Mental Health

Integrated Care: How the VA is Improving Mental Health for Veterans

September 26, 2018

On Wednesday, August 22, I had the honor to attend and present at Swords to Plowshares’ Sixth Annual Mental Health Summit. After five years of writing about the Veterans Health Administration (VHA), I arrived at the meeting familiar with its signature achievement – the full integration of mental and behavioral health services into every aspect of care delivery. After the day-long meeting, I left with even greater respect and admiration for the VHA’s commitment to what the summit was exploring: “Coordinating Mental Health, Specialty, and Primary Care, and Community Services to Address the Complex Needs of Veterans.”

Just how the VA does this—and how unique its approach is—was evident throughout all the plenaries and workshops. Those with private sector healthcare have never experienced integrated care. Our broader healthcare system delivers fragmented, episodic care that is disease and procedure oriented. Its primary imperative is profit, not service.

The difference between VHA and private sector care was well articulated by many nonveterans who work at the VHA but are ineligible for VHA care. During the morning’s introductory session, John McQuaid, chief of the Mental Health Service at the San Francisco VA Healthcare System (SFVAHCS), explained that, “It is hard to get fragmented care in the VA. It’s daunting in the private sector.” McQuaid continued to describe his own experiences. “My primary care provider is not connected to other providers. I envy veterans. They are in a system that is easy to navigate.”

Bonnie Graham, director of the SFVAHCS, related her own recent encounter with the private sector system when she broke her shoulder. “My care was so disjointed,” she told the crowd of about 200 attendees. “I know the healthcare system. Yet none of my care was coordinated. I ran into a number of obstacles. This would have never happened at the VA. We would never focus on money. I kept thinking, ‘How would an average person be able to deal with this? What would a person do who doesn’t have contacts or know what to do?’ The outcome wouldn’t be so positive.”

Graham added that not all health plans are even required to offer mental health coverage. “Meeting the mental health needs of veterans is among the VA’s highest priorities,” Graham elaborated. “Our mission is to look at individuals as whole people and approach their healthcare with integrated mental health services along with any other care they need. Addressing mental health challenges,” she added, “is complex. That’s why the VA is partnering with other organizations to complete the spectrum of care.”

John McQuaid presented an overview of a system that offers veterans access to care through telemental health in their home or in a Community-Based Outpatient Clinic (CBOC). Veterans can text when in a crisis, reach out to peers in the extensive peer support program, attend self-run Vet-to Vet groups, or use self-help apps (I sometimes use the CBT app for insomnia myself). Veterans can also utilize homeless services or find help at VA-sponsored facilities at community colleges, like the Veterans Resource Center at City College of San Francisco.

Geriatrician Anne Fabiny described the kind of elder care available to veterans. This care is largely absent in our broader healthcare system, which has only 7,600 geriatricians nationwide to deal with millions of elderly Americans.

In the introductory session and a workshop that followed, physician Karen Seal, who is chief of the Integrative Health Service, described the integrated pain program at the SFVAHCS. “It is no secret to us that veterans disproportionately suffer from wounds of war, or even wounds that started before war,” Seal said. These include chronic pain, dependency, co-morbid PTSD, depression, TBI, drug and alcohol use disorders, homelessness, unemployment, and more.

“Whenever all these mental health issues are present, then co-occurring chronic illnesses often appear: heart disease, diabetes, stress-induced conditions,” Seal continued. “Trying to silo off treatment for each of these conditions overwhelms the healthcare system.”

Seal then presented a detailed picture of what she and other clinicians offer veterans. This includes an Integrated Care Clinic (ICC) for Iraq and Afghanistan veterans, which starts with a three-hour visit that is basically one-stop shopping. The veteran sees a primary care provider, then there is a warm handoff to a combat stress specialist (psychologist), and then another warm handoff to a combat case manager (social worker). The visit may also involve a Traumatic Brain Injury Assessment if needed. The process is very transparent and involves a lot of teamwork.”

It was clear from these initial presentations that all those who presented shared what Michael Blecker described as, “The mission and passion that drives all of us…What we know is that we must integrate services. Everyone must work together to create a safety net for veterans…Today we can share what we’ve learned, what works and doesn’t, and how we can improve, so that we can do better starting tomorrow.”

