Guidelines as set forth in this document are published to improve the care for a large and often

complex group of veteran patients. These Guidelines reflect what the Veterans Health

Administration (VHA) is capable of doing now and suggest directions for future program

development, particularly in response to the revolutionary changes accompanying the Journey of

Change. The Department of Veterans Affairs (VA) operates a large, diverse healthcare system

that must adapt, create, lead, and innovate, or it will not meet the needs of veterans of future

decades. VA strongly encourages the creation of new, evidence-based, innovative programs,

organizations of clinical services, and alliances with, and input from, community organizations,

as it moves from a predominately hospital-based system to one based in, and serving the entire

veteran community.

This organization of mental health services, based on the concept of an integrated continuum

of care should be incorporated into the regular VA planning process at all levels. If additional

resources are required to provide necessary services, requests should be incorporated into the

planning process at the Veterans Integrated Services Network (VISN) level.

These are guidelines. None of the programs listed are mandated at this time. It is strongly

encouraged to use the enclosed definitions, Decision Support System (DSS) Identifiers, Treating

Specialty Codes, and Consolidated Distribution Report (CDR) Accounts at all sites so that we

can share meaningful information among medical centers and across Veteran Integrated Service

Networks (VISNs).

Thomas V. Holohan, M.D., FACP

Chief, Patient Care Services Officer

FD

Printing Date: 6/99

1. Introduction and Overview ....................................................................................................... 1

a. Authorization ........................................................................................................................ 1

b. Purpose .. 1

2. Guidelines for Providing Mental Health Services .................................................................... 2

a. Principles for Organizing Mental Health Care ..................................................................... 2

b. Principles for Program Planning .......................................................................................... 3

(1) Definition of Program and Program Elements .................................................................. 3

(2) Organizational Structure ................................................................................................... 3

c. Principles for Providing Quality Mental Health Care .......................................................... 4

(1) Mental Health Providers ................................................................................................... 4

(2) The Continuum of Care .................................................................................................... 4

(3) Mental Health and Primary Care ...................................................................................... 5

(4) Case (Care) Management .................................................................................................. 7

(5) Psychosocial Rehabilitation ............................................................................................ 11

d. Principles for Individual Patient Treatment Planning ........................................................ 12

(1) Designing a Treatment Plan ............................................................................................ 12

(2) Intensity of Therapeutic Interventions ............................................................................ 13

(3) Level of Therapeutic Supervision or Structure ............................................................... 14

(4) Principles Regarding Planning Patients’ Living Arrangements ..................................... 15

(5) Principles when Families are Involved in Living Arrangements .................................... 15

3. Special Populations ................................................................................................................. 16

a. The Eligibility Reform Act of 1996..................................................................................... 16

(1) Public Law 104-262 ........................................................................................................ 16

(2) Definition of Disabled Veterans with a Mental Illness ................................................... 16

(3) Subgroups ....................................................................................................................... 16

(4) Comorbidities ................................................................................................................. 17

(5) Specialized Programs ...................................................................................................... 17

(6) Capacity ........................................................................................................................... 17

(7) Special Emphasis Programs ............................................................................................ 17

(8) Resulting Mandate .......................................................................................................... 17

(9) References .......................................................................................................................18

b. Veterans Diagnosed with a Serious Mental Illness ................................................................. 18

(1) Background ..................................................................................................................... 18

(2) Principles for Providing Quality Treatment .................................................................... 18

(3) Treatment Guidelines ...................................................................................................... 19

(4) The Continuum of Care for SMI Veterans ..................................................................... 19

(5) Alternates to Long-term Psychiatric Hospitalization ...................................................... 19

(6) References ....................................................................................................................... 21

c. Veterans Diagnosed with a Substance Use Disorder .......................................................... 23

(1) Background ......................................................................................................................23

(2) Principles of Treatment and Rehabilitation of Veterans

with a Substance Use Disorder .................................................................................. 23

(3) The Substance Abuse Disorder Continuum of Care ....................................................... 23

(4) References ....................................................................................................................... 25

d. Veterans Diagnosed with Post Traumatic Stress Disorder (PTSD) ................................... 26

(1) Background ..................................................................................................................... 26

(2) Principles of Treatment and Rehabilitation of Veterans Suffering from PTSD ............. 27

(3) The PTSD Continuum of Care ....................................................................................... 27

(4) Outcome Monitoring ....................................................................................................... 29

(5) References ....................................................................................................................... 29

e. Homeless Mentally Ill Veterans .......................................................................................... 30

(1) Background and Definition ............................................................................................. 30

(2) Principles of Treating Homeless Veterans Disabled by Mental Illness .......................... 33

(3) Continuum of Care for HMI ........................................................................................... 33

(4) References ....................................................................................................................... 35

f. Elderly Veterans with Psychogeriatric Problems ................................................................ 35

(1) Definitions ...................................................................................................................... 35

(2) Interdisciplinary Approach ............................................................................................. 36

(3) Special Issues .................................................................................................................. 36

(4) Staffing Considerations ................................................................................................... 37

(5) The Psychogeriatric Continuum of Care ......................................................................... 37

(6) References ....................................................................................................................... 38

g. Providing Services to Veterans Living in Rural Areas ...................................................... 38

(1) General Principles to Consider ....................................................................................... 38

(2) Guidelines for Using Tele-Mental Health Technology ................................................... 39

(3) References ....................................................................................................................... 40

h. Special Issues For Women and Other Minority Veterans .................................................. 41

(1) Women Veterans ............................................................................................................. 41

(2) African-American Veterans ............................................................................................ 41

(3) Latino Veterans ............................................................................................................... 41

(4) Native American Veterans .............................................................................................. 42

(5) Reference ........................................................................................................................ 42

4. Program Elements and Settings .............................................................................................. 42

a. Overview ............................................................................................................................. 42

(1) Journey of Change .......................................................................................................... 42

(2) Admission to Mental Health Care .................................................................................. 42

b. General Mental Health (Seriously Mentally Ill Veterans) .................................................. 43

(1) Mental Health Primary Care Teams ............................................................................... 43

(2) Community-based Clinics ............................................................................................... 44

(3) Mental Health Clinics (MHCs)........................................................................................ 45

(4) Standard Case Management ............................................................................................ 46

(5) Intensive Community Case Management (ICCM) ......................................................... 47

(6) Day Treatment Centers (DTCs) ...................................................................................... 48

(7) Day Hospital Programs ................................................................................................... 49

(8) Community Residential Care (CRC) .............................................................................. 50

(9) Community-based Residential Treatment Settings ........................................................ 51

(10) Psychosocial Residential Rehabilitation Treatment Programs (PRRTPs) .................... 51

(11) Mental Health Services Within VA Domiciliaries ....................................................... 53

(12) General Compensated Work Therapy-Transitional Residences (CWT-TR) ................. 53

(13) Nursing Home Care ...................................................................................................... 54

(14) Medical -Psychiatric Sustained Treatment and Rehabilitation Units ........................... 54

(15) Community Reentry STAR Program ............................................................................ 55

(16) Skilled Psychiatric Nursing STAR Unit ....................................................................... 55

(17) General Psychiatry Subacute, and/or Rehabilitation Setting ........................................ 56

(18) Continued Extensive Psychiatric Care (CEPC) ............................................................ 57

(19) General Psychiatric Hospital Unit ................................................................................ 57

(20) Psychiatric Intensive Care Units (PICUs) ..................................................................... 58

(21) Summary of Reporting Codes for SMI Programs.......................................................... 59

c. Substance Use Disorder Services, Program Elements, Settings ......................................... 59

(1) Substance Use Disorder Treatment Clinics .................................................................... 59

(2) Intensive Outpatient Substance Use Disorder Treatment ............................................... 60

(3) Substance Use Disorder Residential Programs ............................................................... 60

(4) Substance Use Disorder Subacute Rehabilitation Settings ............................................. 61

(5) Inpatient Substance Use Disorder Settings ..................................................................... 61

(6) Summary of Reporting Codes for Substance Use Programs ............................................61

d. PTSD Services, Program Elements, Settings ...................................................................... 61

(1) Vet Centers ..................................................................................................................... 61

(2) Subclinics for PTSD ....................................................................................................... 62

(3) Sexual Trauma Counseling ............................................................................................. 62

(4) PTSD Clinical Teams (PCTs) ......................................................................................... 62

(5) Women Veteran Stress Disorder Treatment Teams ........................................................ 63

(6) Substance Use PTSD Treatment Programs (SUPTs) ......................................................63

(7) Day Hospitals for PTSD ................................................................................................. 63

(8) Day Treatment Centers for PTSD ................................................................................... 63

(9) PTSD Residential Rehabilitation Programs (PRRPs)...................................................... 63

(10) Domiciliary-based PTSD Treatment Programs ............................................................ 64

(11) PTSD CWT/TR ............................................................................................................ 64

(12) Specialized Inpatient PTSD Units (SIPUs) ................................................................... 64

(13) Evaluation and Brief Treatment PTSD Unit (EBTPU) ................................................. 64

(14) Summary of Reporting Codes for PTSD Programs ......................................................65

e. Health Care For Homeless Veterans (HCHV) Programs......................................................65

(1) Homeless Chronically Mentally Ill (HCMI) Programs.....................................................65

(2) VA Supported Housing (VASH) Programs .................................................................... 66

(3) SSA-VA Joint Outreach Initiative .................................................................................. 66

(4) HCMI CWT/TR .............................................................................................................. 66

(5) Domiciliary Care Programs ............................................................................................ 66

(6) Summary of Reporting Codes for Homeless Programs ...................................................67

f. Services, Program Elements for Elderly Veterans with Psychogeriatric Problems ............ 67

(1) Concept of Clinical Teams ............................................................................................. 67

(2) Psychogeriatric Integrated Care Teams (PICTs) ............................................................. 67

(3) Collaboration with Pertinent Geriatrics and Extended Care Programs .......................... 68

