Equity in Veterans' Mental Health Care: Veterans Affairs Medical Center Clinics Versus Community-Based Outpatient Clinics

Abstract

This study examined differences in structures and processes of mental health care at Veterans Administration (VA) primary care clinics, comparing VA medical center (VAMC) clinics to community-based outpatient clinics (CBOCs). A survey was conducted of nurse managers at 46 of 49 primary care clinics (23 VAMC clinics and 23 CBOCs) within a VA health care network in the south central United States. Integration of care and services overall was comparable between VAMC clinics and CBOCs. The service mix differed. Integrated CBOCs more often offered group therapy, medication management, and smoking cessation. Integrated VAMC clinics more frequently used written suicide protocols and depression screening. Distance to offsite specialty care and wait times for referrals were shorter for patients at VAMCs than at CBOCs. The provision of mental health care at CBOCs is comparable to that at VAMC clinics, although differences in patient access to offsite care indicate that full equity was not achieved at the time of the survey. Since 2000, the VA has initiated several programs to address this need.

Extreme Makeover: Transformation of the Veterans Health Care System

“…Other steps were taken to better coordinate and integrate care. For example, between 1995 and 1999, 52 VA medical centers were merged into 25 multicampus facilities under single management (229,244); multiinstitutional service lines (e.g., in primary care or behavioral health) were implemented in several VISNs (36); multidisciplinary strategic health care groups were organized at VHA headquarters (130); care management was implemented as a systemwide strategic initiative (55); better continuity of care through more convenient access was pursued by establishing hundreds of new community-based outpatient clinics (CBOCs) (4,33,64,65,129,209); and the national formulary of prescription drugs, nonprescription medicines, and medical supplies was established in 1997 to promote evidence-based drug prescribing and to improve pharmaceutical management (23,140,208,271). (Before the National Formulary was instituted, each medical center had its own formulary, and the variable availability of prescription drugs was the single biggest cause of patient complaints.)…”