Practical Geriatrics: Mental Health Services for Older Veterans in the VA System

In addition to addressing significant demographic changes, VA mental health services have found themselves caring for growing numbers of challenging older veterans who cannot be effectively managed in traditional medical or psychiatric settings. These patients typically suffer from a combination of chronic medical and mental disorders. Additionally, they are often homeless and have already exhausted community resources for various reasons such as substance abuse, problematic behavior, and aggression.

These veterans also require a broad array of services. Although such services are often available, they tend to be fragmented throughout the system. In contrast with mental health services, the VA geriatrics and extended care program has responded to changing demographics by focusing on increasing geriatric services through the establishment of hospital-based home care teams, palliative care hospice units, adult health care programs, geriatric evaluation and management programs, and geriatric research, education, and clinical centers (8). A survey of all VA medical centers in 1992 revealed 87 VA medical centers reporting 192 psychogeriatric programs, including 19 outreach and consultation teams, 41 clinics, 18 home health and day care teams, 40 brief and 43 long-term inpatient programs, and 11 substance abuse programs for older veterans (9).

The following are brief descriptions of clinical programs relevant to mental health services for older persons in the VA system (5). Note that each VA medical center uses a different format and different definitions for its clinical programs.

Since the mid-1990s, the VA has undergone a dramatic transformation during which it has added important new programs to those described and has moved to integrate all of its programs into one system of care. This move can be seen at various organizational levels and in various local and national initiatives. One of the key issues in VA mental health services for older veterans has been how to integrate primary care, geriatrics, and mental health.

The VA has responded to the diverse needs of the veteran population. Since the establishment of the Center for Women Veterans, the VA has established eight comprehensive women veterans' health centers, a national counseling program for victims of sexual trauma, and many other programs specific to women veterans, ranging from mammography to treatment of posttraumatic stress disorder. All VA health care facilities have a women veterans' coordinator to help women veterans of all ages to access VA health care.

The VA is also addressing the growing challenges of the homeless veteran population. Since the first round of homeless provider grants and per diem funding in 1994, a total of 127 grants have been awarded to 101 public or private nonprofit groups in 39 states and the District of Columbia. When all projects are completed, some 2,700 new community-based beds will be available for homeless veterans. In 1998 nearly 3,600 homeless veterans completed specialized programs in VA domiciliary facilities. The Domiciliary Care for Homeless Veterans program provides health care, psychosocial rehabilitation, and residential treatment to homeless veterans who are medically and psychiatrically ill. The program is currently available at 35 VA medical centers across the country and provides more than 1,600 beds. While receiving services through this program, older veterans are encouraged to become involved with programs in the community, such as senior centers and foster grandparent programs.

The Committee on Care of Severely Chronically Mentally Ill veterans was established in 1996 to monitor the care of veterans in the VA system who are seriously medically and mentally ill. In 1998 the committee submitted its second annual report, which addressed the issues of capacity, compliance with treatment, community-based outpatient clinics, intensive community case management, use of new antipsychotic medications, the transition from inpatient to community-based care, services for posttraumatic stress disorder, and the mental health of women veterans.

The committee also assessed the VA's support of mental health research and recommended a greater investment in such research as well as the funding of additional Mental Illness Research, Education, and Clinical Centers (7,10). More recently, on the basis of the Veterans Millennium Health Care and Benefits Act, the geriatrics and extended care strategic health care group developed specific recommendations that will affect the current provision of health care to older persons in the VA system.

Traditionally, much of the impetus for developing psychogeriatric programs has come from individual medical centers. Given the increasing number of older veterans and the fact that resources are limited, most VA medical centers mightily attempt to serve this patient population according to Veterans Health Administration guidelines. This effort requires innovative ideas and full support from the administrative offices of medical centers. Two of the authors (K.Y.K. and E.J.) are affiliated with the VA medical center in Salem, Virginia.

The Salem VA medical center has a fellowship-trained geriatric psychiatrist who runs two 29-bed sustained-treatment and rehabilitation units as well as the memory disorders clinic. One ward treats mainly older patients with major psychiatric disorders. Some of the patients on this unit are less than 65 years old, but they suffer from various major psychiatric disorders, such as schizophrenia and bipolar disorder. The other ward treats older veterans who have various dementias with psychiatric symptoms. Three beds on this ward are designated for respite care to support patients in the community. These patients are referred primarily from the memory disorders clinic.

A built-in grief support group is an integral part of this program. The two wards receive patients on referral from the acute psychiatry unit, the medical and surgical units, and the extended care rehabilitation center. When the patients are stabilized, they are placed in the less restrictive facilities in the community.

The center has a primary care psychiatry consultation and liaison team, which is run by a psychiatrist with extensive experience in psychogeriatrics. This team is actively involved in a variety of psychiatric issues in the primary care clinics, the medical and surgical units, and the extended care rehabilitation center. The team refers its patients to the mental health clinic, the memory disorders clinic, inpatient psychiatric programs, or the day treatment center as needed.

Outreach programs are available for patients in the community via the mental health clinic and the community residential care program. The mental health clinic operates the primary psychiatric care clinic that cares for medically and psychiatrically ill outpatients who have no primary care physician. Many of these individuals are psychogeriatric patients.

The complex medical and psychiatric needs of elderly veterans are also served by other components of the existing programs at the Salem VA medical center. We believe that the interaction and integration of these multiple elements of the continuum of care in the VA medical center will serve the psychogeriatric needs of our veteran population.

The increasing number of older veterans has posed substantial challenges for the VA system. However, the Veterans Health Administration has effectively responded to these challenges by actively advocating various specialized clinical settings, training programs, and research centers. Although it addresses general mental health concerns with veterans, it also focuses on more VA-specific issues, such as homelessness, addiction, and posttraumatic stress disorder. Because there is no VA funding category specific to geriatric mental health, the mental health needs of older veterans are addressed through existing mental health, medical, and extended care programs. Future consideration of specific funding for geriatric mental health may further enhance the advancement of mental health care for older persons in the VA system.

The authors thank Susan Cooley, Ph.D., and William Van Stone, M.D., for their valuable advice in the preparation of this paper.

Dr. Kim and Dr. Jones are assistant professors in clinical psychiatric medicine at the School of Medicine of the University of Virginia and Salem Veterans Affairs Medical Center. Dr. Goldstein, who is editor of this column, is associate professor of psychiatry and director of the division of geriatric psychiatry at the School of Medicine and Behavioral Sciences of the State University of New York at Buffalo. Send correspondence to Dr. Kim at Psychiatry Service, VA Medical Center, Salem, Virginia 24153 (e-mail, [email protected]).