(4) Family and Caregiver Support ........................................................................................ 69

(5) Psychogeriatric Primary Care Clinics ............................................................................. 69

(6) Psychogeriatric Day Programs ........................................................................................ 70

(7) VHA Domiciliaries ..........................................................................................................70

(8) Psychogeriatric Sections Within VA Nursing Home Care Units ................................... 71

(9) Medical - Psychogeriatric Sustained Treatment and Rehabilitation Units ......................71

(10) Skilled Psychogeriatric STAR Nursing Units ................................................................72

(11) High Intensity (Brief Stay) Psychogeriatric Evaluation Settings. ...................................72

(12) Summary of Reporting Codes for Psychogeriatric Programs .........................................73

g. Psychosocial Rehabilitation Program Elements ................................................................. 73

(1) Psychosocial Rehabilitation .............................................................................................73

(2) The Psychosocial Rehabilitation Continuum of Care ......................................................73

(3) Integration of Work Programs .........................................................................................75

(4) Summary of Reporting Codes for Psychosocial Rehabilitation Programs .......................76

A Common Acronyms Used in these Guidelines .................................................................... A-1

B Mental Health Directives and Clinical Practice Guidelines for Mental Health

Practitioners .................................................................................................................... B-1

C Comparative Definitions of "Levels Of Care" for Mental Health Services .......................... C-1

D Current DSS Identifiers (Stop Codes) and CDR Accounts for Mental Health Programs ... D-1

E Index ...... E-1

veterans by providing primary care, specialized care, and related medical and social

support services. To accomplish this mission, the Veterans Health Administration (VHA)

needs to be a comprehensive, integrated healthcare system that provides excellence in

healthcare value, excellence in service as defined by its customers, and excellence in

education and research, and needs to be an organization characterized by exceptional

accountability and by being an employer of choice." (Kizer, Journey of Change, 1997)

(2) "Each eligible (enrolled) veteran will have access to a comprehensive, integrated,

continuum of high quality effective mental health services by the year 2002." (Mental Health

Strategic Healthcare Group (MHSHG), 1997.)

(3) Within the context of the dramatic transformation of VHA as anticipated in Dr. Kizer’s

this document reflects:

(a) A new integrated continuum of mental health services providing continuity of care.

(b) A major shift from an inpatient focus to that of residential treatment and communitybased

services.

(c) An innovative approach to organizing, planning, providing mental health care by

uncoupling patient treatment and rehabilitation modalities from the settings with which they are

traditionally associated.

(d) A framework for integrating the specialized knowledge of mental health into primary care.

(e) Healthcare decision-making at the facility and Veterans Integrated Service Network

(VISN) level.

(f) Accountability through providing national workload definitions, methods for data capture,

and measures of costs and outcomes.

(1) Provide current program guidelines for mental health professionals, planners, and

administrators.

(2) Reflect changes involving current best practice in mental health care as VHA moves into

the next century.

(3) Define levels of care.

(4) Stimulate innovative and evidence-based approaches for clinical care.

(5) Reflect requirements regarding "capacity" contained within the Veterans Healthcare

(6) Provide a template for individual patient treatment planning.

(7) Provide definitions and a crossover to VHA’s new Decision Support System (DSS)

methodology.

health care can be provided to veterans under a variety of organizational structures, including the

traditional professional services model, a product and/or service line (Charns et al, 1998) model,

or a combination of these and other models. In developing an efficient structure for the delivery

and monitoring of quality mental health care in VHA, organizational structures need to:

(1) Promote inter-professional collaboration in leadership, planning, and the monitoring of

(3) Support a continuity of care to meet both the primary care and specialty mental health care

needs of patients while mindful of the patient’s involvement in treatment decisions.

(4) Acknowledge the need for discipline specific involvement in the recruitment and

evaluation of the practice of mental health professionals, including the oversight of training and

research activities.

(5) Include contributions from patients and patient advocate groups in planning and

evaluating mental health care delivery.

Healthcare Delivery Systems, for Industry Advisory Board, Center for Health Management

Research, 1998.

clinical programs to focus on patients’ needs, a useful definition of a program is "an integrated,

comprehensive and cost effective continuum of care for veterans provided under a single

administrative structure." Program elements make up the total program. Under this definition,

all program elements at a single Department of Veterans Affairs (VA) medical center, for

instance, would be considered as a single program if administered as a single program. If

program administration were at a consolidated VA Healthcare System or a VISN level, then the

larger unit would be considered a "program." The word, "program," is also used for some

program elements organized under a single administrative structure and for some settings where

an integrated treatment regimen is indistinguishable from the setting (e.g., day treatment center).

services, whether at the facility or VISN level, need to:

(a) Identify programs and program elements in a manner consistent with local organizational

structures as well as national priorities;

(b) Create plans based on veteran populations rather than existing programs or facilities;

(c) Reflect diversity and creativity in program development;

(d) Partner with other service providers in planning;

(e) Involve patients and patient representatives in the process;

(f) Consult clinical practice guidelines where they are available;

(g) Include, or provide access to, the often multiple sources of expertise required to treat

patients with comorbidities; and

(h) Encourage the evaluation of programs and outcome measurements of delivery systems.

(a) Maximize each patient’s functional independence;

(b) Make ongoing quality mental health care available in the most appropriate location based

on the patient’s medical and functional condition;

(c) Provide an integrated continuum of care including access to long-term care when needed;

(d) Advocate for the needs of patients;

(e) Involve patients, their families, and other caregivers in shared decision-making;

(f) provide continuity of care and a knowledgeable treatment team through case management

(or care management) and primary care approaches; and

(g) Use evidence-based treatment guidelines where available and appropriate (see App. B).

and cost effective continuum of care for veterans with mental disorders.

(a) Program elements along a continuum of care should be driven by needs of the patients and

their families rather than by traditional bed levels or funding sources.

(b) Patients should move among the components of the continuum as is clinically appropriate,

with minimal disruption in treatment, and in a manner which facilitates positive treatment

outcomes.

(c) Veterans within and across VISNs should have equal access to all levels of care within the

continuum.

(d) Treatment of all patients with mental health problems should be provided by appropriately

trained, credentialed, and privileged clinicians and should be managed to assure continuity of

care.

(e) Treatment provided by VA should reflect state-of-the-art care as documented in the

empirical literature and clinical treatment guidelines and should be provided in a cost-effective

manner.

(f) Treatment outcomes should be monitored and serve as a basis for improving care.

(g) Evaluations of VA’s mental health service delivery and outcomes should benchmark

results with comparable non-VA healthcare systems.

(h) During reorganizations of clinical services, primary emphasis should be placed on the

development of an accessible continuum of care for all patients with mental disorders.

(i) When developing admission and readmission policies care should be taken to distinguish

between the intensity of services necessary to address the clinical problem and the setting (i.e.,

(j) Case (care) management is an effective tool and should be utilized to assure that patients

receive all necessary services throughout the continuum in a timely and coordinated manner.

available to veterans with significant mental disorders.

(a) Definition of Primary Care. Primary Care is the coordinated, interdisciplinary provision

of comprehensive healthcare including intake, initial assessment, health promotion, disease

prevention, emergency services, management of acute and chronic biopsychosocial conditions,

management, and patient and caregiver education.

(b) Rationale. As described in The Prescription for Change, VA has adopted primary care as

a fundamental emphasis for the delivery of healthcare to veterans (Kizer, 1995). Mental health

care is the primary focus of healthcare for a substantial proportion of patients in the public and

private healthcare system (Regier, et al, 1978). For many other healthcare patients with

undetected psychiatric problems, mental health services, although often overlooked, can also

reduce the risk and intensity of medical illness and the extent and cost of medical care services

(Friedman, et al, 1995).

(c) Models. There is no one correct way to address mental health primary care delivery. It is

a tenet of primary care that there be continuity of care across service delivery sites and across

episodes of care, ensuring that there is coordination of care, and that patients do not "fall through

the cracks" as can happen in a fragmented care system. Four models are evolving for the

provision of mental health primary care, each of which can be adapted to fit specific sites,

resources, and goals (see VHA Program Guide 1103.2).

(c) Fairweather GW. New Directions for Mental Health Services, The Fairweather Lodge: A

Twenty-five Year Retrospective. San Francisco, CA, Jossey-Bass, 1980.

(d) Goldmeier J, Shore MF, Mannino FV. "Cooperative Apartments: New Programs in

Community Mental Health," Health and Social Work. 2(1), 120-139,1977

(e) Harding, CM, Brooks, GW, Ashikaga T, Sargasso JS, Breier A. "The Vermont Longitudinal

Study of Persons with Severe Mental Illness: Methodology, Study Sample, and Overall Status 32

Years Later," Am. J. Psychiatry. 144(6), p. 718, June 1987.

(f) Hirsch SR, Barnes TR. Clinical Use of High-dose Neuroleptics. 1995.

(g) Knapp M, Cambridge P, Thomason C, Beecham J, Allan C and Darton R. "Residential

Care as an Alternative to Long-stay Hospital: A Cost-effective Evaluation of Two Pilot

(h) Lehman AF. Schizophrenia: Psychosocial Treatment. In Comprehensive Textbook of

Psychiatry/VI. Kaplan HI, Sadock eds, Willliams & Wilkins,.p. 998, 1995.

(i) Marder SR. ‘Antipsychotic drugs," In Key J, Lieberman JA (Eds). Psychiatry.

Philadelphia, PA: WB Saunders, 1996; pp. 1569-1586

(j) "NMHPPMS" National Mental Health Program Performance Monitoring System, FY

1997 Report, (Table 6-3, page 148, Table 6-2, page 147), Northeast Program Evaluation Center

(182), West Haven VA Medical Center, CT.

(k) Okin RL. "Testing the Limits of Deinstitutionalization," Psychiatric Services. 46(6), 569-

574. June 1995.

(l) Rogers and Yaskin. "Helping People With Serious Mental Illnesses Live Successfully in the

Community," J. California Alliance for the Mentally Ill. 8(3), 51-53, 1997.

