VA Mental Health Provider Venting / Problem-solving / Peer Support Thread

[Shiori]

Correction: We got doughnuts.

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[WisNeuro]

Correction: We got doughnuts.

Plain cake?

 

[Sanman]

Mayhaps, it just sucked when you had a 30-40% no show rate that the VA won't do anything meaningful about, have no work on Friday, and can't leave because if your "tour of duty." I much prefer the new system of if an IME no shows, I still get paid for the day, and then I work on other stuff, essentially earning double time for the same work.

That's why SDN exists. Not being able to leave your duty station has different meanings in the age of telework and remote work.

 

[Shiori]

Plain cake?

Glazed, because we're classy.

 

[Sanman]

I’ve been audited. It’s really not a big deal.

The insurance company asks for a random sample of your patient files. In this case, they asked for 5 specific patient files. We sent them off. They looked at the files, and said “looks right”, and that was the end of it. Took less than a month.

I did have a dementia patient complain to Medicare that I had never seen them. They asked that I send the file over to them. I included a note that dementia patients seem to forget things. They said everything was fine, and resumed payments.

That is interesting and I think depends on the insurance company. When Optum did their utilization reviews (different from the formal audits but a pain nontheless), they required 45 min with the provider and if they escalated to level II (which always happened with more complex nursing home patients) that was another 45 min call. I once spent 2 hours on the phone to justify getting paid for 2 or 3 sessions of 90832 and they wanted me to go get an updated screener because it was done when I first saw the patient 3 mths prior (mind you they had not paid for the previous sessions). Multiply that by the dozen or so clinicians I managed and I was not getting paid enough to deal with it.

 

[PsyDr]

That is interesting and I think depends on the insurance company. When Optum did their utilization reviews (different from the formal audits but a pain nontheless), they required 45 min with the provider and if they escalated to level II (which always happened with more complex nursing home patients) that was another 45 min call. I once spent 2 hours on the phone to justify getting paid for 2 or 3 sessions of 90832 and they wanted me to go get an updated screener because it was done when I first saw the patient 3 mths prior (mind you they had not paid for the previous sessions). Multiply that by the dozen or so clinicians I managed and I was not getting paid enough to deal with it.

URs are something different. I'm referring to post hoc insurance reviews.

For URs, I immediately tell the reviewer that I need their name and license number to put in each chart note, and that I will need the exact references from their provider handbook. Then I proceed with the review. Throw in a few reports to the state department of insurance, and suddenly I don't get URs.

 

[WisNeuro]

That's why SDN exists. Not being able to leave your duty station has different meanings in the age of telework and remote work.

They started blocking my fantasy sports sites when I was there. That sucked.

 

[Sanman]

URs are something different. I'm referring to post hoc insurance reviews.

For URs, I immediately tell the reviewer that I need their name and license number to put in each chart note, and that I will need the exact references from their provider handbook. Then I proceed with the review. Throw in a few reports to the state department of insurance, and suddenly I don't get URs.

That's fair, the problem with being a salaried employee is being less motivated to deal with it. Not to mention encouraging others to deal with it. The biggest issue either way, is having the cash on hand to deal with these uncertainties. That's the difference between nuisance and a risk to the business.

 

[psycho1391]

Speaking of burnout.

DK about other VA's , but mine now requires we attend a whole health course for our performance evals. Like a LIVE one. Minimum time requirement is 4 hours.

I'm currently in one of these trainings and we have to keep our cameras on.

This is what burns folks out.

 

[Sanman]

Speaking of burnout.

DK about other VA's , but mine now requires we attend a whole health course for our performance evals. Like a LIVE one. Minimum time requirement is 4 hours.

I'm currently in one of these trainings and we have to keep our cameras on.

This is what burns folks out.

Why? That is your local leadership being dumb. Was this a response to EAS or something else I wonder.

 

[Shiori]

We're required to attend so many Whole Health trainings. They will just block our clinics and tell us we're going. It hasn't been tied to performance evaluations...yet.

 

[AbnormalPsych]

What a weird requirement.

 

[Sanman]

We're required to attend so many Whole Health trainings. They will just block our clinics and tell us we're going. It hasn't been tied to performance evaluations...yet.

You will be less burned out...or else!

 

[R. Matey]

You will be less burned out...or else!

 

[texanpsychdoc]

That's why SDN exists. Not being able to leave your duty station has different meanings in the age of telework and remote work.