Over the next several hours, participants attended workshops on housing and homelessness, medical care, education, justice involvement, substance use, and complementary and alternative modalities. In the medical care workshop, presenters outlined the needs of the transgender population as well as older veterans, and also described the way county veterans service officers (VSOs) can meet veterans’ needs.

In her remarks, Jessica Huckabay, regional education coordinator at the Defense & Veterans Brain Injury Center, said she worries about the increasing number of private sector providers seeing veterans. “A private sector provider who has a suicidal veteran may not know what to do. My advice to him is to contact the suicide crisis line run by the VA and also the VA’s National Center for PTSD.”

In the afternoon workshop on substance use addiction, psychiatrist Tauheed Zaman, medical director of the Addiction Consult Service and Opioid Safety Team at SFVAHCS, and William Hua, clinical health psychologist at the Infectious Disease and Liver Clinics (also at SFVAHCS), were joined by Grant Hower, a community counselor at Swords to Plowshares. Zaman emphasized the team-based nature of care delivery at the VHA. “We are not only interconnected by interactive charts,” he said, making a point few outside the VA seem to understand, “but we are interconnected because people are talking to each other face-to-face about complex patients.” This is the result of how the VA defines its mission: to serve veterans. This is perhaps the biggest difference between the VA and large private, for-profit institutions.

William Hua continued by explaining the connection between substance use and infectious and liver diseases. He also talked about the VA’s extensive use of motivational interviewing techniques to “build intrinsic motivation for change.” Hower then added his perspective on the need for community partnerships like the VA has with Swords to Plowshares and the importance of peers and peer counselors.

The day’s final session explored the threat of privatization of the VHA and the dis-integration of care that would inevitably result. Iraq veteran Diane Reppun, who is also a steering committee member of the Veterans Health Care Policy Institute, said she feared a direct attack on the coordinated care she receives from the VHA. “I’m very concerned that what is currently integrated care is going to be fragmented as they try to send veterans like myself out to private providers who never communicate with each other. I have had great care at the VA both in Palo Alto and now as I have moved to Boise, Idaho. The only bad experience I’ve had in the VA has been with Choice.”

Swords to Plowshares’ Legal Director Kate Richardson spoke of the need to “pry open access” to those ineligible for VA services because of “bad paper” due to the unfair use of other than honorable discharges. Swords to Plowshares’ Executive Director Michael Blecker gave eloquent testimony about the need to “fight the ravages of war and poverty. War is a destructive force that leaves generations affected with impoverishment. We have to fight the rollbacks with this administration of the safety net that serves all of those who are fragile. Veterans are definitely not part of the billionaire club.”

Finally, I warned of the threats of privatization to the tapestry of integrated care that the VA has woven. As the day illustrated, programs in the VA are umbilically connected to one another. Mental and behavioral health programs do not and cannot exist on their own. The success of the kind of programs Karen Seal, John McQuaid, Anne Fabiny, William Hua, and so many others described is a result of their interconnectedness. If the VHA is privatized, it will not only destroy the nation’s only single payer healthcare system. In order to enrich private providers, thousands of veterans will suffer as they will receive healthcare services of lower quality and higher cost. I and others urged veterans and their VA and community caregivers to join together to fight privatization on all fronts.

This message was underscored in the final presentation of the day, which came in a surprise visit from Congresswoman and House Democratic Leader Nancy Pelosi. Pelosi urged the participants to fight privatization, which, she said, “we cannot have. There is an element in the Trump administration that is determined to privatize the VA. You need to weigh in on these issues,” she urged the crowd. “The administration wants a big increase in military spending. When you increase the defense side you must increase the domestic side.”

Pelosi went on to warn the group that we have “three guys from Mar-a-Lago giving advice about where the VA should be going. Their only qualification is that they are members of Mar-a-Lago. It’s all about cronyism and incompetence. We can’t let these people weigh in—even with the President of the United States.”

When it comes to funding the VA MISSION Act and many other things, Pelosi told the group that, “We need to weigh in with the VSOs so they know you’re aware of these issues. We need to fight outside radical forces that want to privatize the VA…Don’t unravel veterans’ health.”

Find out more on about VA healthcare in Suzanne Gordon’s latest book, “Wounds of War: How the VA Delivers Health, Healing, and Hope to the Nation’s Veterans.”

Suzanne Gordon is an author and speaker with special expertise in healthcare systems, teamwork, patient safety, and nursing. Her website is