(m) Rosenheck RA, Neale MS. "Cost-Effectiveness of Intensive Psychiatric Community Care for

High Users of Inpatient Services," Arch Gen Psychiatry. 55, 459-466, 1998.

(n) VHA Clinical Guidelines: Management of Persons with Psychosis, June 13, 1997. This is

available at VHA libraries and on the VA Intranet, Mental Health website

http//:vaww.mentalhealth.med.va.gov.

(o) Weisbrod BA, Test MA, Stein LI. "Alternative to Mental Hospital Treatment: Economic

Benefit-Cost Analysis," Arch Gen Psychiatry. 39, 400-405, April 1980.

(a) History. In the early 1970s, Congressional recognition of the extent of substance abuse in

the active military services led to major funding of substance abuse programs throughout both the

Department of Defense (DOD) and VA. Substance use disorder programs are now authorized

throughout the integrated continuum of care and should be available at all VA facilities.

(b) Cost to VA. In FY 1997, 24 percent of all inpatients discharged from VA medical centers

had a primary or secondary diagnosis of substance use disorder. These patients accounted for 28

percent of the total number of bed days of care provided. Approximately 35 percent of inpatients

with substance use disorder diagnoses were treated by substance use disorder units, 39 percent by

psychiatric units, and 34 percent by medical-surgical units (Piette, et al, 1997).

(c) Treatment Works. The scientific literature is unequivocal in documenting that treatment

of substance use disorder improves clients’ outcome on a variety of measures. Such measures

include duration and amount of substance use, employment, family status, and legal status.

(McLellan et al, 1996; Hubbard et al, 1989; Rice et al, 1991).

diabetes, hypertension, or asthma. Expecting a "complete cure" for a substance use disorder is no

more realistic than expecting total and permanent symptom elimination for these other illnesses.

quality, integrated, comprehensive, and cost effective continuum of care for veterans with

substance use disorders including monitoring of outcomes to increase effective care (see subpar.

2c).

continuum of services should be available to all veterans within a VISN (see VHA Program

Guide 1103.1, 1996).

(a) Primary Care. Substance Use Disorder Programs should be involved in the primary care

of patients. Specific arrangements will vary from setting to setting. In some situations, the

program itself will provide the primary care; in others, it will coordinate with designated primary

care providers.

(b) Special Patient Populations and/or Comorbidities. All substance use disorder

programming should be sensitive to the needs of special populations including the homeless,

ethnic minorities, women, geriatric patients, and patients with PTSD and other psychiatric

comorbidities, human immunodeficiency virus (HIV) infection and other medically compromised

patients, and with a spinal cord injury.

(c) Components Within a Continuum. The following components should be readily

accessible to all veterans when indicated:

1. Early identification and intervention;

2. Assessment, triage, and referral;

3. Acute stabilization and detoxification (including inpatient hospital services as medically

and psychiatrically necessary);

4. Rehabilitation services on an outpatient basis and/or on a residential basis for those patients

in need of such a setting;

5. Other outpatient care, encompassing continuing care, monitoring and relapse prevention;

and

6. Opioid substitution treatment (e.g., methadone maintenance therapy) and other drug

therapies (e.g., long-acting methadone substitutes, etc.) as they are approved for use, in

combination with psychosocial services.

needs, the following services should also be provided or arranged in the intensity and frequency

dictated by a comprehensive individualized treatment plan:

1. Medical services,

2. Psychiatric evaluation and care (including medication management),

3. Family education and counseling,

4. Domestic violence assessment and treatment,

5. Educational, vocational and employment services,

6. Social and independent living skills training,

7. Relapse prevention skills training,

8. Housing services, and

9. Self-help groups.

(e) Service Settings within a Continuum. Service settings within the continuum are:

1. Ambulatory (including intensive outpatient).

2. Partial hospitalization.

3. Residential settings, such as Substance Abuse Residential Rehabilitation Treatment

Programs (SARRTPs), Substance Abuse Compensated Work Therapy Transitional Residences,

Domiciliary Care Programs, and halfway houses.

4. Subacute rehabilitation in a hospital setting.

5. Acute hospital care.

(g) Treatment Guidelines. Evidence-based treatment guidelines are recommended for all

treatment services. Examples can be found in Module S of the Major Depressive Disorder

(MDD) Guidelines published in February 1997 and in Module C of the Psychosis Guidelines,

published June 13, 1997 (see App. B).

(h) Outcome Monitoring. VHA Headquarters (116B), the Program Evaluation Resource

Center (PERC) at Palo Alto VA Medical Center, and the Center of Excellence in Substance

Abuse Treatment and Education (CESATE) at Philadelphia and Seattle VA Medical Centers, in

conjunction with other facilities and VISNs, have developed a standardized national outcome

monitoring system using the Addiction Severity Index (ASI) and GAF. These ratings are now

required for all veterans receiving specialized treatment for substance use disorder.

(4) References

(a) Hubbard RL, Marsden ME, Rachal JV, Harwood HJ, Cavanaugh ER, Ginzburg HM.

Drug Abuse Treatment: A National Study of Effectiveness. University of North Carolina Press,

Chapel Hill, NC, 1989.

(b) McLellan AT, Metzger DS, Alterman AI, Woody GE, Durell EJ, O’Brien CP.

"Evaluating the Effectiveness of Treatments for Substance use Disorders: Reasonable

Expectations, Appropriate Comparisons," Milbank Q. 74:51-85, 1996.

(c) Piette JD, Baisden KL and Moos RH. Health Services for VA Substance Abuse and

Psychiatric Patients: Utilization for FY 1996. Program Evaluation and Resource Center,

HSR&D Center for Healthcare Evaluation, VA Palo Alto Healthcare System,1997.

(d) Rice DP, Kelman S, Miller LS. "Estimates of Economic Costs of Alcohol and Drug

1992.

(e) Information Letter 10-96-021. Substance Abuse Treatment: Standards for A Continuum

of Care (Oct 8, 1996).

(a) Extent of the Problem. The best estimate of the number of Vietnam veterans suffering

from PTSD is found in the National Vietnam Veterans Readjustment Study (NVVRS) (Kulka, et

al, 1988). It shows that 15.2 percent of male Vietnam Theater Veterans, i.e., 479,000 out of 3.1

million, suffer from PTSD. Only 20 percent of these veterans had ever received care for their

PTSD. Another 479,000 had PTSD between the war and the time of the survey but no longer

were symptomatic. NVVRS also described PTSD in 8.5 percent of female theater veterans (610

of 7200). Two studies of Persian Gulf War veterans, one involving over 4500 veterans and the

other involving over 2,000 veterans, identified from 9 to 10 percent of these veterans as having

PTSD symptoms. PTSD ranked first in frequency among the nine problem areas assessed in the

Vet Centers population (Rosenheck, et al, 1992). Of women veterans seeking care from special

Woman’s Veterans Stress Disorder Treatment Teams, 12 percent were exposed to enemy fire,

but 63 percent reported physical harassment and 43 percent reported rape or attempted rape

during military service. Fifty percent of women veterans seen by the Woman’s Stress Disorder

Teams met criteria for PTSD (Fontana et al, 1997).

(b) Cost to VA. In FY 1994, expenditures for specialized PTSD programs (those originally

funded from Congressionally mandated appropriations and monitored by NEPEC) were

$40,655,000. This figure does not include any local support for these programs nor does it

include data from locally developed and funded programs (Rosenheck and Fontana, 1996). In

addition to these direct costs, there are indirect costs to VA and to society in terms of substance

use disorder treatment, lost wages, and incarceration that are not easily measured.

(c) Treatment Works. Positive treatment outcomes for PTSD have been documented for

VA’s inpatient and outpatient PTSD programs and Vet Centers. Improvements are noted in

PTSD symptoms as well as in significant quality of life parameters such as employment, family,

and legal status. However, the nature of treatment appears to require a specific expertise.

Selected psychotherapeutic and psychopharmacological approaches can be effective for PTSD.

(Blake, 1993; US GAO, 1996; Meichenbaum, 1994; Rosenheck et al, 1996 and 1997.)

(d) Nature of Illness

1. PTSD is an anxiety disorder essentially described as:

"…the development of characteristic symptoms following exposure to an extreme traumatic

stressor involving direct personal experience of an event that involves actual or threatened death

or serious injury; or other threat to one’s physical integrity; or witnessing an event that involves

death, injury or threat to the physical integrity of another person; or learning about unexpected or

violent death, serious harm, or threat of death or injury experienced by a family member or other

close associate" (American Psychiatric Association, 1994).

2. The person’s response involves fear, helplessness, or horror. Characteristic symptoms

include re-experiencing the trauma; avoidance of stimuli associated with the trauma, numbing of

responsiveness and persistent symptoms of increased arousal. The effects of war zone trauma

have been demonstrated to be long lasting and severe. Thus for these veterans, the most common

stressor for PTSD is war zone stress, including both combat and dealing with mass casualty

situations (Scurfield RM, 1993; Kulka et al, 1990). Also included may be other non-war zone

military experiences such as the crash of a military aircraft or sexual assault.

(e) Clinical Complexity of VA Patients (Comorbidities). Veterans who are treated for PTSD

in VA have significant complicating features, including;

1. Comorbid anxiety disorders such as panic disorder and general anxiety disorder;

2. Depressive disorders, which are found in the 16 percent to 20 percent range even in nontreatment

seeking Vietnam veteran populations;

3. Substance use disorder, with an incidence reported from 58 percent to 80 percent in veteran

treatment populations; and

4. General medical disorders. Because of the aging of the veteran population, and because of

the implication of PTSD in the development or exacerbation of certain internal medical

disorders, assessment and treatment of patients with PTSD should include a particular focus on

the presence and management of physical disorders (VHA Treatment Guidelines, MDD, Module

A, 1997).

