Deficiencies in Coordination of Care for Patients with Treatment-Resistant Depression at the VA San Diego Healthcare System in California

Report Information

Issue Date
Closure Date
Report Number
20-03359-220
VISN
22
State
California
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Mental Health
Community Care
Care Coordination
Major Management Challenges
Healthcare Services
Recommendations
6
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a healthcare inspection at the request of Chairman Mark Takano, and Representatives Julia Brownley, Chris Pappas, and Mike Levin, members of the House Committee on Veterans’ Affairs, to evaluate allegations related to a lack of care coordination for patients receiving ketamine for treatment-resistant depression (depression that has failed to respond after multiple treatments) in the community after authorizations for the care lapsed in September 2019 at the VA San Diego Healthcare System (facility) in California. The OIG substantiated that the facility ended authorizations for community care for patients receiving ketamine, a medication used for treatment-resistant depression, in October 2019 and again in March 2020. The discontinuation negatively affected 28 patients during the two time frames. While distress related to uncertainties about continuing ketamine treatment were identified as a contributory stressor, the OIG did not substantiate that discontinuation of community care resulted in a patient’s death by suicide as the community provider continued to offer ketamine treatment to that patient. The OIG also identified deficiencies in facility processes. The OIG concluded that risks for negative patient outcomes increased due to • communication and care coordination deficits, • terminating community care authorizations, • accelerating timelines for care transition, • uncertainties from changing treatment for complex patients The OIG made two recommendations to the Under Secretary for Health regarding community care providers’ review of VA’s protocol for ordering ketamine and research related to the use of ketamine for treatment-resistant depression. Four recommendations were made to the Facility Director related to community care processes for coordination of non-VA care and ensuring coordinated, clinically informed plans for transitioning remaining patients to care at the facility.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2022
The Under Secretary for Health requires that all community care providers authorized to provide ketamine or esketamine for treatment-resistant depression receive and review VA’s National Protocol Guidance on ketamine infusion and intranasal esketamine.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2022
The Under Secretary for Health evaluates the need for conducting research on the use of ketamine and esketamine for treatment-resistant depression including the comparative efficacy of ketamine and esketamine, the effect of route of administration, therapeutic dose range, mechanism of action, and efficacy and safety of long-term treatment, and initiates research efforts as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The VA San Diego Healthcare System Director confirms that the facility’s Community Care Service takes timely actions to ensure that administrative processes for care authorization do not disrupt continuity of clinical care.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The VA San Diego Healthcare System Director makes certain that the facility’s Community Care Service processes incorporate relevant clinical service input in decisions regarding authorization, denial, or discontinuation of care.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The VA San Diego Healthcare System Director ensures that the facility’s Community Care Service processes incorporate a consistent mechanism for communication with Veterans Health Administration and community clinical providers and patients to facilitate well-timed coordination of care.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The VA San Diego Healthcare System Director monitors implementation of the coordinated, clinically informed plans for continuing care when transitioning the remaining patients from ketamine treatment in the community to care at the facility.