January 25, 2022

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VA Mental Health Care: Improvements Needed in Tracking and Overseeing Partnerships with Nongovernmental Entities

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<div>What GAO Found In an effort to reduce veteran suicides, the Department of Veterans Affairs (VA) tries to reach veterans through partnerships with nongovernmental entities using memorandums of agreement (agreements) focused on mental health and suicide prevention efforts. However, VA cannot readily track—that is, search for and identify—the full universe of its suicide prevention and mental health agreements. For example, it took officials from VA and its Veterans Health Administration (VHA) more than 4 months to identify for GAO 43 relevant agreements entered into across seven offices over a 5-year period. Number of Suicide Prevention and Mental Health Agreements with Nongovernmental Entities across Seven VA and VHA Offices (Oct. 2015 to Oct. 2020) GAO found that VA cannot readily track its agreements because VA policy does not require use of any single database to store agreement information. VA's Strategic Relationships Application, which VA designed to document agreement information, could be used for tracking, but only four of the seven offices with such agreements used it. Requiring its use would facilitate VA's ability to track all of its agreements and identify areas for improvement to better reach veterans not using its services. Individual VA and VHA offices conduct ongoing oversight of their own suicide prevention and mental health agreements, as required by VA policy. For example, officials monitor performance metrics such as the number of veterans served. VA policy also requires annual reviews that are used to determine if a partnership is still needed. However, GAO found that officials did not always document the completion of these annual reviews. VA's policy requires that “significant activity” be documented, but it does not specify that annual reviews fall under that category, though officials managing the policy confirmed they do. Providing specificity on what VA wants documented as significant activity—e.g., by adding examples to the policy or providing specific guidance—would help ensure that annual reviews are being documented and maintained for future use. Why GAO Did This Study Many veterans struggle with mental health conditions, several of which are risk factors for suicide. VA reported that almost two-thirds of veterans that died by suicide in 2019 did not receive VHA services in 2018 or 2019. VA partners with a variety of entities, such as non-profits or academic institutions, through formal agreements aimed at expanding awareness of and access to suicide prevention activities and mental health services, in part to reach veterans not receiving VHA services. The Veterans' Care Quality Transparency Act contained a provision for GAO to review VA's agreements with non-VA entities that are related to suicide prevention activities and mental health services. This report examines (1) how VA tracks such agreements with nongovernmental entities across the department, and (2) how VA oversees individual agreements. GAO reviewed VA and VHA policies, the agreements VA and VHA identified, and related documentation for tracking and oversight. GAO also received demonstrations of two VA databases and interviewed VA and VHA officials and representatives from 14 selected entities that have agreements with VA or VHA with variation in type of entity and services provided.</div>

What GAO Found

In an effort to reduce veteran suicides, the Department of Veterans Affairs (VA) tries to reach veterans through partnerships with nongovernmental entities using memorandums of agreement (agreements) focused on mental health and suicide prevention efforts. However, VA cannot readily track—that is, search for and identify—the full universe of its suicide prevention and mental health agreements. For example, it took officials from VA and its Veterans Health Administration (VHA) more than 4 months to identify for GAO 43 relevant agreements entered into across seven offices over a 5-year period.

Number of Suicide Prevention and Mental Health Agreements with Nongovernmental Entities across Seven VA and VHA Offices (Oct. 2015 to Oct. 2020)

GAO found that VA cannot readily track its agreements because VA policy does not require use of any single database to store agreement information. VA’s Strategic Relationships Application, which VA designed to document agreement information, could be used for tracking, but only four of the seven offices with such agreements used it. Requiring its use would facilitate VA’s ability to track all of its agreements and identify areas for improvement to better reach veterans not using its services.

Individual VA and VHA offices conduct ongoing oversight of their own suicide prevention and mental health agreements, as required by VA policy. For example, officials monitor performance metrics such as the number of veterans served. VA policy also requires annual reviews that are used to determine if a partnership is still needed. However, GAO found that officials did not always document the completion of these annual reviews. VA’s policy requires that “significant activity” be documented, but it does not specify that annual reviews fall under that category, though officials managing the policy confirmed they do. Providing specificity on what VA wants documented as significant activity—e.g., by adding examples to the policy or providing specific guidance—would help ensure that annual reviews are being documented and maintained for future use.

Why GAO Did This Study

Many veterans struggle with mental health conditions, several of which are risk factors for suicide. VA reported that almost two-thirds of veterans that died by suicide in 2019 did not receive VHA services in 2018 or 2019. VA partners with a variety of entities, such as non-profits or academic institutions, through formal agreements aimed at expanding awareness of and access to suicide prevention activities and mental health services, in part to reach veterans not receiving VHA services.

The Veterans’ Care Quality Transparency Act contained a provision for GAO to review VA’s agreements with non-VA entities that are related to suicide prevention activities and mental health services. This report examines (1) how VA tracks such agreements with nongovernmental entities across the department, and (2) how VA oversees individual agreements.

GAO reviewed VA and VHA policies, the agreements VA and VHA identified, and related documentation for tracking and oversight. GAO also received demonstrations of two VA databases and interviewed VA and VHA officials and representatives from 14 selected entities that have agreements with VA or VHA with variation in type of entity and services provided.

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