(a) VA is committed to providing an integrated, comprehensive, and cost-effective continuum

of care for veterans with PTSD and its associated comorbidities (see subpar. 2c).

(b) It is widely acknowledged that optimal treatment of PTSD requires specialized knowledge

and skill. Accordingly, PTSD treatment is optimally delivered by specialized teams whose work

is primarily focused on treating veterans with PTSD.

present in a single facility, but should be easily accessible by all patients treated within a VISN.

Some components of the continuum may be provided in coordination with neighboring VISNs.

Services provided should be based on the individual patient’s clinical needs; not all patients will

require the entire continuum of services. Patients should move among the components of the

continuum as is clinically appropriate, with minimal disruption in treatment, and in a manner

which facilitates positive treatment outcomes.

(a) Components of a Continuum. The following components in this continuum should be

readily accessible to all veterans:

1. Early identification and intervention.

2. Assessment, triage, and referral.

3. Acute stabilization and intervention (including hospitalization, as necessary).

4. Treatment and rehabilitation; short-term or long-term (greater than 30 days) on an

outpatient or residential basis for those patients in need of such a setting.

5. Other outpatient care, encompassing continuing care, monitoring, and relapse prevention

for those with substance use disorder comorbidity.

(b) Services Within a Continuum. Depending on a patient’s stage of recovery and clinical

needs, the following services should also be available in the intensity and frequency dictated by a

comprehensive individualized treatment plan:

1. Medical services;

2. Psychiatric care for PTSD and non-PTSD comorbid diagnoses, including medication

management;

3. Family education and counseling;

4. Domestic violence assessment and treatment;

5. Educational, vocational and employment services, including Compensated Work Therapy

(CWT);

6. Social and independent living skills;

7. Relapse prevention skills training for patients with substance use disorder comorbidity; and

8. Housing assistance encompassing Health Care for Homeless Veterans (HCHV), placement

assistance, and Domiciliary services.

(c) Service Settings within a Continuum. A spectrum of treatment options needs to be

preserved for veterans with PTSD. Outpatient settings should maximize accessibility, expertise,

and clinical efficacy. Staff should have the capacity to address the severity, chronicity,

complexity, and comorbidities associated with PTSD. There is a small core of patients for whom

treatment in an intensive inpatient or residential setting is a medical necessity. There are times

when a patient whose primary problem is PTSD may also require other psychiatric services in

addition to those found in specialized PTSD settings. Examples include emergencies such as

suicidal behavior, which may require care on a general psychiatric unit; or specialized substance

use disorder treatment needed before PTSD care is initiated, or during the course of treatment.

Service settings within the continuum include:

Hospital; or Day Treatment Centers; Women’s Stress Disorder Treatment Teams, and Vet

Centers.

CWT/Transitional Residences and Domiciliaries and

brief treatment, general psychiatric care, intensive psychiatric treatment, and the specialized care

found within a Specialized Inpatient PTSD Unit (SIPU).

(d) Primary Care. A primary care PTSD program link should be established that provides

appropriate medical services for veterans with PTSD because of the association of stress

disorders with other medical disorders and because the PTSD population is aging. Primary care

services may be coordinated in a variety of ways, such as providing mental health clinicians on

medical primary care teams or providing medical clinicians on mental health primary care PTSD

teams. Designating liaison staff between the two is another alternative. These approaches

promise to promote increased efficiency of overall healthcare by improving outcomes, reducing

medical costs and improving patient satisfaction.

(e) Special Veteran Populations. All PTSD treatment programs should be sensitive to the

special needs of their patients including issues of homelessness, substance use disorder, physical

disabilities, HIV positive status, and other medically compromising conditions. In addition,

treatment programs should be responsive to the special needs of elder veterans, members of

ethnic minority groups, and female veterans. PTSD symptoms in older combat veterans may first

appear after they retire from their life’s work.

(f) Practice Guidelines Practice guidelines for PTSD are available within Module P, MDD

Guidelines available at VHA medical libraries and the intranet,

http://vaww.mentalhealth.med.va.gov (see App. B).

facilities and the VISNs, have developed a standard national outcome monitoring system

including GAF and performance measures for the PTSD SEPs. These include both population

outcome measures and program outcome measures. Such measures will assist in evaluating the

effectiveness of treatment.

(b) Blake DD. "Treatment Outcome Research on Post-Traumatic Stress Disorder," Clinical

Newsletter, National Center for Post-Traumatic Stress Disorder. 3(2), 14-17, 1993.

(c) Kulka RA, et al., Contractual Report of Finding from the National Vietnam Veterans

Readjustment Study (NVVRS). Research Triangle Park, NC. Research Triangle Institute, 1988.

(d) Fontana A and Rosenheck R. Women Under Stress: Evaluation of the Department of

Veterans Affairs Woman’s Stress Disorder Treatment Teams. West Haven, CT., Northeast

Program Evaluation Center, July 21,1997.

(e) Meichenbaum D. A Clinical Handbook/Practical Therapist Manual for Assessing and

Treating Adults with Post-Traumatic Stress Disorder (PTSD). Institute Press, Waterloo, Ontario,

1994.

(f) Rosenheck R, Becnel H, Blank AS, Farley F, Fontana A, Friedman MJ, et al. Returning

Persian Gulf War Troops: First Year Findings. West Haven, CT., Northeast Program Evaluation

Center, 1992.

(g) Rosenheck R and Fontana A. Treatment of Post-traumatic Stress Disorder in the

Department of Veterans Affairs: Fiscal Year 1995 Service Delivery and Performance (LJH IV).

West Haven, CT. Northeast Program Evaluation Center, February 6, 1996.

(h) Rosenheck R and Fontana A. Treatment of Post-traumatic Stress Disorder in the

Department of Veterans Affairs: Fiscal Year 1996 Service Delivery and Performance. West

Haven, CT. Northeast Program Evaluation Center, 1997.

(i) Scurfield RM, "Posttraumatic Stress Disorder in Vietnam Veterans," International

Handbook of Traumatic Stress Syndromes. Wilson JR and Raphael R, eds. Plenum Press, New

York and London, 285-295, 1993.

(j) US General Accounting Office. "Readjustment Counseling Service: Vet Centers Address

Multiple Client Problems, but Improvement is Needed," (GAO/HEHS-96-113). Washington,

DC: US Government Printing Office, 1996.

(a.) History. VA’s homeless programs were initiated in 1987 with the passage of Public Law

gave VA authority to establish clinical teams to address the needs of homeless veterans and to

contract with community-based organizations for the provision of residential care. Services were

broadened and additional sites were funded and, although HCMI remained the core of these

programs, in 1993, the term HCHV was adopted to serve as a broader title. HCHV is sometimes

used interchangeably with HCMI but generally it is used to reflect augmented program designs

and services and to reduce the stigma that may be associated with the "chronically mentally ill"

title. Subsequent legislation and increased Congressional appropriations, as well as additional

collaborations with other Federal, state, and local agencies, and non-profit organizations, have

created an expanded and diverse mix of treatment and assistance programs for homeless veterans

that varies with each site dependent on local need and ingenuity. In a statement before the

Committee on Veterans Affairs’ Subcommittee on Health, on June 17, 1998, the Under Secretary

for Health identified medical services and other support to homeless veterans as VHA’s fifth

mission (in addition to general medical care, education, research, and support to DOD).

(b) Current Programs. Currently, VA offers a wide array of special programs and initiatives

specifically designed to help homeless veterans live as self-sufficiently and independently as

possible. In fact, VA is the only Federal agency that provides substantial hands-on assistance

directly to homeless persons. Although limited to veterans and their dependents, VA's major

homeless-specific programs constitute the largest integrated network of homeless treatment and

assistance services in the country. Many of VA’s homeless programs operate under the auspices

of HCHV. Other VA initiatives that provide services to homeless veterans were established by

subsequent public laws, encouraged by parallel efforts of complementary VA mental health

programs, or set up through collaborations with other federal agencies. Key VA programs that

provide services for homeless veterans are outlined as follows:

1. HCMI Veterans Program: outreach, assessment, case management and community-based

contracts for housing.

2. Domiciliary Care for Homeless Veterans (DCHV) Program: outreach, assessment,

treatment planning, service delivery, outplacement, and after care.

3. CWT/TR: vocational development and work therapy linked to community-based

residential living;

4. Department of Housing and Urban Development – VA Supportive Housing (HUD-VASH)

Program: case management in the community and HUD assisted independent living.

5. Supportive Housing (SH): case management in the community and independent living.

6. Social Security – VA Outreach (SSA-VA): outreach and social security benefits

assistance.

7. Veterans Benefits Administration (VBA) – VHA Collaborative Initiative: outreach and

veterans benefits assistance.

8. Community Homelessness Assessment, Local Education and Networking Groups

(CHALENG) for Veterans: National assessment, coordination, and planning of services for

homeless veterans.

9. VA Homeless Providers Grant and Per Diem Program: assistance for community

providers in creating and operating supportive services.

(c) Extent of the Problem. It has been estimated that one-third of all homeless adults and 40

percent of homeless men are veterans of the United States armed forces (Rosenheck et al, 1994)

and that on any given night there are approximately 250,000 homeless veterans living in shelters

or on the streets of American cities. Perhaps twice as many veterans may experience

homelessness over the course of a year. Many other veterans are considered at risk because of

their poverty, lack of support from family and friends, and precarious living conditions in

inexpensive hotels or in overcrowded or substandard housing.

(d) Patient Characteristics. Almost all homeless veterans are male (about two percent are

female) and the vast majority are single. Homeless veterans tend to be older and more educated

than homeless non-veterans (Rosenheck and Koegel 1993). A majority of veterans seen in the

HCHV programs in Fiscal Year (FY) 96 were judged to have a serious psychiatric or substance

use disorder problem. Just under one-half had a serious psychiatric problem (i.e., psychosis,

mood disorder, or PTSD) and three-fourths were described as dependent on alcohol and/or drugs.

Roughly 55 percent were African American or Hispanic (Kasprow et al, 1997).

