In light of recent news here in CO (and across the US) that wait times at the VA are still egregiously long or are being manipulated to a point where veterans cannot utilize the Veterans Choice Act and seek covered care outside the VA medical system, I wanted to re-voice my concern over this issue because it was one I was thinking about at this very time a year ago.
See, I was in Washington DC, interviewing with Congressman Tim Walz of MN to be his Senior Legislative Assistant of Veteran Affairs…and as part of the process, his Senior Legislative Director asked me to draft a solution to long VA wait times as if it were something about which I would brief the congressman. The Phoenix VA scandal had recently broken, and was still fresh on the minds of those working in the vet health space as Congressman Waltz does.
Long story short, I wrote the brief, and got the job offer (holy buckets of awesome!), but did not end up accepting the position. That was November/December 2015. My passion for this work certainly has not waned, though. So this fall, November 2016, Dr. Kate Hendricks Thomas, college professor and fellow USMC veteran, and I teamed up to address this serious issue in a bit more detail.
We asked: how do we fix those long wait times??? We answered: by providing trauma-informed care for veterans. This may not seem like the swiftest, most obvious answer to the problem, but I argue that it’s the most sustainable. If we could train physicians and staff to think more like social workers, care would be more effective, efficient, and appropriate.
As Kate and I say in our article titled “Trauma Informed Care for Veterans,” as published by online resource, Social Work Helper, an increase in trauma-informed care leads to more efficient and effective response at every level of patient care, and thus, a reduction of wait times at VA Hospitals.
We open with a vignette…Rebecca served nine years as a Marine Officer, and had relied upon the Veterans Administration Medical Center (VAMC) for her health care since departing active duty. She was a devoted runner trying to get back in shape, but a few months into this well-intentioned effort she found herself calling the VAMC appointment line. Her Achilles tendon was swollen and painful, and she found herself limping through busy days. The first call to the appointment line resulted in a referral, a message taken, and the promise of a call back. The nurse who called back wasn’t authorized to book anything beyond 24-hours out, and the promise of a return call was again offered. A week later, the phone had not rung, and Rebecca was still limping along without an appointment.
Military veterans consistently report access problems with Veterans Affairs (VA) hospitals and outpatient clinics. Patients in Phoenix reportedly died while waiting for slow cancer care. The issue is an administrative and ethical conundrum; veteran satisfaction rates and overall patient wait times must be improved.
The solution is not entirely structural, though more infrastructure and staff would directly reduce wait times because more providers are available. The answer to date has been the bandage of increased oversight – stipulating tighter regulation and monitoring of recorded wait times. The intention of such accountability measures is consistently undermined by employees incentivized to modify the numbers, and it is a rare whistle-blower willing to call attention to the statistical maneuvering.
If adding more directives to reduce wait times has been met with maintenance of the defunct status quo, how can we improve accountability while working within the current system reality?
The answer involves expanding the standard of care and embracing holistic wellness. First and foremost, we need to make the process of receiving care easier, more effective, and more efficient, and one of the best and most empirically validated ways to do so is to offer trauma-informed care. Trauma-informed means knowing the history of past and current abuse or trauma in the life of the consumer with whom one is working and to understand the role that violence and victimization play in the lives of most consumers of mental health and substance abuse services, thereby utilizing that understanding to design service systems that accommodate the vulnerabilities of trauma survivors and allow services to be delivered in a way that will facilitate consumer participation in treatment. With trauma at the center of understanding, all parties – clients, providers, clinicians, and programs – will benefit.
We must begin providing trauma-informed care at all levels of care, from point A to point Z in the care cycle for our veterans, working with existing VA employees, staff, and providers. Our veterans are coming from a place of trauma, be that trauma combat or simple transition.
VA hospitals are not public hospitals. Therefore, trauma-informed care must be a requirement for any person in the VA.
Research has convincingly shown that it is not just mental health care providers who need a trauma-informed approach, and sadly even many of those providers do not have this background. For instance, psychiatrists are not taught to account for cultural, environmental, economic, gender, or trauma history differences among clients. Social workers, for example, are exclusively trained and educated from this perspective of the prevalence of trauma and the impact of environmental factors.
How does this impact wait times? Education of the entire staff is required, not just the person the veteran encounters after the 5th stage of waiting (multiple phone calls, an employee they encounter in the parking lot, the volunteer at the front desk, employees inside the building, the receptionist at the clinic office) because all of those stages of interaction impact how care is sought, followed up with or not, or perceived by the patient. Part of wait time computation involves the actual time but some of it is the perception of time – sometimes a 2 hour wait can feel worse than a week long wait; it depends on how the person who is addressing you talks to you. Veteran perceptions are important and impact how they feel about care received.
- Improving the staff’s trauma-informed perspective improves wait times by improving and tailoring the environment. Frankly, this trauma-informed paradigm can be used as an incentive to the care provider because the whole process becomes more humane to them. As they are trauma-informed they address people differently.
- Trauma-informed personnel are more likely to address issues more effectively and efficiently. As empathy and understanding increase, so does efficiency because veterans come in to be treated, feel safe doing so, are being treated one time, versus becoming overwhelmed and leaving, necessitating another visit. For instance, if a veteran enters the hospital and is yelled at by the person behind the desk, or harassed by a janitor, he or she very well may turn around and leave. The veteran will then have to call in again, make another appointment, likely be perceived as disrupting the system and be chastised for not showing up for their appointment. The whole process not only may be re-traumatizing, but will add to the backlog of appointments.
- Trauma-informed care creates safer environments. Feelings of safety are fundamental to effective health care, especially effective mental health care. Thus, veterans are more likely to feel comfortable coming in for proactive and preventative care versus waiting until they find themselves in a most extreme case which then often requires more resources for a longer amount of time, resulting in more pressure on the system again.
- Trauma-informed care creates better-informed clients. Veteran patient clients, when treated with the respect a trauma-informed model demands, are well-informed at every stage of care, from administrative matters to the care itself. Lack of information leads to confusion and threatens the basic need for feelings of safety. Waiting for return phone calls that never come, or waiting in a waiting room for hours on end well after their scheduled appointment time, are re-traumatizing (and common) occurrences for veterans seeking care at VA hospitals. Trauma-informed care standards would mandate that appointment times be honored, that waiting room facilities are safe and comfortable, and that a patient is communicated to regularly and with respect about the process required to receive care.
Every single employee at a VA hospital needs some trauma-informed education and training, not just psychiatrists. Through a trauma-informed lens, any staff member can see issues more clearly and solve problems where they occur. This would mean, for instance, having a person at the entrance of the VA Hospital who is calm, clear and helpful; not an untrained, random volunteer. Having staff members who are trained in harm reduction and de-escalation techniques is also critical to trauma-informed training, education, and care provision. To shift culture, you cannot just train the leaders. All employees at the VA should receive at least a basic level of training of trauma-informed care. This absolutely also includes care providers.
We do not need more regulations and stipulations on time-frames, which are already in place and already not being followed. Veterans and the families who support them are calling for a true cultural shift in care, one that can be achieved with training and standard of care expansion.
*Note: This article was jointly authored. Sarah Plummer Taylor, MSW is an established leader in the field of resilience building, holistic wellness, and leadership training. Learn more at SEMPER Sarah®. Kate Hendricks Thomas, PhD is an Assistant Professor of Public Health at Charleston Southern University.