VA/Vet Center Program Quality Care Being Compromised
Background & Issues
The VA/VET Center Program, which is officially referred to as the Readjustment Counseling Service (RCS); has dedicated, well-qualified and outstanding counselors who perform great clinical work that has a significant positive outcome in the lives of veterans. So, veterans and their families are encouraged to continue receiving services since treatment is effective.
However, the program is being jeopardized because of excessive clinical visit count and production mandates that have adversely impacted the health and well-being of counselors, which has degraded their ability to provide quality care to veterans and their families.
This started when the VET Center Program established minimum productivity requirements for counselors in March 2016 that required them to have 30 clinical visits per week. Under the old policy, clinicians were required to have 50% direct service time with veterans which equated to 20 hours of contact out of a 40-hour work week. Considering the industry standard that a visit is for 50–60 minutes in duration, this would mean counselors have to achieve 20 visits in a week to accomplish this under the old system. Consequently, the new mandate expects clinicians to increase their productivity by 50% through having 30 visits/30 hours of direct service time versus 20 visits/20 hours of direct service time in a 40-hour work week.
Plus, these performance mandates do not account for more time that is needed with complex cases, crisis intervention, and family & couples sessions. They also do not allow enough time to conduct trauma treatment with combat veterans who suffer from PTSD, which sometimes requires more than 60 minutes per session to do this properly with some evidenced-based interventions.
Over the next year into 2017, VA/VET Center Program counselors were burning out because of these excessive clinical performance standards. This was addressed to management by numerous VET Centers through the chain of command, to include how these productivity mandates were negatively impacting the health and well-being of clinicians and degrading their ability to provide quality care to veterans. The adverse effect on counselors was compounded by a low performance directive in July 2017 which basically threatened that clinicians would ultimately be held accountable through HRMS-Labor Relations action if they did not achieve these quantitative production metrics. As a result, this created an ethical dilemma since many counselors feel pressured having to choose between providing adequate care and producing the numbers that the VA/VET Center Program demands due to fear of negative consequences or losing their jobs if they do not meet these clinical visit performance expectations.
In September 2017, at a VET Center staff meeting in Warwick, RI during a clinical site visit, these concerns about the unreasonable performance expectations and its impact were unanimously expressed to the VA/RCS District 1 Deputy Director (Dale Willis). Counselors present at this meeting witnessed Mr. Willis acknowledge that these same issues were consistently conveyed to him by other VET Centers he had visited.
When VA/RCS management failed to address these problems after it had been brought to their attention multiple times through the normal chain of command, Ted Blickwedel, who was a counselor at the Warwick, RI VET Center and a retired Marine and combat veteran; sent an email on January 18 & 25, 2018 to the RCS Chief Officer (Mike Fisher), all RCS District Directors, all VET Center Directors, and all RCS Counselors throughout the RCS system regarding the negative impact that clinical productivity mandates were having on the health and well-being of counselors, and how this was adversely affecting their ability to provide quality therapeutic services to veterans. Additionally, this email link included Mr. Fisher’s response on January 26, 2018 that these performance standards (i.e. clinical visit counts) were justified; without addressing the underlying issue about the harmful effect it was having on counselor welfare, and how this was negatively impacting their capacity to deliver quality care to veterans.
From January 25 to January 27, 2018; Mr. Blickwedel received email responses from 57 different counselors from 42 VET Centers across 25 states who all stated that they and other clinicians at their centers have been adversely affected by the clinical performance mandates, which has degraded their ability to provide quality services to veterans (i.e. excessive stress, burnout, poor morale, health issues, depression, having to go on a medication protocol and/or seeing a therapist, time out of work, retiring early, looking for another job, etc.). In separate phone conversations Mr. Blickwedel had with each of these counselors; most of them said they were afraid to speak up because of retaliation they would experience, to include the possibility of losing their job. Exact quotes in those email replies from 33 of these clinicians in 20 different states have been anonymously presented which collaborate the harmful impact these excessive productivity metrics are having on counselor welfare and quality care for veterans. The original emails have been safeguarded to protect the identity of these clinicians, and to prove the authenticity of these quotes in situations where it is necessary.
Due to the inadequate response of Mr. Fisher to resolve these issues, Mr. Blickwedel sent a 5-point Likert Scale survey with 11 questions to all RCS counselors across the country via email on January 27, 2018; in order to assess the degree to which these concerns were affecting the health and well-being of clinicians and their capacity to provide quality services to veterans. Only 27 completed surveys were received since VA/RCS management terminated Mr. Blickwedel’s computer account, claiming that he did not follow the chain of command. However, he did not violate the chain of command since this communication regarding the survey was between him and his peers only about work-related matters, which did not involve management.