(e) Cost to VA. In FY 97, VA spent a total of $93.1 million on programs specifically for

homeless veterans. In addition to these direct costs, there are additional associated costs. VA

continues to treat homeless veterans in its acute inpatient units. The FY 96 End-of-Year Survey

of Homeless Veterans in VA Acute Inpatient Programs (Seibyl et al, 1997) revealed that 13.5

percent of all veterans hospitalized in acute care described themselves as homeless at the time of

their admission. Additionally, the study reported that 7.5 percent of these patients in acute care

were objectively homeless, residing in shelters, the streets, and similar locations prior to their

admission.

(f) Treatment Works. The core programs of VA’s Homeless Treatment and Assistance

programs are monitored by the VA’s NEPEC. Data from these monitoring efforts demonstrate

the success of specific courses of treatments designed to address the cause and/or effects of

homelessness. Additionally, the literature suggests that successfully reaching the homeless

populations at times requires nontraditional techniques and practices. It has been shown that

there are unique dynamics of and within the homeless population. The homeless veteran has

specific needs. These needs can be addressed by VA’s continuum of care, consisting of a diverse

mix of community-based services.

(g) Nature of Illness. Homelessness itself is not an illness, however, the causes and effects of

homelessness can be. Causes of homelessness may include mental illnesses such as depression

or psychosis; substance use disorder; or personality disorders. A veteran may be homeless

because of a lack of education or job training. Confounding this issue is the fact that mental

illness could also be an effect of homelessness. Other effects of homelessness include physical

problems; diseases or infections; social isolation; and criminal complications. An accurate

assessment as to the causes versus the effects of homelessness is an important part of evaluating

the homeless veteran and formulating a successful treatment plan.

June 3, 1999 VHA PROGRAM GUIDE 1103.3

33

(2) Principles for Treating Homeless Veterans Disabled by Mental Illness

community referrals, VA facilities, and community treatment providers. Staff should ensure that

(3) Continuum of Care for HMI

4. May work with CWT or other supported/therapeutic work programs;

5. May work in conjunction with Psychosocial Residential Rehabilitation Treatment

Programs (PRRTPs) to develop psycho-educational skills to be practiced in the residential setting

then transferred into independent living.

(e) DSS identifiers for DTCs include 505 (DTC individual) and 553 (DTC group). Exceptions

would be psychogeriatric Day Hospitals, which would use DSS 578 (Psychoger Day Program).

Level 1 Level 2 Level 3 Level 4 Level 5

Intensity Community Partial Residential Professional High staff

Low

Moderate

High

Very High

(a) Day Hospitals are the most labor-intensive ambulatory psychiatric care programs. They

provide a moderate, specialized degree of structure that falls between full hospitalization or

residential rehabilitation programs and the more traditional models of ambulatory care.

(b) These programs are designed to:

1. Assist the veteran in avoiding full hospitalization and to allow the veteran to maintain

community ties.

2. Provide intensive diagnostic and treatment services to patients following inpatient care to

allow shortened lengths of stay and a more rapid return to the community.

3. Provide rapid evaluation, crisis intervention, transitional treatment, and further stabilization

of psychiatric conditions in order to prevent rehospitalization.

4. Provide therapeutic services to:

a. Seriously mentally ill patients (see subpar. 3b) in crisis;

b. Patients with medical and/or surgical impairments who are having difficulty adjusting to

the limitations imposed by their illnesses; and

c. Veterans with PTSD and/or substance use disorder problems as comorbidities.

(c) Patients who benefit from Day Hospitals include those with few previous significant

mental health problems whose condition has been precipitated in part by situational crisis.

(d) Following a period of intense treatment in Day Hospitals patients may receive additional,

less intense treatment in MHCs, or may be prepared to return to full independent living.

(e) Day Hospitals may:

1. Be used for initial evaluation of patients applying for psychiatric care;

2. Work closely with intensive psychiatric community care teams; and/or

3. Have a psychogeriatric emphasis.

(f) DSS identifiers for Day Hospitals are 506 (DH individual) and 554 (DH group).

Exceptions would be Psychogeriatric Day Hospitals, which would use DSS 578 (Psychoger Day

Program).

Level 1 Level 2 Level 3 Level 4 Level 5

Intensity Community Partial Residential Professional High staff

Low

Moderate

High

Very High

(a) The CRC Program offers residential care, including room, board, and limited personal

care and supervision (often including supervision of medications depending upon individual state

laws) to veterans who do not require hospital or nursing home care, but who, because of medical

or psychosocial health conditions, are not able to live independently and have no suitable family

resources to provide needed care.

1. This program, originally designated as "Foster Care," began in the 1950s as a community

reentry program for psychiatric patients no longer in need of acute hospital care.

2. Although the CRC Program has been expanded to include general medical and surgical

patients, nearly 75 percent of the 11,000 veterans currently enrolled in the program have primary

psychiatric diagnoses.

(b) The patient must essentially be capable of performing activities of daily living (ADL) with

minimal, or no assistance, exhibit socially acceptable behavior, and not be a threat to self or

others.

1. Care is provided at the veteran's own expense in private homes or state-licensed private

care facilities inspected and approved by VA, but chosen by the veteran.

2. The veteran generally receives follow-up visits approximately monthly from VA social

workers and other healthcare professionals as indicated, and is an outpatient of the local VA

medical centers.

(c) DSS Identifier for contacts with CRC patients in their settings is 503 (residential care,

individual). The DSS identifier, 121 (Res Care FU), will be not credited for SMI capacity

determination or for 30 day post discharge follow-up measures.

include psychiatric half-way houses, structured therapeutic group homes, and community-based

residential treatment facilities.

(a) They are designed to provide transitional therapeutic experiences for patients who

have just been discharged from VA psychiatric inpatient settings. In these settings veterans

may consolidate gains acquired in the hospital and further prepare themselves for full

reentry into the community.

(b) In contrast to PRRTPs, these settings are generally owned by private entrepreneurs,

non-profit groups, or veterans organizations; they generally provide room and board plus

access to mental health treatment programs.

(c) Sometimes VA staff may be directly assigned to provide or augment care.

(d) Except for VA contract half-way houses for drug and alcohol abusers, and HCMI

contracts, the veterans generally must pay rent from their own funds.

(e) Since patients at this level are considered outpatients, the same DSS identifiers would

Level 1 Level 2 Level 3 Level 4 Level 5

Intensity Community Partial Residential Professional High staff

Low

Moderate

High

Very High

(a) Program Description. PRRTPs (VHA Dir. 10-95-099, and ch. 1) represent a bed level of

care within the psychiatric continuum that is separate from inpatient hospital beds. These

residential beds provide a 24-hour therapeutic treatment setting for acute patients with multiple

and severe psychosocial skill deficits related to their psychiatric disorder. PRRTPs utilize the

residential "therapeutic community" of peer and professional support, with a strong emphasis on

increasing personal responsibility to achieve optimal levels of independence upon discharge to

independent or supported community living.

(b) Location. PRRTPs may be established either on VA medical center grounds or in VAowned

or leased space in the community. Regardless of their location, PRRTP beds are counted

as VA beds, and must be reflected in the associated VA medical center’s Gains and Loss (G&L)

statement along with Nursing Home care Units (NHCUs) and Domiciliaries.

(c) Treatment Services. Veterans in PRRTPs generally participate in an intensive regimen of

outpatient services, such as substance use disorder, PTSD or general psychiatric treatment, day

treatment programs, or vocational rehabilitation. These outpatient services are then augmented

by the residential component of the program that emphasize self-care and personal responsibility.

Rehabilitation goals generally addressed in PRRTPs include, but are not limited to:

1. Social and independent living skill development,

2. Community survival skills, vocational rehabilitation,

3. Nutrition,

4. Shopping,

5. Medication management,

6. Patient and family education, and

7. Acquiring appropriate housing.

(d) Staffing. These bed sections are minimally staffed, since, by their residential (versus

hospital inpatient) nature, they are designed to maximize peer support and self-care.

Professionals, para-professionals, trained volunteers, non-professionals, and/or "senior" residents

member of the professional PRRTP staff must be on call by radio, telephone, or beeper, at all

times, and clear channels of communication with VA medical center on-call staff must always be

maintained.

(e) Workload documentation. Workload for PRRTP residential services that are not tailored

to a specific psychiatric diagnosis are reported by Bed Days of Care, using Treating Specialty

Code 25.

(a) Domiciliaries provide 24-hour supervision by professional and/or paraprofessional staff.

Each Domiciliary patient has an identifiable interdisciplinary team and a treatment plan with

concrete functional objectives.

(b) Some Domiciliaries offer specialized mental health programs of psychosocial residential

rehabilitation services that are similar in nature and design to those described for PRRTPs.

Domiciliaries tend to offer a broader range of biopsychosocial rehabilitation services than most

PRRTPs.

(c) In contrast to PRRTPs, general Domiciliary settings (without specialized rehabilitation

programs) may offer a structured therapeutic environment that may be appropriate for

psychiatrically disabled (and often aging) veterans for whom community living is not a

reasonable clinical expectation.

(d) Workload documentation. Workload for Domiciliary mental health services that are not

tailored to a specific psychiatric diagnosis is reported by Bed Days of Care, using Treating

Specialty Code 85.

(a) General CWT/TRs are work-based residential rehabilitation programs that are not tailored

to the treatment of patients with a specific psychiatric diagnosis. The CWT/TR model is unique

to other VA-operated residential programs in that participants contribute (using their CWT

earnings) to the cost of operating and maintaining their residential units and are generally

responsible for the planning, purchase, and preparation of their own meals and other "household"

activities.

(b) Workload for General CWT/TR residential services is reported by Bed Days of Care,

using Treating Specialty Code 39.

state-operated veterans nursing homes in which VA participates through a grant program, all treat

veterans with complex medical and functional limitations who also have psychiatric and/or

behavioral disorders. These programs are administered centrally by VHA’s Geriatrics and

Extended Care Strategic Healthcare Group. With the exception of designated Psychogeriatric

Sections in VA NHCUs (see psychogeriatric program elements, subpar. 4f), there are no centrally

defined mental health programs in VA nursing homes.

