Interview transcript:

 

Terry Gerton Your office has recently published the results of your audit on the homeless screening clinical reminder process in the Veterans Health Administration. Let’s start by having you explain what that process is and how it’s supposed to work, and what difference it makes for veterans who are perhaps experiencing housing instability.

Steve Bracci First, I do want to acknowledge that VA has prioritized ending veteran homelessness. There are several programs to help veterans who are homeless or at risk of becoming homeless. The homeless screening clinical reminder process really is an outreach effort. During health care visits, the screening tool, which is a series of questions, is used as a proactive way for VA to identify and help veterans who are either homeless or concerned about their housing stability. And this is really important because veterans may be unaware of the programs and assistance VA has to offer, or they might be reluctant to ask for help. So the screening tool prompts clinical staff to ask veterans if they have any housing concerns that they want help with. This then allows the clinician to make a referral to a social worker who can then connect with the veteran to discuss options and provide them with the assistance they need. This is, again, really important because it can have a major impact on veterans’ housing stability and their overall health and wellbeing.

Terry Gerton And VHA has established a target timeframe for that follow-up, right? Will you walk us through that?

Steve Bracci When a veteran says they want help, they are supposed to acknowledge that and act on it within seven days, but the goal is to actually resolve and have a conversation with the veteran within 30 days. But of course they recognize that it’s important to do it as quickly as possible.

Terry Gerton And so I guess the big finding, as you did your audit, was that in cases where the medical centers used both VistA and the Oracle Health System, almost 61% of veterans didn’t receive appropriate follow-up. What exactly is going wrong there?

Steve Bracci First, I want to clarify the 61%. That only refers to the veterans we were able to review at the VistA sites. The issues we saw at the Oracle sites were more focused on the lack of reliable data, which prevented our team and actually prevents VA from being able to view veterans’ cases and make sure that they’re being followed up on. So the 61% does refer to the VistA site. I just wanted to make that clear. But to answer your question about what went wrong, there were two key breakdowns that we saw in the process. First, the staff that screened the veterans, the clinicians, did not always refer veterans to social workers. Facilities have different ways of doing this and the processes varied across the sites we reviewed. For example, some facilities do a formal referral through the electronic health record using the consult process, while others use more informal methods, like sending an instant message to social workers. That’s an example. But we did find instances where these referrals just weren’t made. And as a result, no one reached out to the veterans to provide them with the assistance they needed. So that was the first part. The second part is the staff who received the referrals didn’t always follow their local procedures for conducting outreach with respect to how they tried to reach the veterans or how many attempts they made to reach the veterans. The intent of a follow-up is for social workers to have an actual interaction with the veteran and to have a conversation, identify their needs, and then they can provide the appropriate intervention. But we found instances where there was no interaction at all and it was just a letter was sent, or an email. So there was no way to ensure that the veterans’ needs were actually being met.

Terry Gerton Homeless veterans can be amongst some of the toughest folks to actually contact. They may not have a reliable mailing address. They may have a predictable phone number. What are the contact mechanisms that the referral team is supposed to use to reach them?

Steve Bracci Whatever method possible. They try to reach them using a telephone number. They try email. They try text messages. I think that’s not something we really touched on too much in our report, but it does show the importance of trying multiple times to reach a veteran before closing out that referral.

Terry Gerton I’m speaking with Steve Bracci. He is a deputy assistant inspector general for the Office of Audits and Evaluations at the Department of Veterans Affairs. So you mentioned the 61% with VistA cases, but you also said with the Oracle Health System, they have unreliable data. I’m interested — it seems like two different IT systems, but I’m presuming they have sort of the same SOPs across the network, regardless of what IT system they’re using. What makes the difference in terms of reliable follow-up reports, or root causes?

Steve Bracci I think it’s just a matter of how reliable that follow-up report is. We found with the VistA sites that the report was accurate as far as identifying the actual veterans who screened positive and wanted help. It was the actual follow-up part of that that was missing, whether or not the veteran had actually been reached and whether or not the follow-up had been completed. So that was the piece that was missing with the VistA sites. With the Oracle sites, we just found that it wasn’t accurate at all. The actual report was somewhat unusable with identifying whether or not veterans had actually screened positive and then any sort of follow-up had been done. So, that was a distinction there.

Terry Gerton So you’ve got really two fundamentally different, systemic problems. Talk us through your recommendations. How do you want VA to tackle this issue?

Steve Bracci That’s a challenge for VA is when you have two systems — anytime you have IT systems and there need to be updates, that is a challenge. I think it’s just a matter of doing what they need to do to make sure that the systems are accurately capturing the data and reporting the veterans who need help so that that follow-up can be taken.

Terry Gerton How did VA respond to these recommendations, and who’s responsible for fixing the problem?

Steve Bracci I do want to acknowledge that VA concurred with our recommendations and they developed a responsive action plan for each one. So that’s important. Carrying out the action plans will require significant effort because not only are we dealing with two different systems, but we’re dealing with many VA medical facilities and each facility can do things a little bit differently. So identifying what works and taking steps to standardize that process across the system will take some effort. So that’s an important piece. Like I said, the recommendation about ensuring reliable reports could require additional coordination because we are dealing with VistA sites and Oracle sites, and it will require significant communication and collaboration across program offices and VA stakeholders to get the reports where they need to be. So ultimately responsible, you know, I mean the VA secretary is ultimately responsible for everything within VA. But you have many different program offices that are relevant in this case, and you have many different VA leaders also.

Terry Gerton Does VA have, say, a task force lead for this project?

Steve Bracci Not that I’m aware of.

Terry Gerton Let’s assume that they figure out how they’re going to orchestrate all of those different pieces that need to respond to this. What do you want veterans to know about how this might change their interaction or their service when they’re screened for homelessness or housing insecurity?

Steve Bracci I want veterans to know that they can expect to see improvements to the process. That’s why the OIG is so important: Our oversight focuses on topics and programs and services that are important to veterans. Our team does a really good job. When we conduct an audit, our team does really good job communicating with the different program offices and with VA leadership throughout the project. So when our report is issued, it doesn’t come as a surprise. So that communication, I think, is really important and it gives VA the opportunity to start making improvements and corrective actions immediately. And we’ve found that that is the case, that they take those meetings and they take our findings and our recommendations seriously. So I want veterans to know that. And, you know, I think VA as part of their response to our report, they have planned corrective actions that should be implemented by August of 2026. So if they follow through and they take action and they complete those plans, then veterans will see improvements to this process.

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