Even though 27 survey responses is not a large enough sample to establish statistical significance in an organization that has over 1,300 counselors, it still has some merit since the results of the survey were consistent with comments made by clinicians via email and phone conversations who were unable to return the survey to Mr. Blickwedel because of his computer access being shut off. So, there is an obvious trend that could not be fully exposed due to VA/RCS management disabling Mr. Blickwedel’s computer account and discouraging counselors from submitting the survey.
The survey revealed that the vast majority of counselors who were able to respond to the questionnaire have been negatively affected by the clinical productivity standard in the following ways:
- Adversely impacted their health, welfare, and morale.
- Degraded their ability to provide quality care to veterans.
- Caused them to seek therapy or start a medication protocol.
- To retire early or seek other employment.
Additionally, in response to the survey VA/VET Center clinicians further feel that:
- The RCS leadership does not care about them or their well-being.
- Only managers and directors with a clinical background should make policy decisions pertaining to clinical roles and functions.
- The current productivity standard for the number of clinical visits required needs to be reduced to a reasonable level.
The productivity mandates of the VA/VET Center Program exceed what research shows to be harmful to both counselors and quality of care. A nation-wide study was conducted by Southern Connecticut State University between 1996 and 2003 (led by Carina Vocisano, associate professor of psychology) where it was determined that counselors tend to get better results than those with a heavy caseload. Specifically, it was found that there was a significant drop off in treatment effectiveness when a therapist had a caseload of 25 clients or more per week. There is other research which also substantiates that seeing too many clients per week is predictive of higher counselor burnout rates and has an adverse impact on quality care (Hancock, Allen, Bosco, McDaniel, and Pierce, 2011 — Journal of Management, March 2013, Vol. 39/№3, 573–603; Knapp, Smith, and Sprinkle, 2017 — Nonprofit and Voluntary Sector Quarterly, 2017, Vol. 46/№3, 652–671; Wright and Bonett, 2007 — Journal of Management, April 2007, Vol. 33/№2, 141–160; and Ballenger-Browning, Schmitz, Rothacker, Hammer, Webb-Murphy, and Johnson, 2011 — Military Medicine, March2011, Vol. 176/№3, 253–260).
Further, these clinical production expectations are not in compliance with the 2016 edition of the NASW Standards for Social Work Practice in Health Care Settings. Standard 11, under the “Workload Sustainability” section (pages 37–38), outlines the factors that affect caseload size and workload manageability based on the literature. It stresses that social workers, managers, and organizations practicing in health care settings shall responsibly advocate for workloads and scope of work that permit efficient and high-quality social work services delivery; and that they have a joint responsibility for establishing and maintaining a workload that allows for adequate and appropriate interventions and monitoring of services and outcomes. However, the excessive clinical performance standards being forced on counselors by VA/VET Center Program managers and their refusal to address this issue and its consequences does not allow this to occur, which makes what VA/RCS management is doing an unethical practice. This is also supported by the National Association of Social Workers (NASW) and the Case Management Society of America who collaborated and did a literature review highlighting the wide variation in staffing ratios for case management across settings. It was revealed that a client/counselor caseload ratio should be between 50:1 and 40:1 in community mental health (Hromco, Moore, & Nikkel, 2003). Yet, many VET Center Counselors have caseloads that significantly exceed this ratio, which has caused them to see more than 25 veterans per week.
Equally appalling and scandalous, is the refusal of VA/RCS management to implement the recommendations of a Clinical Capacity Report which was compiled in early 2015 by an RCS Working Group which identified shortfalls in the VET Center Program, to include excessive clinical productivity standards that they recognized would cause counselor burnout and adversely impact quality of care for veterans. One of the participants in this working group informed Mr. Blickwedel and NBC News that none of their suggestions were incorporated into VA/RCS policy or guidelines, to the detriment of the VET Center Program. Several VET Center counselors who spoke with Mr. Blickwedel afterwards told him that the problems with productivity metrics have become even worse, since clinicians have been given additional administrative duties while being expected to achieve the same performance mandates.
Due to the unwillingness of VA/VET Center Program management to resolve the counselor burnout and quality care issues, driven by the unreasonable visit count and quantitative performance expectations, Mr. Blickwedel decided to retire 3 years earlier than he had intended. On February 1, 2018 he went on extended leave prior to his official 04/28/2018 retirement date. Before his departure, Mr. Blickwedel was prevented from having closure with colleagues by his VET Center Director, Rochelle Fortin, who interrupted and harassed him when he and his peers attempted to do so at his last staff meeting on January 31, 2018.