(previously "STAR I")

Level 1 Level 2 Level 3 Level 4 Level 5

Intensity Community Partial Residential Professional High staff

Low

Moderate

High

Very High

(a) Patents in this setting have long-term medical, neurological, and psychiatric disorders that

interact in such as way as to make care in traditional long-term psychiatric or nursing home

settings problematic. An emphasis on rehabilitation potential and on individual assets should be

included.

(b) Treating Specialty Code 89 will be used to identify all bed and assigned staff costs.

Level 1 Level 2 Level 3 Level 4 Level 5

Intensity Community Partial Residential Professional High staff

Low

Moderate

High

Very High

(a) This program is appropriate for SMI patients who may have adjusted to a hospital

environment, but have marked deficits in social-functional skills and poor judgment. They may

have potential for discharge to residential or community-based outpatient programs following an

intensive psychological, social and vocational evaluation, and functional skills training program

(b) Generally, these psychiatric patients should have no significant medical problems

requiring high level hospitalization; however, they may lack basic self-care skills required for

participation in psychosocial residential rehabilitation or intensive supportive living communitybased

programs. The emphasis should be on patient self-help and self-care as opposed to staff

caregiving.

(c) Community Reentry rehabilitation programming may occur, as appropriate, outside of a

specific ward area and may be available to patients from more than one ward. Both

programming and rehabilitation staff may follow patients as they move from hospital beds to less

structured living settings in the community.

(d) Treating Specialty Code 89 will be used to identify all bed and assigned staff costs.

(e) Workload for patients discharged from Community Reentry inpatients programs and

followed on an outpatient basis should be reported using DSS identifiers appropriate to the

setting.

Level 1 Level 2 Level 3 Level 4 Level 5

Intensity Community Partial Residential Professional High staff

Low

Moderate

High

Very High

(a) This program element offers skilled psychiatric nursing care for patients with chronic,

refractory, partially stabilized, major psychiatric or organic brain disorders who no longer require

intensive treatment, are not actively suicidal or chronically assaultive, are medical stable, and do not

meet the requirement for ADL deficiencies associated with a NHCU setting. Periodic reassessments

at least every 6 months, including potential for rehabilitation, and trials on alternative settings are

recommended.

(b) Treating Specialty Code 89 will be used to identify all bed and assigned staff costs.

Level 1 Level 2 Level 3 Level 4 Level 5

Intensity Community Partial Residential Professional High staff

Low

Moderate

High

Very High

(a) Psychiatric rehabilitation programs represent a group of specialized programs

designed for SMI patients that are of higher intensity and shorter duration than the

Community Reentry STAR program, but the distinction may disappear over time. Eligible

patients require:

1. Training or relearning in social skills,

2. Group living,

3. Reentry,

4. Discharge planning, and

5. Community survival skills, etc.

(b) The SMI psychiatric patient often needs help with:

1. Housing,

2. Shopping,

3. Consuming appropriate food, and

4. Understanding the nature of the individual's illness and the need for continued

medications.

(c) Family members and caregivers also need help in understanding their roles in

providing a stable post-hospital environment.

(d) Treating Specialty Code 92 will be used to identify all bed and assigned staff costs.

Level 1 Level 2 Level 3 Level 4 Level 5

Intensity Community Partial Residential Professional High staff

Low

Moderate

High

Very High

(a) The CEPC, a long-term program requiring a high staffing level, is authorized in

recognition of a relatively small group of psychiatric patients found primarily in the larger,

predominately psychiatric medical centers who require a high level of staffing because their

behavior is such that it cannot be managed on a STAR level program and they are too disruptive

and unresponsive to remain for long on a general psychiatric ward or Psychiatric Intensive Care

Unit (PICU). All patients on CEPCs should have a thorough diagnostic review, trial on newer

medications, and possibly a periodic trial in alternative settings.

(b) Treating Specialty code 89 will identify all costs associated with this program.

Level 1 Level 2 Level 3 Level 4 Level 5

Intensity Community Partial Residential Professional High staff

Low

Moderate

High

Very High

(a) General Psychiatric Wards offer thorough, comprehensive, psychiatric evaluation,

diagnosis, and treatment in a highly structured hospital environment for new patients requiring

hospital-level structure, as well as for patients experiencing recurrence of illness who cannot be

assessed, or treated, at a lesser level of care.

(b) The primary objective is to provide an intensive care setting with a shift to a less intensive

level of care as soon as clinically appropriate. All or parts of such units should be securable in

order to accommodate involuntary patients and patients who are temporarily out of control or at

risk of harming themselves or others.

(c) Treating Specialty Code 93 will be used for all costs.

Level 1 Level 2 Level 3 Level 4 Level 5

Intensity Community Partial Residential Professional High staff

Low

Moderate

High

Very High

(a) The PICU offers smaller size, increased staffing, security (safe, quiet seclusion rooms),

and more specialized clinical expertise than a general psychiatric ward. A PICU may be

physically within or adjacent to a traditional admitting or general psychiatric ward.

(b) Patients admitted to this level of care will have the most severe behavioral problems

including:

1. High suicide risk,

2. Assaultiveness,

3. Severe agitation,

4. Disorganized behavior secondary to psychosis,

5. Confusion, or

6. Other severe psychiatric disorders.

(c) Psychiatric patients presenting with such symptoms may be rapidly stabilized on such a

unit, obviating the need for transfer to a long-term or more secure facility often some distance

away.

d) Treating Specialty code 93 will also be used for all program costs.

* See Appendix D for definitions listed by DSS Identifier numbers.

** CDR refers to the Cost Distribution Report used to allocate staffing costs.

*** Not applicable to CDR; Automated Medical Information System (AMIS) segment J-19 is

used by CDR currently for workload

(a) Substance Use Disorder Clinics (formerly Substance Abuse Treatment Programs or "SATPs")

provide settings for outpatient care to patients with substance use disorders. Both initial and ongoing

interventions may be undertaken in a clinic setting. Treatment is designed to provide the full-range of

treatment and rehabilitation services for patients with substance use disorders, including:

1. Detoxification.

2. Treatment of the psychological and behavioral aspects of addiction.

3. Opioid substitution treatment, methadone maintenance therapy and other drug therapies

(e.g., levo-alphacetylmethadol (LAAM), etc.) as they are approved for use, in combination with

Telephone, General Psych 527 2780 6) Day Treatment, Individual 505 2311

Mental Health Primary Care Team, Indiv. 531 2331 6) Day Treatment,Group 553 2310

Mental Health Primary Care Team, Group 563 2330 7) Day Hospital, Individual 506 2311

Psychiatry, Consultation 512 2311 7) Day Hospital,Group 554 2310

Psychiatry - Group 557 2310 8) Mental Health Residential

Psychology, Individual 510 2311 Care, Individual 503 N/A***

Psychology, Group 558 2310 10) PRRTP 25 1711

Mental Health Clinic, Individual 502 2311 11) Mental Health, Domiciliaries 85 1510

Mental Health Clinic, Group 550 2310 12) CWT-TR) 39 1717

(ICCM) 564 2311 14)-16) STAR Units 89 1316

Telephone, ICCM (pair) 147-564 2780 17) Psychiatry Rehab Settings 92 1311

IPCC, Community Visit 552 5117 18) CEPC 89 1311

19) General Psychiatric Ward 93 1310

20) PICU 93 1310

4. Vocational and other rehabilitation services.

(b) Outpatient care emphasizes the development of social and vocational skills and the

abstinence necessary to successfully remain in the community.

(c) DSS identifiers include 513 (SA indiv), 560 (SA group), and 523 (opioid maint).

Day Treatment Center and/or Day Hospital)

(a) A setting for substance use disorder interventions that can provide structured activities 3

or more hours per day, 3 days a week at a minimum.

(b) The DSS identifier for this program element is 547 (Intensive Substance Abuse

Treatment).

(a) Substance Abuse Residential Rehabilitation Treatment Program (SARRTP). A SARRTP

is a PRRTP (see subpar. 4b(1)(c)) residential setting focusing on treatment of patients with

substance use disorder problems.

(b) Domiciliary based Substance Use Disorder Treatment Programs. Domiciliary based

Substance Use Disorder Treatment Programs provide residential services focusing on treatment

and rehabilitation of substance use disorder problems in a Domiciliary setting.

(c) Substance Abuse CWT/TR (S/A CWT/TR). A S/A CWT/TR is a work-based residential

rehabilitation program tailored to the treatment of patients with substance use disorders. The

CWT/TR model differs from other VA-operated residential programs in that participants

contribute (using their CWT earnings) to the cost of operating and maintaining their residential

units and are generally responsible for the planning, purchase and preparation of their own meals,

and other "household" activities. CWT/TRs are a special class of PRRTPs that focuses on

rehabilitation of substance use disorder problems within a work and living setting.

(d) Community-based contract residential facilities.

(e) Cooperative agreements with other community providers.

hospital-based, clinically managed Substance Use Disorder Rehabilitation Settings will be given

Treating Specialty Code 84 (Psychiatry-Substance Abuse Intermediate Care).

1) Substance Abuse, indiv 513 2316

1) Substance Abuse, home visit 514 2316

1) Telephone, Substance Abuse 545 2780

1) Substance Abuse, Group 560 2316

1) Substance Use Dis./PTSD teams 519 2317

1) Opioid Substitution 523 2316

2) Intensive Substance Abuse

Treatment (formerly Day Hosp.).

