Introduction
The outpatient Mental Health Clinic (MHC) at the West Los Angeles VA Medical center has a current backlog of nearly 200 referrals for veterans in need of intake assessments for ongoing treatment. Veterans who are referred for assessment may currently be required to wait 3-4 weeks for an intake interview slot. Most recently, the solutions for reducing the backlog have simply focused on the clinical staff taking on a larger workload. The current procedure used for referring and scheduling clients warrants change and could benefit greatly from a new technology that would bridge the gap between the time the client is referred for intake and the day of their intake interview.
The introduction of a direct phone contact 3-4 days before the scheduled interview would aid in reducing the referral backlog by increasing the show rate for scheduled clients, screening out clients who plan to decline services by not showing for their appointment, and improving the client worker relationship to reduce the number of clients who drop out of treatment only to return and need another intake months later.
Description of the VA
The West Los Angeles VA Medical Center provides a full range of medical, mental health, and rehabilitation services to United States military veterans who have received anything other than a dishonorable discharge from the service. The Medical Center consists of dozens of buildings including a full-service medical hospital, a spectrum of ambulatory care clinics and several transitional living facilities. While some limited case management and emotional support services are offered to family members of veterans at the West Los Angeles VA, the vast majority of services are provided to veterans exclusively.
Description of the MHC
The VAMC Mental Health Clinic (MHC) is one of several different mental health treatment programs on the VA campus. MHC utilizes the technologies of medication management, case management, psychoeducation groups and limited individual and family therapy to vets with major mental illness. The MHC is directed by a licensed clinical psychologist who acts as a liaison between the greater administration of the VA and the MHC staff. The clinical staff consists of psychologists, psychiatrists, social workers, and paraprofessionals known as Social Science Technicians (SSTs).
Goals of the VA
President Abraham Lincoln defined the goal of the VA in his second inaugural address, stating that it aimed “to care for him who shall have borne the battle and for his widow and his orphan.” (U.S. Department of Veterans’ Affairs, 2006). The VA Mission statement says that the agency’s number one strategic goal is to “restore the capability of veterans with disabilities to the greatest extent possible and improve the quality of their lives and that of their families.” The VA Mental Health Department asserts that the goal of their department is “to maintain and improve the health and well-being of veterans through excellence in health care, social services, education, and research.” (U.S. Department of Veterans’ Affairs, 2006). These sentiments closely parallel what Hasenfeld defines as “people-changing technologies”-those that focus on restoration and enhancement as their two sub-functions (Hasenfeld, 140).
Goals of MHC
Hasenfeld describes a “people-sustaining technology” as one that aims:
“to prevent, arrest, or delay the deterioration of a person’s well-being or social status…The underlying assumption…is that the clients have little, if any, potential for change in directions that will significantly improve their social functioning.” (Hasenfeld, 137).
Despite the similarities between the mission statements of the VA and the VA Mental Health Department and Hasenfeld’s description of people-changing technologies, the VAMC/MHC is currently limited to nearly exclusive use of people-sustaining technologies. The director of the MHC is now receiving intense pressure from the administration of the VA to reduce the wait time for client intakes.
The resources of the clinic are focused on treating mental illness through classic people-sustaining technologies such as medication, brief psychoeducation groups, and maintenance of the client’s social status through enrollment in programs like SSI for income maintenance. People changing technologies like individual and family therapy are used rarely if at all by some clinicians. Direct staff-client interaction is minimized. It is difficult to discern whether the current focus on people-sustaining technologies by the MHC is due to a conscious choice to focus on these procedures, or merely a default method of operating the clinic that is understaffed and overextended.
Changing the Organization from Within
The current climate in the MHC provides an ideal opportunity to implement Resnick’s concept of “Changing the Organization from Within” (COFW). Resnick identifies three major elements to his technique of COFW: the change catalyst, the action system, and the change goal (Resnick, 30). In COFW, the motivated individual worker acts at the change catalyst to form a coalition of supporter who will work as an action system to implement and advance a new process or idea-the change goal. In the case of MHC, the clinic director used a recent staff meeting to open the floor to suggestions for reducing the backlog of intake referrals. Any member of the clinical staff attending the meeting has the opportunity to act as what Resnick would refer to as the change catalyst.
Because the morning clinical staff meeting is attended by all of the clinicians directly affected by the intake backlog, the attendees of this meeting, if presented with an innovative change goal, could form an effective action system. The change goal of the PIPC is derived from identification and analysis of faults in the clinic’s intake process.
Problem Identification and Analysis: The Intake Process at the VAMC Mental Health Clinic
Resnick states that “the goal selection process consists of two parts: (a) problem identification and analysis, and (b) consideration of goals” (Resnick, 1978, p. 32). In this case, the problem has already been identified, but needs to be analyzed for appropriate goal selection.