My tour was 8-4:30. If I was working on site, my ass was typically gone by 1PM because of the amount of no shows we had in SDTP. On days I worked remotely....I barely did stuff.

 

[psy.d. 2021]

You will be less burned out...or else!

the beatings will continue until morale improves

 

[Shiori]

When I do trainings/intern didactics, I remember I enjoy teaching. I wish I could do it more often.

 

[JustNoticing]

Looks like VA sec is getting chewed out by the senate committee, who are calling them out on freezing MH hiring in a number of locales, after saying specifically they weren't doing that:

https://www.cnn.com/2024/04/18/politics/senators-va-healthcare-staffing-invs/index.html

 

[AcronymAllergy]

The "long wait times" are ubiquitous to much of healthcare in general and, when you can't "fire" patients and can just file a congressional complaint when you aren't getting the care (or SC) you think you deserve, won't be going anywhere anytime soon.

That being said, VA leadership doesn't have the best record for transparency. Saying you're not going to fire front-line providers while then firing front-line providers (or rescinding offers to such) is not a good look. If it were accurate that of the 10,000 cuts, most or all would be programmatic/managerial staff, that'd be great; VA could probably spare twice as many "champions" and such.

The interesting part would come when VA's funding continues to balloon and becomes a matter of VA vs. Medicare and Social Security.

 

[WisNeuro]

The "long wait times" are ubiquitous to much of healthcare in general and, when you can't "fire" patients and can just file a congressional complaint when you aren't getting the care (or SC) you think you deserve, won't be going anywhere anytime soon.

That being said, VA leadership doesn't have the best record for transparency. Saying you're not going to fire front-line providers while then firing front-line providers (or rescinding offers to such) is not a good look. If it were accurate that of the 10,000 cuts, most or all would be programmatic/managerial staff, that'd be great; VA could probably spare twice as many "champions" and such.

The interesting part would come when VA's funding continues to balloon and becomes a matter of VA vs. Medicare and Social Security.

At least for my patients, getting a new neurology appointment in the community is about 4-6 months, other specialties (derm) even longer. Can't imagine the VA here is doing worse than that. I know the neuropsych department is at a month or less, which is a small fraction of the community waitlist time.

 

[Shiori]

It's weirdly cathartic that even at the highest level, people are being asked to do contradictory things. Take care of every veteran above and beyond what they could get in the community, but make sure it's not too expensive.

 

[cara susanna]

The "long wait times" are ubiquitous to much of healthcare in general and, when you can't "fire" patients and can just file a congressional complaint when you aren't getting the care (or SC) you think you deserve, won't be going anywhere anytime soon.

That being said, VA leadership doesn't have the best record for transparency. Saying you're not going to fire front-line providers while then firing front-line providers (or rescinding offers to such) is not a good look. If it were accurate that of the 10,000 cuts, most or all would be programmatic/managerial staff, that'd be great; VA could probably spare twice as many "champions" and such.

The interesting part would come when VA's funding continues to balloon and becomes a matter of VA vs. Medicare and Social Security.

And their funding was cut BY YOU GUYS, what do you expect them to do?? Make money appear out of thin air?

 

[Sanman]

And their funding was cut BY YOU GUYS, what do you expect them to do?? Make money appear out of thin air?

Honestly, the entire argument is a bit silly. Even if they don't cut providers, the money has to come from somewhere. Having worked in VAs with MSA shortages, things don't get done all the same despite "clinical staff" not being cut. Either fund it appropriately or stop complaining. There are already plenty of folks leaving for telehealth jobs due to quality of life concerns and I am half way out the door with them.

 

[cara susanna]

Might help if they funded HEALTHCARE and not just the bloated disability system, but no one's gonna touch that with a ten thousand foot pole

 

[cara susanna]

Just saw that they cancelled a bunch of EBP trainings because of the budget deficit. Sigh.

 

[Fan_of_Meehl]

Just saw that they cancelled a bunch of EBP trainings because of the budget deficit. Sigh.

