Plans for hospital closures and transfers of mental health services from one facility to another in the Department of Veterans Affairs (VA) were a major target of criticism from mental health advocates (see page 2 and facing page).

The plans were outlined in the "Under-Secretary for Health’s Draft National CARES Plan," published in the Federal Register on August 20.

As noted in the draft plan, the "campus realignment proposals" were developed after the plans submitted by the Veterans Integrated Service Networks (VISNs) as part of the coordinated CARES planning process.

Among the proposals are the transfer of inpatient psychiatry from the Bedford, Mass., campus to Brockton, West-Roxbury, and "other appropriate campuses"; transfer of acute inpatient psychiatry from the Canandaigua, N.Y., campus to unspecified medical centers; transfer of inpatient psychiatric services from Waco, Tex., to unspecified locations in Temple and Austin; and "contract for psychiatry" from an unspecified source at Walla Walla, Wash.

Ralph Ibson, vice president for government affairs at the National Mental Health Association, testified before the CARES Commission on October 7 that the Federal Register document includes "only a bare summary of a multitude of sweeping proposals. Just a few terse sentences describe each proposed facility closure or shift in services from one facility to another."

He went on to charge, "[T]he plan proposes dramatic changes in the setting of VA mental health care without providing detailed justifications for the proposals, information on alternatives that were considered, or any specificity or safeguards regarding future access to mental health care."

The National Alliance for the Mentally Ill submitted written testimony to the CARES Commission about the hazards of losing inpatient psychiatric beds, particularly in light of inadequate community-based programs.

Prakash Desai, M.D., chief of staff at the West Side Division of VA Chicago Health Care System and speaker of the APA Assembly, told Psychiatric News that it is important to consider the social and historical context of the VA in examining the impact of the hospital closures and other recommendations of the plan.

"Many factors impact the ability of the VA to offer effective mental health services," he said.

The current fiscal constraints that limit the ability of states to serve people with severe mental illness, for example, put increased pressure on the VA to serve those populations. In the past, when state systems eliminated psychiatric beds, veterans tried to get care from VA hospitals, which were also downsizing.

In recent years, many veterans have turned to the VA for prescription drugs because of their escalating costs and limited availability through public and private insurance plans.

More specifically, Desai said, "When a steel mill recently shut down on the south side of Chicago, workers lost their jobs and insurance. Many came to the VA for health services." The increasing number of people without insurance throughout the country will strain all components of the VA’s health budget.

He expressed concern that the CARES draft plan repeats past mistakes in that it does not sufficiently address the need for outpatient services. "When we close hospitals and eliminate psychiatric beds, we must be prepared to offer alternative housing that fits the needs of people with serious mental illness," Desai said.

"Homelessness is an important problem for veterans with mental illness and for the VA," he added.

The "Under-Secretary for Health’s Draft National CARES Plan" is posted on the Web at www.carescommission.va.gov, along with an opportunity for comment. ▪