Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic

The VA Office of Inspector General (OIG) conducted a review of 58 Veterans Health Administration (VHA) outpatient clinics’ emergency preparedness for the delivery of telemental health care as of November 1, 2019. The review focused on clinic-specific emergency procedures, emergency procedure roles and responsibilities, emergency contact information of staff, and patient safety reporting methods. The review excluded telemental health care provided to patients in their homes, which was a preferred setting for pandemic telemental health care, and non-VA clinic settings. OIG staff interviewed VHA leaders from the Office of Connected Care and the Office of Mental Health and Suicide Prevention, as well as facility telehealth coordinators and mental health service chiefs or representatives from 58 patient-clinic locations. OIG distributed questionnaires to 333 telepresenters and remote providers to evaluate knowledge of the patient-clinic locations’ emergency preparedness of those 187 staff-completed questionnaires. The OIG identified the following findings that could lead to delays in patient intervention and missed opportunities for patient safety: 1. Missing telehealth emergency plans and procedures 2. Emergency procedures not specific to telehealth care or the patient-clinic location 3. Lack of a process for annual updates to telehealth emergency procedures 4. Undefined emergency procedure roles and responsibilities for telehealth staff 5. Missing or insufficient emergency contact information 6. Lack of a process to verify and communicate emergency contact information 7. Lack of a consistent process to designate the telehealth setting in patient safety reporting methods The OIG made five recommendations to VHA.