VA’s $369 billion budget for 2025 anticipates increased disability payments but reduction in VA health care staff​

VA’s $369 billion budget for 2025 anticipates increased disability payments but reduction in VA health care staff

The VA is proposing a $369.3 billion spending plan for fiscal 2025 that includes nearly $25 billion for a toxic exposures fund that compensates veterans diagnosed with medical conditions from contact with burn pits, radiation and other environmental hazards.

www.stripes.com

And, from a 2023 'The Hill' article:

How runaway disability compensation is straining Veterans Affairs

The share of veterans receiving disability compensation benefits is increasing rapidly and is at an all-time high.

thehill.com

"From 2000 to 2022, the overall VA budget grew from $76 billion to $267 billion (in 2022 $) despite a 30 percent decline (from 26.4 million to 18.4 million) in the veteran population over the same period. As a result, annual spending by the U.S. Department of Veterans Affairs per veteran has quintupled, from $2,900 to $14,500. Some of this growth has been driven by an aging veteran population, rising healthcare prices and much-needed improvements to VA healthcare facilities

But the biggest contributor to the VA’s steadily expanding budget has been the unprecedented increase in veterans’ enrollment in disability compensation, a VA program designed to compensate America’s veterans for injuries incurred or aggravated during their military service. The share of veterans receiving disability compensation benefits is increasing rapidly and is at an all-time high. Between 1954 and 2000, the share of veterans receiving disability compensation was very stable, fluctuating between 8 percent and 10 percent. Today, nearly 30 percent of the country’s 18.5 million veterans receive it.

Additionally, the average annual payment to veterans receiving disability has increased substantially, from about $12,000 in 2000 to $21,000 today. This growth has been driven by a shift to much higher disability ratings since payments are higher for those who are found to be more disabled.

From 2000 to 2022, the number of disability compensation recipients with a rating of 70 percent or more increased by 7-fold (from 0.34 million to 2.66 million) while the number with a rating of just 10 or 20 percent hardly changed (from 1.23 million to 1.30 million). This rating system used by the VA encourages disability compensation recipients to apply for increases in their ratings and may discourage some from improving their health."

Anecdotally, over the past decade or so, I've seen nothing but net reductions in total number of full-time psychotherapist positions while workload/'productivity (by RVU's)' has increased, amount of (paper)work per patient has increased, wait times have increased, etc. There has been a significant increase in 'non-caseload-bearing' positions for licensed clinical staff (it's ridiculous) as well as hyper-specialization/ fragmentation of mental health care.

All the while, the overall VA budget has skyrocketed, along with disability compensation.

 

[AcronymAllergy]

It probably won't get much attention, but at least some attention is being drawn to the issue.

 

[cara susanna]

I'm starting to wonder if the VA needs to stop trying to be all things. Either focus on disability compensation or treatment, but not both. They're inherently opposed to each other, and each by itself needs a huge budget without trying to combine the two.

 

[aim-agm]

I have a thought that, except for schizophrenia (and select cases of other conditions) service connection for mental health conditions should be 0% ( or thereabouts) so treatment is payed for but illness is not, because psychiatric conditions can generally be reliably put into remission or cured.

 

[cara susanna]

I have a thought that, except for schizophrenia (and select cases of other conditions) service connection for mental health conditions should be 0% ( or thereabouts) so treatment is payed for but illness is not, because psychiatric conditions can generally be reliably put into remission or cured.

Oh, I totally agree, or at least make the standards higher and more rigorous like state disability does. But I don't think the genie can be put back into the lamp anymore.

 

[Fan_of_Meehl]

Oh, I totally agree, or at least make the standards higher and more rigorous like state disability does. But I don't think the genie can be put back into the lamp anymore.

Maybe in 3 to 5 years--when the total VA budget tops $500 billion (half a TRILLION) dollars and medicaid/medicare and SS are feeling the pinch--the wind will start blowing in the other direction. Then the VA leadership will do a 180 and basically raise the bar so high on diagnosing PTSD that even legit cases won't be properly diagnosed.

 

[AcronymAllergy]

I have a thought that, except for schizophrenia (and select cases of other conditions) service connection for mental health conditions should be 0% ( or thereabouts) so treatment is payed for but illness is not, because psychiatric conditions can generally be reliably put into remission or cured.

I would not disagree with that setup, but the uphill battle being it goes against pretty much all other worker's comp/disability systems. But that'd be an interesting optic to have to debate, and would the politicians be willing to debate that same thing for other worker's comp situations (i.e., does a person need or deserve to be paid for a treatable condition when all treatment costs are covered). Or assign perhaps a flat-rate, time-limited benefit for the various MH conditions.

But the more realistic alternative is probably what Fan_of_Meehl said. So politicians can then say, "see, 'legitimate' cases are being fairly compensated," without being the ones to have to get involved in evaluating what "legitimate" means.