547 2316

3)a) SARRTP 27 1713

3)b) S/A CWT/TR 29 1715

3)c) Domiciliary-based S/A program 86 1511

4) Hospital-based Rehabilitation 84 1312

5) Inpatient ward 74 1313

*See Appendix D for definitions listed by DSS Identifier numbers

** CDR refers to the Cost Distribution Report used to allocate staffing costs.

trauma is provided through a nationwide system of 206 community-based counseling facilities

known as Vet Centers. The Vet Centers were the first VA service program to systematically treat

PTSD in returning war veterans. Vet Centers have line authority to and are administered by the

Readjustment Counseling Service (RCS). As provided at the Vet Centers, readjustment

counseling features a non-hospital community setting, a varied mix of social

(e) CWT/TR. This work-based Psychosocial Residential Rehabilitation Treatment Program

(PRRTP) offers a 24-hour therapeutic residential setting for patients involved in Compensated

Work Therapy with multiple and severe psychosocial skill deficits. It utilizes peer and

professional support, with a strong emphasis on increasing personal responsibility. It differs

from the VA-operated residential bed program described elsewhere in that participants contribute

(using their CWT earnings) to the cost of operating and maintaining their residences and are

responsible for planning, purchase and preparation of their own meals, etc.

1. Workload for CWT/TR residential services is reported by Bed Days of Care with unique

Treating Specialty Codes depending upon the subspecialty care being provided (see summary

table following subpar. 4g(3)(c)).

2. Outpatient services provided by staff not assigned to the CWT/TR programs should be

reported using the DSS identifiers appropriate to the site and intervention.

(f) Non-Specific Clinics. With the increasing use of Psychosocial Rehabilitation to address

life skill development, such as job readiness and job survival skills, budget and money

management, consumer skills, housing issues, meal planning, etc., non-specific clinics have been

established to record psychosocial rehabilitation services that may be delivered outside of

(a) The following chart is offered to help in the design and development of Psychosocial

Rehabilitation Therapeutic Work Programs. It is meant to be descriptive in nature, not

prescriptive. Individual sites should have the flexibility to develop programs that will best suit

the needs of the veterans, considering available resources.

Employment X

Independent

Living Skills

X X

Work Hardening X X

Training X X

Evaluation X X X X

Avocational

Experience

X X

(b) Experience has shown that functional level has much to do with success. The table

following illustrates common practices:

CWT Workshop X X

CWT Transitional Work X

(c) Again, the preceding information is descriptive. For instance, some facilities maintain

state of the art Therapeutic Print Plants, requiring a much higher level of functioning than would

normally be expected in such an environment.

Psychosocial Rehabilitation,

Individual

532 2315

Psychosocial Rehab, Group 559 2314

Telephone, Psychosocial

Rehabilitation

537 2780

MH Compensated Work

Therapy (CWT) Group

574 2314

MH Incentive Therapy-

Group

573 2314

MH Vocational Assistance

Group

575 2314

MH Vocational Assistance

Individual

535 2315

Telephone, Vocational Asst. 536 2780

General CWT/TR 39 1717

S/A CWT/TR 29 1715

PTSD CWT/TR 38 1716

HCMI CWT/TR 28 1714

*See Appendix D for definitions listed by DSS Identifier numbers

**CDR refers to the Cost Distribution Report used to allocate staffing costs

and Philadelphia VA Medical Centers

Networking Groups) for homeless veterans

programs

Housing) program

Health Research)

collaborative initiative for homeless veterans

Public Law 104-262, the Veterans Health Care Eligibility Reform Act of 1996,

§ 1706(b)(1) referring to the capacity legislation.

a. VHA Directive 10-94-100, "Guidance for the Implementation of Primary Care in

Veterans Health Administration," 1994.

b. VHA Directive 10-95-028, "Designation of Psychogeriatric Sections Within

Nursing Home Care Units." Veterans Health Administration, March 21, 1995.

c. VHA Directive 10-95-099, Psychiatric Residential Rehabilitation Treatment

Programs (PRRTP)(RCS 10-0889), October 11, 1995.

d. VHA Directive 96-051, "Veterans Health Administration Special Emphasis

Programs," August 14, 1996.

e. VHA Directive 97-059, "Instituting Global Assessment of Function (GAF) Scores

in Axis V for Mental Health Patients," November 25, 1997.

a. VHA Program Guide 1103.1, "Substance Abuse Treatment: Standards for A

Continuum of Care," Oct 8, 1996.

b. VHA Program Guide 1103.2, "Provision of Primary Care Services for Mental

Health Clinicians," Oct. 31, 1997.

c. VHA Program Guide 1103.22, "Integrated Psychogeriatric Patient Care," March

26, 1996.

d. VHA Program Guide 1120.1, "Telephone Liaison Care," March 25, 1997.

a. VHA Clinical Guidelines: "Clinical Guidelines for Major Depressive Disorder

(MDD)," including comorbidities of Substance Use Disorder and Post Traumatic Stress

Disorder. Jan 31, 1997, revised March 10, 1998.

b. VHA Clinical Guidelines: "Management of Persons with Psychosis." June 13,

1997.

(from VHA Program Guide 1103.3, 1998)

Levels Mental Health Programs

Level 1 Community / Outpatient

Level 2 Partial Hospitalization

Level 3 Residential Treatment

Level 4 Professional Care Setting

Level 5 Hospital Setting

(from Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition,

Chevey Chase, Maryland, 1996)

Levels Adult Admission Criteria Levels Detoxification Services

Level 0.5 Early Intervention

Level I Outpatient Services Level 1-D Ambulatory without Extended On-site Monitoring

Level II.1 Intensive Outpatient Level 2-D Ambulatory with Extended On-site Monitoring

Level II.5 Partial Hospitalization (Day Hospital)

Level III Residential Services Level 3-D Clinically-Managed Residential Detoxification

Level III.1 Clinically-Managed Low Intensity

Level III.3 Clinically-Managed Medium

Intensity

Level III.5 Clinically-Managed Medium -High

Intensity

Level III.7 Medically Monitored Intensive

Inpatient Services

Level 4-D Medically Monitored Inpatient Detoxification

Level IV Medically Managed Intensive

Inpatient Services

Level 5-D Medically Managed Intensive Inpatient

Detoxification

(from 1996 Standards Manual and Interpretive Guidelines for Behavioral Health)

Levels Mental Health Programs Levels Alcohol/Drug Programs

1 Case Management 1 Case Management

2 Crisis Management 2 Detoxification Services

3 Outpatient Treatment 3 Outpatient Treatment

4 Partial Hospitalization 4 Community Housing Services

5 Residential Treatment 5 Residential Treatment

6 Inpatient Treatment 6 Inpatient Treatment

564 Intensive Community Case Management (ICCM)

589 Non-Active Duty Sex Trauma

730 Domiciliary- General Care

731 Psychiatric Residential Rehabilitation Treatment Program (PRRTP)- General Care

527564 Telephone – ICCM

510474 Psychology (PSO) Research

(1) Definition changes have occurred in the following primary stop codes: 121; 503; 505;

506; 509; 520; 524; 531; 532; 550; 552; 553; 554; 563; 574; 580; 581.

(2) Definition changes have occurred in the following credit pairs: 510473, 516726.

501 Inactivated 10/1/94 Homeless Mentally Ill (HMI) Outreach

510475 Research. Use 510-474

574513 Compensated Work Therapy (CWT) and Substance Abuse

999510 PSO-EAP. Optional.

a. The Department of Veterans Affairs (VA) has two programs intended to provide special

support to Mental Health patients to avoid hospitalization.

prevent repeat hospitalizations due to exacerbating mental illness. If a patient has been stable on

the outside, but suddenly becomes hallucinatory and uncontrolled on current medications, that

patient may be referred to the Day Hospital. It is meant to be used to prevent hospitalization in

acute crisis or exacerbations only. Usually patients are not assigned to Mental Health Day

Hospital for more than 3-week episodes.

This is intended to be used for long-term conditions needing support to maintain care or

wellbeing on the outpatient side only.

b. In Fiscal Year (FY) 99, the hours and days for the two programs: Day Hospital and Day

Treatment were changed to match and to more realistically reflect programs 4 to 8 hours per day,

3 to 7 days per week.

(1) Purpose. The major distinction is that Day Treatment is long-term for continuing care and

community maintenance. Day Hospital clinics are prioritized for crisis treatment, transitional

care and rehabilitation.

(2) Duration. Duration of episode of treatment typically on average, do not extend beyond 3

to 4 weeks per client per acute episode in a Day Hospital Clinic, unlike Day Treatment care

which is expected to go on for months or years.

be used when providing counseling to any veteran who received this type of trauma while on

active military duty. These patients may or not, have had sexual trauma as children, or before

and/or after active duty. If any sexual trauma occurred during active military duty, this DSS

Identifier (524) should be used.

589 should be used for patients who have received sex trauma at some time, but not during active

military duty. If it occurred during active military duty, stop code 524 must be used. (see Public

Law 102-585).

