frames, and key attributes, such as balance to prevent skewed incentives over-emphasizing certain goals. Additionally, Standards for Internal Control in the Federal Government states that documentation provides a means to retain organizational knowledge and mitigate the risk of having that knowledge limited to a few personnel. Without clearly documented objectives, performance goals, and related performance measures, VHA is hindered in its efforts to define success for its same-day service initiative and measure progress achieving it. VHA officials stated they rely on VISN and VA medical center officials to oversee same-day services; however, we found that without performance goals and related performance measures, VISNs and VA medical centers found it challenging to oversee the same-day services initiative. Specifically, officials at five of the six medical centers and two of the four VISNs we visited stated that it is difficult to measure same-day services; which in turn makes assessing the initiative’s impact on veterans’ access to care difficult. Officials at one medical center explained that the challenge stems from the fact that that VHA has not defined what outcome it wants to achieve. In addition, officials at another VA medical center stated that they have a number of access measures available to them, but it was unclear to them which measures they should be prioritizing as part of their oversight of the same-day services initiative. Further, absent performance goals, we found that VISNs and medical centers, which operate in a decentralized environment, varied in their oversight strategies. For example, one VISN required all medical centers to complete a self-assessment of their access capacity and sustainability, and collected information on a number of key open access elements, including Patient-Aligned Care Team staffing levels and provider panel sizes, among others. However, oversight by other VISNs was reportedly less robust. For example, at one VISN, officials stated it is difficult to audit access broadly and described their oversight of same-day services as “fairly minimal.” At the medical center level, oversight also varied as officials tried to develop their own oversight solutions. Officials at one medical center we visited used a feature within the outpatient appointment scheduling system that allowed them to count the specific services, such as pharmacy refills, that veterans seeking same-day mental health care had requested. According to these officials, the tool provided additional data not found in existing VHA access-related reports and allowed them to better understand veterans’ demand for specific same-day services and utilize resources more efficiently. These officials added that they developed this solution because they had not received guidance from VHA on how they should measure demand, and they had skilled staff with the ability to develop their own measures. However, not all VA medical centers we visited had the skilled staff to develop similar solutions. Developing performance goals and related performance measures would better position VHA to obtain useful, comparable information on the impact of same-day services on access to care across VISNs and medical centers. Moving forward, VHA is planning to conduct a “mystery shopper” evaluation of same-day services to assess the impact of same-day services. The mystery shopper evaluation will consist of various scenarios in which veterans, engaged through a contractor, will attempt to access same-day care at a variety of clinics in VA medical centers. As described in a VHA planning document, the evaluation is intended to provide VHA with information on veterans’ experience in obtaining same-day services and will attempt to understand variations in how same-day services are provided. However, VHA officials have not determined if the evaluation will be ongoing. VHA officials stated that in addition to the mystery shopper evaluation, they are considering additional measures to better assess the impact of same-day services beyond their current measures, such as the number of pharmacy refills completed the same day they were requested. However, as of May 2019, VHA had not developed specific performance goals to align these measures to, or set timeframes for their creation. Without overall performance measures that are tied to documented performance goals, VHA will continue to be limited in its ability to assess the impact of same-day services on veterans’ access to care. Conclusions VHA’s same-day services initiative for primary and mental health care is one of several efforts by VHA to help improve veterans’ access to care in the 5 years since access issues garnered national attention. VHA’s stated objectives for the same-day-services initiative are to improve veterans’ access to care and customer service while having minimal impact on medical centers’ existing workflows. However, VHA has not documented these objectives or developed performance goals and related measures that provide for monitoring towards the desired outcomes. VHA primarily relies on veteran satisfaction scores and the number of same-day appointments to monitor the same-day-services initiative, but these measures alone do not enable an assessment of the impact of same-day services on access to care. Without documented objectives, and performance goals and related measures tied to these goals, VHA will continue to be limited in its ability to determine, how, if at all, the same- day-services initiative has improved veterans’ access to care. Recommendation for Executive Action The Under Secretary for Health should document same-day services objectives and develop performance goals and related performance measures to facilitate the periodic assessment of the impact of same-day services on veterans’ access to care. (Recommendation 1) Agency Comments We provided a draft of this report to VA for review and comment. In its written comments, which are reproduced in appendix I, VA concurred in principle with our recommendation. VA stated that its Office of Veterans Access to Care will clarify objectives, develop performance goals, and explore the options for reliable performance measures. VA noted that identifying options for performance measures will take approximately 9 months and that additional time may be needed for development, testing and refinement. VA provided a target completion date of April 2020. We are sending copies of this report 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 II. Appendix I: Comments from the Department of Veterans Affairs Appendix II: GAO Contact and Staff Acknowledgments GAO Contact Staff Acknowledgments In addition to the contact named above, Ann Tynan (Assistant Director), Dan Klabunde (Analyst-in-Charge), Jennie F. Apter, and Q. Akbar Husain made key contributions to this report. Also contributing were Muriel Brown, Jacquelyn Hamilton, Ethiene Salgado-Rodriguez, and Merrile Sing.