 

[cara susanna]

I'm tired of calling people 5 min into VVC appts when they don't show. From now on, I'm gonna wait 15 min, unless it's a new patient who doesn't have my phone number, and if I reach them say that we have to r/s.

 

[psycho1391]

I'm tired of calling people 5 min into VVC appts when they don't show. From now on, I'm gonna wait 15 min, unless it's a new patient who doesn't have my phone number, and if I reach them say that we have to r/s.

I stopped doing that a while ago. Even for new patients. They get the clinic number on their reminder letter. Most of them get my business card when the complete orientation for our program.

My in-person appts don't get a 5 minute phone call, why should vvc be any different?

 

[cara susanna]

I stopped doing that a while ago. Even for new patients. They get the clinic number on their reminder letter. Most of them get my business card when the complete orientation for our program.

My in-person appts doing get a 5 minute phone call, why should vvc be any different?

My new patients wouldn't have my number yet, plus sometimes VVC just really is terrible so I'm willing to give them a bit more leeway. That's it, though! If they had received my card already, I would also wait 15 min.

 

[Shiori]

I usually end up calling my VVC clients. I have tried to give the feedback that I'm not just going to no-show them and they should call the front desk if I'm not there in 2 minutes. I'm weak though and just end up calling them anyway.

 

[psycho1391]

I usually end up calling my VVC clients. I have tried to give the feedback that I'm not just going to no-show them and they should call the front desk if I'm not there in 2 minutes. I'm weak though and just end up calling them anyway.

I think the difference here is that I call and make all of my intakes and appointments with vets. If it is vvc, I assess their comfortability with the tech and provide help desk phone numbers. I do alert them if it takes more than 5 minutes to connect to call me/the clinic.

 

[Shiori]

I don't make any of my appointments. Our MSA is fabulous though and walks everyone through the process.

 

[cara susanna]

Welp, our facility is on a full hiring freeze. Wooo

 

[Sanman]

Welp, our facility is on a full hiring freeze. Wooo

They are actually calling it that? Ours is on a "don't call it a hiring freeze" hiring freeze. Though I think we had one new MH hire. MSAs are completely frozen.

 

[cara susanna]

Trying to control the lives of your


They are actually calling it that? Ours is on a "don't call it a hiring freeze" hiring freeze. Though I think we had one new MH hire. MSAs are completely frozen.

That's what my supervisor called it, but I dunno if he's using their language.

 

[cara susanna]

In addition to firming up my boundaries with VVC, I am now implementing a new EBP policy where if you cx or no show 2 consecutive appts, I am not going to give my usual call to check in and give a week grace period, but will rather cx future appts and move onto the next person who's on deck. This is actually in line with clinic policy, btw.

The recent change to the MH minimum scheduling efforts SOP is a gamechanger.

 

[aim-agm]

In addition to firming up my boundaries with VVC, I am now implementing a new EBP policy where if you cx or no show 2 consecutive appts, I am not going to give my usual call to check in and give a week grace period, but will rather cx future appts and move onto the next person who's on deck. This is actually in line with clinic policy, btw.

The recent change to the MH minimum scheduling efforts SOP is a gamechanger.

Do you have a link to the SOP?

 

[cara susanna]

Do you have a link to the SOP?

This is the best I could do: D.24 No Show-Minimum Scheduling Effort SOP 02.pdf

Basically, unless there is a HRF, for two consecutive NS or late cx or three within the episode of care we no longer have to make rescheduling efforts.

 

[Fan_of_Meehl]

Supreme court case that will be coming up...Bufkin v. McDonough. All I can say is, 'wow.'

Here's a news article (that doesn't contain the relevant details)

Supreme Court to hear another major veterans benefits case this fall

The high court will consider whether VA officials are properly reviewing benefits decisions that deny veterans medical help.

www.militarytimes.com

Actual details (details of Bufkin's situation start on page 9):

https://www.supremecourt.gov/DocketPDF/23/23-713/294539/20231229124320086_Bufkin%20Cert%20Petition.pdf

TLDR:

Veterans suing because they are alleging that VA didn't follow the 'benefit of the doubt' principle in adjudicating disability claims for PTSD.
Haven't looked into the second case yet but the first one (Bufkin) is a real doozy.