During the month of February 2018, Mr. Blickwedel was refused a meeting he requested multiple times with his VET Center Director and the VA/RCS District 1 Deputy Director, Dale Willis. The purpose of this encounter was to reconcile having proper closure with VET Center Staff; and to resolve the retaliation Mr. Blickwedel was experiencing by his Director and VA/RCS management, especially since his VET Center Director insinuated false notions about him at a staff meeting on February 7, 2018 to give the appearance that he was some kind of threat. Further, Mr. Blickwedel was told by the VA/RCS District 1 Deputy Director that he was not permitted to come to the VET Center, without citing specific reasons or clear rationale for this action. This was upsetting to some counselors who witnessed all this because of knowing Mr. Blickwedel never said or did anything to warrant this kind of treatment. They felt this was being done to Mr. Blickwedel to isolate/distance him from VET Center employees and prevent him from having a voice, due to his addressing the declining clinician welfare and quality care issues that VA/RCS management did not want to be accountable to rectify. Also, they believe that management unjustly treated him in this manner in order to perpetuate fear of reprisals among VET Center Counselors if they expressed their concerns about these matters.
In March 2018, Mr. Blickwedel filed a grievance with the VA Office of Inspector General (OIG) since the Readjustment Counseling Service (RCS) through the VET Center Program has been engaged in unfair and unethical practices by enforcing excessive clinical performance standards which has adversely impacted the health and well-being of counselors and degraded their ability to provide quality care to veterans and their families. This was preceded by a formal complaint he submitted in February 2018 to the Office of Special Counsel (OSC) because of the discriminatory, hostile, and harassing retaliation he received from VA/RCS management.
Since June 2018, Mr. Blickwedel has been affiliated with Whistleblowers of America (WoA) which is a non-profit organization devoted to providing peer-to-peer mentor support for those who are in the process of reporting unethical conduct of their federal employers, so they can understand retaliation tactics that are used against them and develop strategies to help them effectively manage this course of action. Jackie Garrick, who is the founder of WoA, is also actively involved with members of Congress in Washington, DC to promote legislation that will enhance whistleblower support and protection. Her website, www.whistleblowersofamerica.org, provides more details on this and other useful information (e.g. Resources, News and Press Releases, & Testimonials).
Mr. Blickwedel also has a blog that was posted by WoA on their website which describes the issues he addressed regarding the excessive clinical performance standards of the VA/VET Center Program, to include his experience with retaliation he encountered by VA/RCS management. The blog further explains what can be done to raise awareness and promote action in order to resolve these concerns. Readers can access the blog and post comments at the following link: https://whistleblowersofamerica.org/2018/12/12/vet-center-quality-care-and-counselor-welfare-issues/
Political Action & Media Coverage
In August 2018, as a result of Mr. Blickwedel’s meeting with Senator Reed’s Staff and documents that he provided to them; Senator Reed (D-RI) who is the Ranking Member of the Senate Armed Forces Committee and Senator Tester (D-MT) who is the Ranking Member of the Senate Veterans Affairs Committee both consigned a letter formally requesting the Government Accountability Office (GAO) to conduct an investigation into the counselor burnout and compromised quality care allegations within the VA/VET Center Program.
Mr. Blickwedel also spoke with Congressmen Cicilline (D-RI) and Takano (D-CA) who is the Chairman of the House Veterans Affairs Committee about these issues on July 14, 2019 at an annual Veterans Community Conversation event that was hosted by Congressman Cicilline in Pawtucket, RI. Subsequently, Mr. Blickwedel’s statement for the record was submitted to the House Subcommittee on Oversight & Investigations for Veterans Affairs via Jackie Garrick prior to her testimony at a hearing before the committee on July 23, 2019.
On November 13, 2019 Mr. Blickwedel met with one of Congressman Cicilline’s Staff to provide him with the same documentation that was given to Senator Reed’s Staff regarding the neglect of VA/RCS management to address the unethical clinical performance standards they have imposed on counselors which has negatively impacted their health and well-being and degraded their ability to provide quality services to veterans. Later this same month, Congressman Cicilline’s Office informed Mr. Blickwedel that the documents supporting these claims were received by the House Committee on Veterans Affairs in Washington, DC.
