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VA Myths and Stereotypes: Myth Busting Continues

Posted By Katherine Dollar, Thursday, March 28, 2013
Military and Veterans

Kathy's blog is the third
post in a series on
integrated care for
military and veterans.


When I began my training as a clinical psychologist, I did not envision myself working for the Department of Veterans Affairs. In fact, I would have predicted that I would end up in almost any other setting. The myths or stereotypes described by Dr. Pomerantz’s prior blog predominated my thinking. As I suspect happens to many of us, my early career projections were wrong, as were my stereotypes of the VA.

Through the lens of a clinician, I hope that I can further dispel some of the common myths and present a clear picture of integrated care within the VA. There is a great deal of variation across our large network of facilities, and my thoughts may not be consistent with the experiences of clinicians at every location. However, I do believe that there are common themes experienced in most VA integrated care settings.

Firstly, it has been my experience that providers within the VA care deeply about Veterans and Veteran healthcare. I consistently see primary care colleagues going to extraordinary lengths to ensure high quality, patient-centered care. In a recent hallway conversation with two of my primary care colleagues, we ended up discussing the overwhelming sense of duty and responsibility to provide exceptional care for the Veterans and how this translates not only into direct service delivery, but also into interactions with patients in hallways, over the phone, and in the community. The reality is that VA employees care tremendously about Veterans and about providing high quality care.

We also have a high degree of accountability built into the system through policy and programmatic expectations. It is experienced as a system of checks and balances with multiple requirements and high levels of accountability and oversight. Integrated care, including both collocated collaborative care and care management, are not options, but programmatic expectations.

An integral part of functioning as a behavioral health provider in a VA primary care clinic is communicating and working closely with all primary care team members. Typically, this means that days begin with a team huddle, including the primary care provider, the RN, LPN, administrative support, and other primary care-based professionals (e.g., dieticians, pharmacists, medical social workers). Fully consistent with the tenants of the medical home, we are implementing team-based care. Skills in collaborating with other medical professions are necessary to be successful. Indeed, several of my colleagues who were not used to team-based care have had to change their practice management styles or risk becoming irrelevant to the clinic.

During the huddles we usually review patients who are scheduled to be seen by the team that day and discuss the plan for care. As the integrated clinician, and the behavioral change expert, I provide input for mental health concerns as well as medical conditions that have a strong behavioral component. I might discuss potential ways for the other team members to approach these concerns, offer to join the provider or one of the nurses in their appointment with the patient, or offer to see the patient individually the same day.

Same day, or open/advanced access is another integral component of integrated care within the VA. There are many ways this can be achieved and this has been structured differently in various locations. The clinics in which I have become most familiar, have structured schedule grids such as scheduled 30 minute appointment slots on the hour, with the back half of the hour usually unscheduled. This allows access to appointments for Veterans the same day that they see their primary care team.

Although there is much variation in implementation, Veterans and the other primary care team members value this scheduling feature. It provides direct access to a behavioral health specialist not only allowing the Veteran to start an intervention the same day that symptoms were identified by the primary care team, but also allows the primary care team members to have direct communication and consultation with a mental health provider. This process de-mystifies mental health service delivery.

Within the VA primary care setting, we see a surprisingly diverse population of Veterans, including women, reservists, individuals who served in the National Guard, and younger individuals recently returning from active duty who have young families. If you visit expecting to find the image of the Veteran conjured up from the song, "Take Me to the Mountains”, you will be surprised. Clinics are busy, vibrant locations with diverse patient populations, that have dramatically moved beyond the stereotypical view of Veteran healthcare settings.

As part of meeting the needs of the diverse population we have incorporated technology into our communication and interventions for patients. We routinely use telephone, video teleconferencing, and secure instant messaging to communicate with Veterans and provide service delivery. As the Veteran population has shifted to include younger individuals, who communicate primarily through advanced technological platforms, the VA has embraced these technologies and has remained relevant to this population by finding ways to incorporate technology into care within and outside of the primary care setting. Further, these innovative advancements allows us to increase access to and communication with Veterans living in rural locations, who may not be able to make routine visits to medical centers to obtain mental health services. As a clinician, I like having to capacity to serve Veterans who may not be engaged in treatment without the use of technology.

The types of services being provided in VA integrated care are complementary. Through the provision of collocated, collaborative care, and care management, we combine same day access to a therapist who may provide a brief intervention, with the use of evidence-based screening, assessment, decision support, and symptom monitoring . Thus, patients receive a unique blend of evidence-based services that are tailored to their individual needs, are tracked over time, and adjusted based on symptom severity. This system, when optimally functioning, creates a feedback loop between the patient and all team members.

In closing, I hope through a combination of our posts, we have dispelled many of the myths and outdated stereotypes about VA service delivery while providing a picture of a modern, patient-centered, results-driven healthcare system. I am honored to work for the Department of Veterans Affairs, as are my colleagues and co-team members. I am thankful that my career projections were just as erroneous as my stereotypical views of the VA. Through continued implementation of the medical home model, the VA continues to be a leader in patient-centered, team-based, results-driven, innovative care.



Katherine Dollar

Katherine M. Dollar, PhD is the Clinical Coordinator at the VA Center for Integrated Healthcare (CIH) and a Research Assistant Professor, in the Department of Community Health & Health Behavior at SUNY Buffalo. Dr. Dollar is also a Consultant to the VA Office of Mental Health Operations (OMHO). CIH is VA Center of Excellence devoted to advancing research, education, and clinical consultation to enhance the integration of mental health and primary care services for America's Veterans. She provides consultation, education, and technical assistance, for facilities, networks, and individuals requesting program assistance to achieve full implementation of VA integrated care components.

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