Basically, Bufkin is claiming that an administrative decision to give him an ultimatum was his traumatic stressor that caused him to develop PTSD. He was in the Air Force and said that because his wife had so many mental health issues (including suicidal ideation, gestures), he couldn't perform his duties. Air Force said, 'Yeah...well...either you find a way to perform your duties or divorce your wife but...this is the military and you have to be able to perform your duties.' Yeah, I know, 'shape up or ship out' is so yesterday, I get it but...there is no way it is a Criterion A traumatic event. Appropriate diagnosis is far more likely to be adjustment disorder or MDD. Finding oneself in a difficult situation (conflicting responsibilities between work and familial obligations) and having, therefore, to make a difficult choice is not a Criterion A stressor.

So, Bufkin gets (I think THREE) several providers to write letters (or maybe complete DBQ's) arguing that the administrative decision (ultimatum) by the Air Force was his Criterion A trauma and caused bona fide PTSD (even though the apparently minimally competent (at least) VBA examiner said 'nope, not a Criterion A stressor').

An excerpt from one of Bufkin's providers writing in support of the PTSD diagnosis:
In support, he
submitted a letter from yet another VA physician,
who determined that Mr. Bufkin “suffers from chronic
PTSD due to a number of issues, but the primary is-
sue is that he was essentially forced out of the mili-
tary due to intense family problems that put him in a
very difficult psychological situation. … Some exam-
iners do not consider this to be PTSD, but it was
clearly traumatic for” Mr. Bufkin.

So, Bufkin and his lawyers are arguing that since they were able to find three incompetent providers to misdiagnose him as having PTSD (per the explicit criteria in DSM-5), the VBA did not extend to him the 'benefit of the doubt' when medical evidence stands in equipoise.

No doubt this case will be cited as evidence that the VBA follows the implicit policy of 'deny, deny, until they die' and is doing everything possible to deny veterans their right to be diagnosed with PTSD.

With all the fanfare about 'quality' and 'best care anywhere' and 'zero harm' and 'high reliability organization...'

...and all the ridiculous mandatory trainings (annual required demonstration that we know how to use a fire extinguisher)...

at what point will licensed, MD psychiatrists (or doctoral level psychologists) be required to demonstrate that they have the core competency of being able to identify a clearly insufficient 'traumatic stressor' as not crossing threshold to qualify as a Criterion A event for possible diagnosis of PTSD? This is UNDERGRAD level material. In my opinion this is malpractice on the part of the incompetent providers. Medication prescribers are choosing medication treatments (with both presumed therapeutic and adverse effects) based on accurate diagnostic determinations. The 'differential diagnosis' (especially of PTSD) is so horrible/non-existent in VA mental health it is unreal and the fact that this case even exists--let alone is being appealed to the SUPREME COURT--is 100% proof of it.

Parenthetically, I am doing a chart review for a PCT intake this morning that has in his chart---not joking--at least 100 chart notes/encounters with paid licensed mental health providers and at least 10 'assessments/evaluations' by same without ONE provider doing a basic military/trauma history or even doing the most preliminary diff dx interviewing around trauma/sterssor disorders despite numerous acute inpatient and residential stays for MDD/substances/mental health. Taxpayers have paid probably more than a million dollars, to date, for ostensibly competent MH services for this veteran but no one has done a military/trauma history or attempted to rule in/out PTSD for this veteran patient in his late 60s getting VA care for over 20 years.

 

[cara susanna]

Could he have gotten adjustment or another MH condition if he'd just adjusted his claim? Is he upset because he wants PTSD specifically, because PTSD is the "cool" mh diagnosis in the VA? Or is he one of those veterans who thinks it's PTSD or nothing?

 

[WisNeuro]

Could he have gotten adjustment or another MH condition if he'd just adjusted his claim? Is he upset because he wants PTSD specifically, because PTSD is the "cool" mh diagnosis in the VA? Or is he one of those veterans who thinks it's PTSD or nothing?

I'd be curious if this person was also pursuing other avenues of disability as well, and PTSD would have a much easier time at something like SSDI than adjustment disorder.

 

[Sanman]

Anyone else get the urgent email this morning from FSAfeds that the deadline for 2023 claims is April 30th? Let me just hop back in my time machine...

 

[aim-agm]

Anyone else get the urgent email this morning from FSAfeds that the deadline for 2023 claims is April 30th? Let me just hop back in my time machine...

Make sure to complete the Time Machine TMS training first

 

[Sanman]

Supreme court case that will be coming up...Bufkin v. McDonough. All I can say is, 'wow.'