There are currently two different avenues by which a client can be referred for an intake referral to MHC. A licensed clinician from another part of the Medical Center who feels a veteran displays symptoms of mental illness may refer their patient directly to the MHC for an intake referral. The MHC often receives these types of direct referrals for veterans who may suffer from depression due to chronic medical illness.
A veteran can also refer himself for mental health services by entering the walk-in the medical screening clinic on the first floor of the MHC building. The screening clinic works as a triage station for veterans in need of mental health services. Clients exhibiting severe symptoms psychiatric symptoms such as hallucinations, severe changes in mood, or impairments in everyday functioning may be prescribed medication immediately, and then referred for an intake interview in the MHC. Veterans may also receive one-time services through the screening clinic to address psychosocial problems such as homelessness, and then refer the veteran for long term case management through MHC.
The veteran’s first visit to MHC will consist of a two hour biopsychosocial interview, and may be followed by a ten to fifteen minute interview with a psychiatrist. There is currently a backlog of 150 intake referrals waiting to be processed in the mental health clinic, and a three to four week wait for an intake interview. This means that clients who have been reporting noticeable symptoms of such serious illnesses such as depression, bipolar disorder and schizophrenia may be waiting for up to a month after their initial walk-in date before any sort of treatment plan is developed or enacted.
Intake Backlog
The backlog of consults for intake interviews is compounded by the significant no-show rate among clients with all diagnoses. The no-show rate for MHC intake slots fluctuates between 40-60% a week. Taking into consideration the nature of mental illness, it is not surprising that veterans do not show up for an appointment that was scheduled three to four weeks prior. Clients who miss their appointments and want to reschedule for another interview often have to wait at least another three weeks before a new intake slot comes open. These clients go back to the end of a very long line of unprocessed referrals. They remain in the backlog, which never decreases.
The clinicians at MHC are currently receiving pressure from the VA administration to reduce the backlog. Suggestions to reduce the backlog have included scheduling more than one patient in the same time slot on the assumption that many clients won’t show up. Of course, if two clients do show up in this time slot, the clinician is forced to scramble and possibly compromise both interviews in order to manage her time. Another suggestion has merely been for all clinicians to increase their workload to accommodate more intakes in their already very busy schedules.
The MHC intake backlog was compounded by the instituting of new requirements for those performing intake interviews since August 2006. Prior to August 2006, intakes were not only performed by social workers and psychologists, but by paraprofessionals known as Social Services Technicians (SSTs) as well. In August of 2006, VA administrators required that all future intake interviews be performed by licensed clinicians or those in the process of working towards licensure. This meant that the intake load of the paraprofessionals had to be redistributed among the licensed clinicians.
The clinicians are currently keeping the wait time to 3-4 weeks by double booking appointment slots on the assumption that any clients won’t show up. Other suggestions to reduce the backlog have included cutting the amount of time allocated to each interview in half, and scheduling intake times for during hours when clinicians are already assigned to cover walk-in patients. These proposals require clinicians to either over-commit themselves for their available time slots, or reduce the amount of time they spend with the client. Both of these strategies require clinicians to reduce the quality of care provided to the client.
Consideration of Goals: The Pre-Intake Phone Contact
The backlog of referrals and wait time for intake appointments could be greatly improved by the introduction of a Pre-Intake Phone Contact (PIPC) to the intake process. The PIPC would consist of a clinician contacting the veteran 3-4 days prior to their scheduled appointment to cover four specific points. First, the PIPC will act to confirm that the client understands why he has been referred to the MHC for an intake. Second, the PIPC will act to educate the veteran as to what they can expect to encounter on the day of their intake interview at MHC. Third, the PIPC will act to confirm the appointment date and time with the veteran, and clarify the location of and directions to the MHC. Fourth, the PIPC would remind the veteran how to obtain emergency mental health assistance if they felt unsafe before their scheduled intake appointment.
The PIPC will reduce the referral backlog on multiple fronts. Firstly, the PIPC will eliminate slots given to clients who have no interest or intention of receiving services through MHC. Because some clients are referred by doctors in other departments of the clinic, veterans may be signed up for an appointment with little explanation as to why they are being referred or what services will be offered to them. Due in part to the stigma attached to mental illness, some veterans decline services outright. Veterans who are contacted after missing an intake interview will sometimes report that they have no interest whatsoever in coming in attending an intake interview. If the veteran is contacted 3-4 days prior to their appointment for a PIPC, and they refuse services over the phone, their intake slot is now freed up for a veteran who is interested in services and needs a treatment plan as soon as possible.
The PIPC will also reduce client wait-time by increasing the show rate among clients. The PIPC works to increase the show rate on several different fronts. Many veterans who are contacted after missing an intake appointment report that they forgot that they had an appointment. In addition to the confusion that can sometimes accompany appointments that are booked several weeks in advance, many MHC clients may experience difficulties in concentrating and organization that often accompany mental illness. It is not surprising that the no-show rate for clients for Clinician X have averaged out to about 50% over the last 2 ½ months. (personal communication, November 29 2006.) By simply confirming the veteran’s appointment time and directions to the clinic, the PIPC addresses one of the most common reasons why veterans report that they missed an appointment. Increasing the client show rate reduces the number of clients that are repeatedly fed into the backlog after missing appointments.
