Federal Reports

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.

The VA Office of Inspector General (OIG) conducted a national review to evaluate the Veterans Health Administration’s (VHA’s) suicide risk screening and evaluation training, adherence, and oversight procedures. VHA’s standardized Suicide Risk Identification Strategy (Risk ID) process requires annual screening using the Columbia-Suicide Severity Rating Scale (screening) and comprehensive suicide risk evaluation (evaluation) in response to a positive screening. VHA also recognized the need for screening beyond annual screening and implemented setting-specific Risk ID requirements in 10 clinical settings.

The OIG found that VHA’s required suicide prevention training does not include Risk ID processes or requirements. Training related to Risk ID responsibilities is available. However, the training is optional and not monitored.

VHA has not established annual or setting-specific Risk ID performance benchmarks and has conveyed inconsistent expectations to facility leaders and staff. In fiscal year 2023, annual screening and evaluation adherence was 55 and 82 percent, respectively. In a November 2020 memorandum, VHA expected 100 percent adherence, while other VHA documents reference expectations ranging from 81 to 95 percent. Furthermore, except for emergency department and urgent care settings, VHA does not monitor setting-specific Risk ID adherence.

The OIG determined that staff encountered barriers to completing Risk ID screening and evaluation, which included (1) limited engagement of facility clinical staff, (2) lack of facility leaders’ support, (3) limitations of performance data, and (4) unclear delineation of responsibilities.

The OIG made six recommendations to the Under Secretary for Health related to suicide risk and intervention training, suicide screening and evaluation performance benchmarks, setting-specific Risk ID monitoring, effectively addressing barriers to Risk ID non-adherence, non-mental health clinical specialty leaders’ awareness of Risk ID requirements, and clear identification of Risk ID monitoring and oversight responsibilities.

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.