Federal Reports

This report presents the results of our audit of Network Changes: Local Transportation Optimization.

The VA Office of Inspector General (OIG) conducted a review of Veterans Health Administration (VHA) inpatient mental health unit (mental health unit) suicide risk identification processes, suicide prevention safety plans, mental health treatment coordinator (MHTC) role requirements, and discharge care coordination procedures.

Given patients’ increased suicide risk after discharge, continuity of care is critical to mitigating risk. VHA requires that every patient receiving mental health services be assigned a principal mental health provider to support care coordination.

Staff failed to document required suicide risk screening for 27 percent of patients and did not complete safety plans for 12 percent of discharged patients. The OIG concluded that failure to complete suicide risk identification processes may result in an underestimation of patients’ risk, and failure to complete a safety plan can contribute to diminished utilization of coping strategies and supportive resources.

Over 30 percent of facilities lacked an MHTC policy and mental health unit staff failed to assign an MHTC for nearly 40 percent of patients. Over half of surveyed patients with an assigned MHTC could not identify the MHTC and more than 25 percent of MHTCs were uninvolved in discharge care coordination or the transition to outpatient care. 

While most patients, regardless of MHTC assignment, attended at least one outpatient mental health appointment within 90 days, over half of surveyed patients identified self-motivation and 20 percent identified encouragement from a family member or friend as contributing to appointment attendance. The OIG concluded that the MHTC model failed to effectively facilitate care coordination and MHTC assignment was not associated with a patient’s likelihood of attending post-discharge treatment engagement.

The OIG made eight recommendations to the Under Secretary for Health related to suicide risk identification and safety planning; MHTC written guidance, assignment, and effectiveness; post-discharge mental health appointment scheduling; and post-discharge treatment engagement.