Letter

ACT and Other Case Management Services for Veterans

To the Editor: We agree with the conclusions of McCarthy and colleagues' study ( 1 ) published in the February issue that 2004 inpatient data from the Veterans Affairs (VA) health system suggested a need to increase the availability of assertive community treatment (ACT) services, with special attention to the needs of homeless and elderly veterans and veterans who do not live near VA facilities. However, as is often the case, reliance on administrative data can lead to oversimplification of clinical evaluation practices and incomplete consideration of the policy context.

To expand on this study, we offer the following clarifications and additions. First, the clinical appropriateness of ACT services can be only roughly approximated with data on hospital use. The Mental Health Intensive Case Management (MHICM) program, as the national VA implementation of ACT is named, currently serves 7,300 veterans on the basis of detailed clinical assessments of need ( 2 ). The criteria for admission to MHICM as outlined in fiscal year 2000 (Veterans Health Administration [VHA] Directive 2000-030) include multiple indicators of difficulty with community functioning and need for intensive community-based services. Although this program may be optimally targeted at high-cost inpatients, not all veterans with a history of high hospital use need this service, and some who have not been recently hospitalized have greater need than those who have. A second consideration is that since 2005 VA's Strategic Mental Health plan has expanded the program considerably. Through the funding of 52 new teams, more than 3,000 MHICM treatment slots have been added, which is almost seven times the number of entrants recorded in McCarthy and colleagues' study of 2004 data.

Third, although it is true that few homeless veterans are admitted to MHICM, this low rate of admission is largely a result of the VA's provision of specialized case management services to more than 65,000 homeless veterans per year through its specialized homeless outreach program. This program provides access to over 10,000 residential treatment beds and over 10,000 permanent supported housing units through the recently expanded HUD-VASH program (Department of Housing and Urban Development-Veterans Affairs Supportive Housing) ( 3 ). Fourth, although it is expected that veterans who live farther away from MHICM programs are less likely to receive this service, it is important to acknowledge that full MHICM or ACT teams cannot be efficiently implemented in less populated areas, especially in rural or frontier areas. Some existing programs serve substantial numbers of veterans in rural areas, and the VA has also implemented a pilot program at 19 rural sites with a modified model called Rural Access Network for Growth Enhancement (RANGE), designed to operate efficiently on a smaller scale ( 4 ). Finally, although McCarthy and colleagues found that elderly veterans were less like to be referred to MHICM, another recent study has shown that the MHICM program effectively serves a substantial number of elderly veterans—a group with quite distinctive characteristics (Mohamed S, Neale MS, Rosenheck RA, unpublished manuscript, 2009).