The PIPC also increases the clinic’s efficiency later in the veteran’s treatment process. The PIPC works to establish rapport with the veteran before he even walks through the clinic doors. It also works to empower the client by educating them about the intake process at MHC. Client’s who feel a strong connection to a clinician or who feel empowered to take charge of their treatment may be more likely to remain in treatment instead of dropping out sporadically, and having to re-enter the MHC multiple times each year for reassessments.
In addition to a goal’s potential for integration, Resnick emphasizes the importance of the potential for the goal to be permanently internalized in the organization. (Resnick, 1978, p.33.) The PIPC could be easily internalized into the VA system through their electronic records tracking database. The VA currently uses an electronic database that serves as a task reminder in addition to a way to store client notes. When clinicians sign on to the database, they are immediately alerted to any pending notes awaiting their signature, and reminders pop up on the screen for patients who require specific screenings or services. The system could be programmed to remind clinicians to call their scheduled clients 3-4 days prior to their interview. Successful use of the PIPC in reducing the intake backlog in the MHC could have multiplier effects for the rest of the Medical Center clinics. Because the VA tends to standardize the technologies they employ throughout all of their care systems, the administration could view the PIPC as a beneficial tool in many other clinics providing outpatient services.
Prediction of Resistance
There are several areas that immediately jump out as points will produce resistance. Because the clinicians on the unit area already overloaded with work, resistance is likely to occur at the prospect of having to perform yet another procedure.
Clinicians are likely to point out that it is often difficult to reach clients by phone, and that many of our clients are homeless and have no phone. The action team might respond to these dissenting voices within the team by proposing practical solutions such as contacting the veterans without phones via mail. In the cases of homeless veterans without access to phones or their own mail, requests could be made for access to P.O. Boxes at the VA Post Office.
Clinicians are also likely to voice concerns regarding the clinical implications of the PIPC. Some clinicians may assert the veterans may be scared off and deterred from coming to treatment when they find out the length of the interview and the sort of information that will be gathered about them. Clinicians may also assert that we may be allowing clients who are very sick the opportunity to decline treatment when they may be a danger to themselves or others. The action team might respond to these concerns by emphasizing the idea that openness with our clients regarding their treatment will help to establish trust, and that clients have the right to determine their own course of care.
Strategy Selection
Resnick emphasizes that when selecting a strategy for implementing a change goal, it is important to examine whether the proposed change will benefit workers outside of the action system as well as those within it. Strategies that strive to integrate the needs of multiple layers of an organization increase solidarity between workers and between levels of administration. The PIPC can be viewed as an integrative strategy in that it serves the goals of multiple layers of administration in that it reduces the wait time for clients to be seen, but it also increases the quality of client care.
It is not only the clinicians with the reduced backlog that will benefit from the new procedure. Because the issue of inefficiency in the VA system has received national attention, administrators in all levels of the VA Healthcare System would benefit from an improvement in the backlog numbers. The integrative nature of this strategy essentially comes from those defending it having the opportunity to fall back on the positive clinical implications of the PIPC while waiting for the backlog numbers to decrease.
Implementation and Maintenance of New Procedure
The implementation of the PIPC as a change goal for MHC will be implemented by the action team that helped to design it. Feedback on the PIPC’s effectiveness should be solicited from all clinicians using the procedure, both to refine the procedure, and promote the collaborative nature of the change goal. Implementation of the PIPC should be followed up with a biweekly review of clinicians’ success rates in contacting clients in comparison to their interview attendance rates. Time should be allowed for clinicians to process the emotional reactions they may have in response to the new procedure.
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Conclusion
If the PIPC proves effective in reducing the backlog of intake referrals, there will be a greater amount of time and resources available to dedicate towards the kind of people-changing technologies described in the VA’s mission statement. Successful use of this new procedure has the potential to not only increase the efficiency of how quickly clients are assessed, but also how invested they believe their clinicians to be in their treatment. The new procedure is designed to benefit clinicians by both reducing their workload, and increasing the compliance rate for veterans receiving ongoing treatment.
References Cited:
Hasenfeld, Yeheskel. (1983). Human Service Organizations. Upper Saddle River:
Prentice Hall.
Resnick, Harold (1978). Tasks in Changing the Organization From Withing (COFW).
Administration in Social Work, Vol. 2(1), 29-44.
U.S. Department of Veterans’ Affairs (May 23, 2006). Mission, Vision ,Core
Values & Goals. Retrieved December 2, 2006, from http://www.va.gov/about_va/mission.asp
U.S Department of Veterans’ Affairs (August 14, 2006). Mental Health – Health
Benefits. Retrieved November 25, 2006 from
http://www.mentalhealth.med.va.gov/