Here's a news article (that doesn't contain the relevant details)

Supreme Court to hear another major veterans benefits case this fall

The high court will consider whether VA officials are properly reviewing benefits decisions that deny veterans medical help.

www.militarytimes.com

Actual details (details of Bufkin's situation start on page 9):

https://www.supremecourt.gov/DocketPDF/23/23-713/294539/20231229124320086_Bufkin%20Cert%20Petition.pdf

TLDR:

Veterans suing because they are alleging that VA didn't follow the 'benefit of the doubt' principle in adjudicating disability claims for PTSD.
Haven't looked into the second case yet but the first one (Bufkin) is a real doozy.

Basically, Bufkin is claiming that an administrative decision to give him an ultimatum was his traumatic stressor that caused him to develop PTSD. He was in the Air Force and said that because his wife had so many mental health issues (including suicidal ideation, gestures), he couldn't perform his duties. Air Force said, 'Yeah...well...either you find a way to perform your duties or divorce your wife but...this is the military and you have to be able to perform your duties.' Yeah, I know, 'shape up or ship out' is so yesterday, I get it but...there is no way it is a Criterion A traumatic event. Appropriate diagnosis is far more likely to be adjustment disorder or MDD. Finding oneself in a difficult situation (conflicting responsibilities between work and familial obligations) and having, therefore, to make a difficult choice is not a Criterion A stressor.

So, Bufkin gets (I think THREE) several providers to write letters (or maybe complete DBQ's) arguing that the administrative decision (ultimatum) by the Air Force was his Criterion A trauma and caused bona fide PTSD (even though the apparently minimally competent (at least) VBA examiner said 'nope, not a Criterion A stressor').

An excerpt from one of Bufkin's providers writing in support of the PTSD diagnosis:
In support, he
submitted a letter from yet another VA physician,
who determined that Mr. Bufkin “suffers from chronic
PTSD due to a number of issues, but the primary is-
sue is that he was essentially forced out of the mili-
tary due to intense family problems that put him in a
very difficult psychological situation. … Some exam-
iners do not consider this to be PTSD, but it was
clearly traumatic for” Mr. Bufkin.

So, Bufkin and his lawyers are arguing that since they were able to find three incompetent providers to misdiagnose him as having PTSD (per the explicit criteria in DSM-5), the VBA did not extend to him the 'benefit of the doubt' when medical evidence stands in equipoise.

No doubt this case will be cited as evidence that the VBA follows the implicit policy of 'deny, deny, until they die' and is doing everything possible to deny veterans their right to be diagnosed with PTSD.

With all the fanfare about 'quality' and 'best care anywhere' and 'zero harm' and 'high reliability organization...'

...and all the ridiculous mandatory trainings (annual required demonstration that we know how to use a fire extinguisher)...

at what point will licensed, MD psychiatrists (or doctoral level psychologists) be required to demonstrate that they have the core competency of being able to identify a clearly insufficient 'traumatic stressor' as not crossing threshold to qualify as a Criterion A event for possible diagnosis of PTSD? This is UNDERGRAD level material. In my opinion this is malpractice on the part of the incompetent providers. Medication prescribers are choosing medication treatments (with both presumed therapeutic and adverse effects) based on accurate diagnostic determinations. The 'differential diagnosis' (especially of PTSD) is so horrible/non-existent in VA mental health it is unreal and the fact that this case even exists--let alone is being appealed to the SUPREME COURT--is 100% proof of it.

Parenthetically, I am doing a chart review for a PCT intake this morning that has in his chart---not joking--at least 100 chart notes/encounters with paid licensed mental health providers and at least 10 'assessments/evaluations' by same without ONE provider doing a basic military/trauma history or even doing the most preliminary diff dx interviewing around trauma/sterssor disorders despite numerous acute inpatient and residential stays for MDD/substances/mental health. Taxpayers have paid probably more than a million dollars, to date, for ostensibly competent MH services for this veteran but no one has done a military/trauma history or attempted to rule in/out PTSD for this veteran patient in his late 60s getting VA care for over 20 years.

If the Supreme court rules in his favor, the VA will go broke. That'll be fun.

As for the intake, I usually look for trainee notes for this reason. Usually much more comprehensive than the folks just 'moving the meat' for numbers. I have recently been more pushy with my folks to do things like keep appointments (they are homebound, what else are they doing?) and set actual goals for therapy. This receives push back from the primary care teams and makes my numbers look bad due to dropouts. Because, you know, boundaries are bad.

EDIT: While writing this post, I have been no-showed by the same patient for the second time this week.