Additionally, Mr. Blickwedel has been interviewed by numerous national, state, and local media organizations about the excessive clinical production mandates of the VA/VET Center Program and how this has caused counselor burnout and threatens quality care (e.g. NBC News, Military Times, NPR, RI PEG Access TV, and WPRI TV in Providence, RI). These broadcasts and associated web articles can be viewed at the links below.
NBC
Military Times
NPR
https://www.npr.org/2018/05/09/609653871/veterans-counselors-feeling-overworked?live=1
WPRI TV Channel 12, Providence, RI
https://www.wpri.com/news/combat-veteran-counselor-files-complaint-over-quota/
https://www.wpri.com/target-12/feds-investigate-combat-vet-counselor-quota-claim/
https://www.wpri.com/military/ri-whistleblower-prompts-congress-to-consider-more-oversight-of-va/
RI Cable PEG TV
https://www.youtube.com/PEG TV/VA-VET Center Program Quality Care Being Compromised
https://drive.google.com/file/d/1Z3m-k_NH0AFH7QkSP7XESCbVg1CrIUT0/view
Government Accountability Office (GAO) Report
From about November 2019 to around August 2020, the Government Accountability Office (GAO) investigated the claims being made regarding the adverse impact that productivity expectations are having on quality care & counselor welfare within the VA VET Center Program. They released their report on September 23, 2020 which substantiates these claims and other concerns (https://www.gao.gov/products/GAO-20-652). They also made recommendations for corrective action. A Summary of the GAO Report provides a condensed and thorough version of their findings.
Congressional Legislation
As a result of the findings in the GAO Investigation Report, Congressional Legislation entitled the “VET CENTER IMPROVEMENT ACT OF 2021” was introduced to the House and Senate Committees on Veterans Affairs at the end of May 2021 (H.R. 3575 & S. 1944). This legislation mandates the VA to annually evaluate the impact of clinical productivity expectations on quality of care and counselor welfare in the VET Center Program, and to make any necessary adjustments in these metrics to ensure quality care and counselor welfare is not compromised. This is to be based on Congressional and GAO oversight, as well as the recommendations of an internal working group consisting of counselors and VET Center Directors that the VA is directed to establish for this purpose. They will rely on feedback from clinicians in the field that is anonymously, safely, and securely collected and stored in an electronic database that cannot be altered by any parties.
Conclusion & Recommended Action
The consequence of the VET Center Program’s unreasonable clinical production metrics and excessive administrative workload policies that has been forced on counselors, combined with a shortage of clinicians, high caseloads, and increased counselor turnover rates; prevent veterans from getting adequate services they deserve, and especially puts suicidal veterans at higher risk. This is further harmful to the health, welfare, and morale of clinicians who take care of our veterans.
Therefore, it is imperative that clinical performance standards and other administrative requirements be continually monitored through GAO and Congressional oversight, in accordance with the GAO recommendations in their report (https://www.gao.gov/products/GAO-20-652), so adjustments can be made when necessary to ensure quality care and counselor welfare is not compromised. Otherwise, the health and well-being of clinical staff will continue to suffer which will hurt their ability to deliver quality care, and this will result in veterans and their families not receiving sufficient quality services they deserve. This will also allow less emphasis on achieving excessive quantitative production numbers which only serves the bureaucratic system instead of the veterans we are here to help. The VA/VET Center Program management must be held accountable for this and for retaliation against employees who speak up to address these issues.
Subsequently, your assistance is urgently requested to support this important ongoing effort by doing the following:
- Contact your U.S. Senators and Congresspersons by going to their website or sending them a letter via email or regular U.S. mail strongly encouraging them to take the following corrective action in order to resolve these issues:
- Vote for and Enforce the “VET CENTER IMPROVEMENT ACT OF 2021” (H.R. 3575 & S. 1944).
- Maintain the Clinical Visit Count and Performance Standards at a Reasonable and Ethically Compliant Level in the VA/VET Center Program with a Greater Emphasis on Quality Care and Counselor Well-Being.
- Approving/Allocating Adequate Funding to Hire Enough Clinicians to Meet the Demand for Services and Reduce Excessive Caseloads.
- Passing Tough Legislation to Protect and Support Whistleblowers, with Severe Consequences for those who retaliate against them.
2. Notify as many people as you can via email and social media to bring attention to these concerns, urging them to help with this effort.
3. Reach out to Veteran Service Organizations (VSOs) asking them to support this campaign through their local, state, and national chapters (i.e. DAV, VFW, VVA, AMVETS, MOAA, NVOA, Marine Corps League, American Legion, MOFW, etc.).
4. Post your remarks on this Facebook page and other social media platforms so these issues get maximum exposure and recognition.