509 Psychiatry MD (Individual)

512 Psychiatry Consultation

557 Psychiatry Group

502 Mental Health Clinic (Individual)

550 Mental Health Clinic (Group)

535 Mental Health Vocational Assistance (Individual)

573 Mental Health Incentive Therapy (Group)

574 Mental Health CWT (Group)

575 Mental Health Vocational Assistance (Group)

510 Psychology (Individual)

510473 Neurospsychology Lab

510474 Psychology Research

510509 Psychology - Psychiatry (PSO-PSI)

558 Psychology (Group)

529 Health Care for Homeless Veterans (HCHV)/HMI

522 Department of Housing and Urban Development (HUD)-VA Shared Housing (VASH)

523 Opioid Substitute

540 Post Traumatic Stress Disorder (PTSD) PTSD Clinical Team (PCT)-PTSD (Individual)

561 PCT-PTSD (Group)

577 Psychogeriatric Clinic (Group)

576 Psychogeriatric Clinic (Individual)

559 Psychosocial Rehabilitation (Group)

532 Psychosocial Rehabilitation (Individual)

562 PTSD (Group)

516 PTSD (Individual)

516-726 PTSD DOM Aftercare (Group)

524 Active Duty Sexual Trauma

560 Substance Abuse (Group)

513 Substance Abuse (Individual)

513461 Substance Abuse: Alcohol Dependence (Individual)

513469 Substance Abuse: Drug Dependence (Individual)

560461 Substance Abuse: Alcohol Dependence (Group)

560469 Substance Abuse: Drug Dependence (Group)

519 Substance Use Disorder-PTSD Teams

525 Women’s Stress Disorder Treatment Teams

589 Non-Active Duty Sexual Trauma

527 Telephone General Psychiatry

527564 Telephone ICCM

528 Telephone Homeless Mentally Ill

530 Telephone HUD/VASH

536 Telephone Mental Health Vocational

537 Telephone Psychosocial Rehabilitation

542 Telephone PTSD

545 Telephone Substance Abuse

545461 Telephone Substance Abuse Treatment-Alcohol Dependence

545469 Telephone Substance Abuse Treatment-Drug Dependence

546 Telephone IPCC

579 Telephone Psychogeriatrics

503 Mental Health Residential Care (Individual)

514 Substance Abuse Home Visit

520 Long Term Enhancement

521 Long Term Enhancement (Group)

552 IPCC Community Visit

564 ICCM

590 Community Outreach to Homeless Vets by Staff other than HCHV and Domiciliary

Care for Homeless Veterans (DCHV) programs

505 Day Treatment (Individual)

506 Day Hospital (Individual)

547 Intensive Substance Abuse Treatment

547461 Intensive Substance Abuse Treatment-Alcohol Dependence

547469 Intensive Substance Abuse Treatment-Drug Dependence

553 Day Treatment (Group)

554 Day Hospital (Group)

578 Psychogeriatric Day Program

527564

TELEPHONE –

ICCM

Records patient consultation or

psychiatric care, management, advice,

and/or referral provided by telephone

contact between patient or patient’s next

of kin and/or the person(s) with whom

the patient has a meaningful relationship,

and clinical, professional staff assigned

to the ICCM program. Includes

administrative and clinical services.

NOT to be used for telephone contacts

with the New England Program

Evaluation Center (NEPEC)-supported

Intensive Psychiatric Community Care

(IPCC) teams. **Provisions of 38 U.S.C.

Section 7332 requires that records which

reveal the identity, prognosis, diagnosis,

or treatment of VA patients which relate

to drug abuse, alcoholism or alcohol

abuse, infection with HIV or sickle cell

anemia, are strictly confidential and may

not be released, discussed unless there is

written consent from the individual.

HOMELESS

MENTALLY ILL

Records patient consultation or medical

care management, advice, and/or referral

provided by staff funded through the

Health Care for Homeless Veterans

(HCHV) programs (except for those

programs assigned to other specific stop

codes, such as the HUD-VASH program)

to homeless veterans with mental and or

substance abuse disorders, or to family

members of these veterans. **Provisions

of 38 U.S.C. Section 7332 requires that

records which reveal the identity,

diagnosis, prognosis, or treatment of VA

patients which relate to drug abuse,

alcoholism or alcohol abuse, infection with

HIV, or sickle cell anemia are strictly

confidential and may not be released or

discussed unless there is a written consent

from the individual.

529 2312.00 HCHV/HMI Records any visit provided by clinical staff

funded through a HCHV program (except

for the programs with specific stop codes,

such as the HUD-VASH program) to

Homeless Chronically Mentally Ill (HCMI)

veterans with mental and/or substance

abuse disorders or family members of such

veterans.

HUD-VASH

Records patient consultation or medical

care management, advice, and/or referral

provided by telephone staff of the HUDVASH

program to homeless veterans who

are being case-managed in the HUD-VASH

program, or who are being screened for

placement, and to family members of these

veterans. **Provisions of 38 U.S.C. Section

7332 requires that records which reveal the

identity, prognosis, diagnosis, or treatment

of VA patients which relate to drug abuse,

alcoholism or alcohol abuse, infection with

HIV or sickle cell anemia, are strictly

confidential and may not be released or

discussed unless there is written consent

from the individual.

531+ 2331.00 MENTAL HEALTH

PRIMARY CARE

TEAM -

INDIVIDUAL

Records individual care provided to patients

assigned to a Mental Health Primary Care

Team, characterized by a coordinated

interdisciplinary approach consisting of; (a)

intake and initial needs assessment; (b)

health promotion and disease prevention;

(c) management of acute and chronic

biopsychosocial conditions; (d) access to

other components of health care; (e)

continuity of care; and, (f) patient and non-

professional care giver education and

training. Includes clinical, ancillary and

administrative services.

532+ 2315.00 PSYCHOSOCIAL

REHABILITATION

INDIVIDUAL.

Records individual services provided to aid

veteran's successful community re-entry,

i.e., case management, advocacy,

counseling, social and living skills

development, interviews, etc. (For use by

Psychosocial Rehabilitation Programs and

other programs where more specific DSS

Identifiers do not exist).

535 2315.00 MH VOCATIONAL

ASSISTANCE -

INDIVIDUAL

Records individual patient visit for

vocational testing, assessment, guidance,

counseling, or hands-on treatment provided

by Vocational Rehabilitation (Voc Rehab)

Therapy programs for veterans with

psychosocial rehabilitation needs.

VOCATIONAL

ASSISTANCE

Records vocational services provided via

telephone for veterans with psychosocial

rehabilitation needs.

PSYCHOSOCIAL

REHABILITATION

Records services provided via telephone to

aid veterans' community re-entry, i.e., case

management, advocacy, counseling, social

and living skills development, interviews,

etc. (For use by psychosocial rehabilitation

programs where more specific DSS

Identifiers do not exist).

540 2313.00 PCT POST -

TRAUMATIC

STRESS

INDIVIDUAL

Records consultation, evaluation, and/or

follow-up provided to a patient with a

diagnosis of post traumatic stress syndrome.

Treatment is provided by a specialty

multidisciplinary PTSD Clinical Team

(PCT).

care management, advice, and/or referral

provided by telephone contact between

patient or patient's next of kin and/or the

person(s) with whom the patient has a

meaningful relationship, and clinical,

professional staff assigned to the PCT.

Includes the administrative and clinical

services. **Provisions of 38 U.S.C. Section

7332 requires that records which reveal the

identity, diagnosis, prognosis, or treatment

of VA patients which relate to drug abuse,

alcoholism or alcohol abuse, infection with

HIV, or sickle cell anemia, are strictly

confidential, and may not be released,

discussed unless there is a written consent

from the individual.

543-

Inactivated

4/1/97

2316.00 TELEPHONE/

ALCOHOL

DEPENDENCE

Records patient consultation or medical

care management, advice, and/or referral

provided by telephone contact between

patient or patient's next of kin and/or the

person(s) with whom the patient has a

meaningful relationship, and clinical,

professional staff assigned to the alcohol

dependence treatment team. Includes the

administrative and clinical services.

**Provisions of 38 U.S.C. Section 7332

requires that records which reveal the

identity, diagnosis, prognosis, or treatment

of VA patients which relate to drug abuse,

alcoholism or alcohol abuse, infection with

HIV, or sickle cell anemia, are strictly

confidential, and may not be released,

discussed unless there is a written consent

from the individual.

544-

Inactivated

4/1/97

2316.00 TELEPHONE/

DRUG

DEPENDENCE

Records patient consultation or medical

care management, advice, and/or referral

provided by telephone contact between

patient or patient's next of kin and/or the

person(s) with whom the patient has a

meaningful relationship, and clinical,

professional staff assigned to the

dependence treatment team. Includes the

administrative and clinical services.

**Provisions of 38 U.S.C. Section 7332

requires that records which reveal the

identity, diagnosis, prognosis, or treatment

of VA patients which relate to drug abuse,

alcoholism or alcohol abuse, infection with

HIV, or sickle cell anemia, are strictly

confidential, and may not be released,

discussed unless there is a written consent

from the individual.

SUBSTANCE

ABUSE

Records patient consultation or medical

care management, advice, and/or referral

provided by telephone contact between

patient or patient's next of kin and/or the

person(s) with whom the patient has a

meaningful relationship, and clinical,

professional staff assigned to the substance

abuse treatment team. Includes the

administrative and clinical services.

**Provisions of 38 U.S.C. Section 7332

requires that records which reveal the

identity, diagnosis, prognosis, or treatment

of VA patients which relate to drug abuse,

alcoholism or alcohol abuse, infection with

HIV, or sickle cell anemia, are strictly

confidential, and may not be released,

discussed unless there is a written consent

from the individual.

SUBSTANCE

ABUSE

TREATMENT -

ALCOHOL

DEPENDENCE

Use for Alcohol Dependence Treatment

Phone Calls. Using the full definition for

545.

545-

2780.00 TELEPHONE

SUBSTANCE

ABUSE

TREATMENT -

DRUG

DEPENDENCE

Use for Drug Dependence Treatment Phone

Calls. Using the full definition for 545.

care, management, advice, and/or referral

provided by telephone contact between

patient or patient's next of kin and/or the

person(s) with whom the patient has a

meaningful relationship, and clinical,

professional staff assigned to the special

psychiatry service. Includes administrative

and clinical services. **Provisions of 38

U.S.C. Section 7332 requires that records

which reveal the identity, prognosis,

diagnosis, or treatment of VA patients

which relate to drug abuse, alcoholism or

alcohol abuse, infection with HIV, or sickle

cell anemia, are strictly confidential and

may not be released or discussed unless

there is written consent from the individual.

547 2316.00 INTENSIVE

SUBSTANCE

ABUSE

TREATMENT

Records visits for intensive substance abuse

services provided by substance abuse

treatment program staff. Treatment

program is usually an interdisciplinary

outpatient program designed for substance

abuse clients based upon day hospital, day

treatment, psychosocial rehabilitation

models (may include outpatient

detoxification). Patients generally are

expected to participate in a program of 3 or

more hours per day, 3 days a week at a

minimum.