VA Health Care: Spending for Mental Health Strategic Plan	 
Initiatives Was Substantially Less Than Planned (21-NOV-06,	 
GAO-07-66).							 
                                                                 
The Department of Veterans Affairs (VA) provides mental health	 
services to veterans with conditions such as post-traumatic	 
stress disorder (PTSD) and substance abuse disorders. To address 
gaps in services needed by veterans, VA approved a mental health 
strategic plan in 2004. VA planned to increase its fiscal year	 
2005 allocations for plan initiatives by $100 million above	 
fiscal year 2004 levels and its fiscal year 2006 allocations for 
plan initiatives by $200 million above fiscal year 2004 levels.  
GAO was asked to provide information on VA's allocation and use  
of funding for mental health strategic plan initiatives in fiscal
years 2005 and 2006, and to examine the adequacy of how VA	 
tracked spending and the extent of spending for plan initiatives.
GAO reviewed VA reports and documents on plan initiatives and	 
conducted interviews with VA officials at headquarters, 4 of 21  
health care networks, and seven medical centers. VA networks	 
provide oversight of medical center operations and most medical  
center resources.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-07-66						        
    ACCNO:   A63646						        
  TITLE:     VA Health Care: Spending for Mental Health Strategic Plan
Initiatives Was Substantially Less Than Planned 		 
     DATE:   11/21/2006 
  SUBJECT:   Alcohol or drug abuse problems			 
	     Allocation (Government accounting) 		 
	     Budget outlays					 
	     Funds management					 
	     Health care services				 
	     Health centers					 
	     Internal controls					 
	     Mental health care services			 
	     Mental illnesses					 
	     Performance measures				 
	     Post-traumatic stress disorders			 
	     Strategic planning 				 
	     Veterans						 
	     Veterans benefits					 
	     Cost underruns					 

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GAO-07-66

   

     * [1]Results In Brief
     * [2]Background

          * [3]Organizational Structure and Funding of VA's Mental Health S
          * [4]VA's Mental Health Strategic Plan

     * [5]VA Allocated about $88 Million of the $100 Million Planned f

          * [6]VA Allocated Approximately $53 Million Directly to Medical C
          * [7]VA Allocated $35 Million through Its General Resource Alloca
          * [8]VA Did Not Allocate about $12 Million Planned for Mental Hea
          * [9]Medical Center Officials Reported Using Allocated Funds for

     * [10]VA Allocated about $158 Million of the $200 Million Planned

          * [11]VA Allocated about $158 Million Directly to Medical Centers
          * [12]VA Did Not Allocate about $42 Million for Mental Health Stra
          * [13]Medical Center Officials Reported Using Allocated Funds for

     * [14]VA Tracking of Funds Spent for Mental Health Strategic Plan
     * [15]Conclusion
     * [16]Recommendation for Executive Action
     * [17]Agency Comments
     * [18]GAO Contact
     * [19]Acknowledgments
     * [20]GAO's Mission
     * [21]Obtaining Copies of GAO Reports and Testimony

          * [22]Order by Mail or Phone

     * [23]To Report Fraud, Waste, and Abuse in Federal Programs
     * [24]Congressional Relations
     * [25]Public Affairs

Report to Congressional Requesters

United States Government Accountability Office

GAO

November 2006

VA HEALTH CARE

Spending for Mental Health Strategic Plan Initiatives Was Substantially
Less Than Planned

GAO-07-66

Contents

Letter 1

Results In Brief 5
Background 7
VA Allocated about $88 Million of the $100 Million Planned for Mental
Health Strategic Plan Initiatives in Fiscal Year 2005, but Officials
Reported That Not All Allocated Funds Were Used for Plan Initiatives 10
VA Allocated about $158 Million of the $200 Million Planned for Mental
Health Strategic Plan Initiatives in Fiscal Year 2006, but Some Officials
Were Uncertain If All Funds Would Be Used for Plan Initiatives 18
VA Tracking of Funds Spent for Mental Health Strategic Plan Initiatives
Was Inadequate, but Available Information Indicates That Spending for
These Initiatives Was Substantially Less Than Planned 24
Conclusion 25
Recommendation for Executive Action 26
Agency Comments 26
Appendix I Department of Veterans Affairs (VA) Health Care Networks,
Medical Centers, and Other Facilities GAO Selected for Review 28
Appendix II Description of Selected Department of Veterans Affairs (VA)
Mental Health Services 29
Appendix III Comments from the Department of Veterans Affairs 31
Appendix IV GAO Contact and Staff Acknowledgments 32
Related GAO Products 33

Tables

Table 1: Summary of VA Information on Mental Health Strategic Plan
Allocations to Medical Centers and Certain Offices by Type of Mental
Health Service, Fiscal Year 2005 11
Table 2: Summary of VA Information on Planned Funding for Mental Health
Strategic Plan Initiatives Not Allocated by Type of Mental Health Service,
Fiscal Year 2005 16
Table 3: Summary of VA Information on Mental Health Strategic Plan
Allocations to Medical Centers and Certain Offices by Type of Mental
Health Service, Fiscal Year 2006 19
Table 4: Summary of VA Information on Planned Funding for Mental Health
Strategic Plan Initiatives Not Allocated by Type of Mental Health Service,
Fiscal Year 2006 22

Abbreviations

CBOC community-based outpatient clinic CWT Compensated Work Therapy OEF
Operation Enduring Freedom OIF Operation Iraqi Freedom OMHS Office of
Mental Health Services PTSD post-traumatic stress disorder RFP request for
proposal VA Department of Veterans Affairs VERA Veterans Equitable
Resource Allocation system

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separately.

United States Government Accountability Office

Washington, DC 20548

November 21, 2006

The Honorable Lane Evans Ranking Minority Member Committee on Veterans'
Affairs House of Representatives

The Honorable Michael Michaud Ranking Minority Member Subcommittee on
Health Committee on Veterans' Affairs House of Representatives

The Department of Veterans Affairs (VA) provides a range of inpatient and
outpatient mental health services to veterans with conditions such as
depression, post-traumatic stress disorder (PTSD), and substance abuse
disorders. In November 2004, the Secretary of VA approved a mental health
strategic plan that identified additional services that VA planned to add
to the baseline of mental health services that it already offered to meet
veterans' mental health needs.1 This mental health strategic plan was
based on previous VA efforts that identified gaps in the availability and
adequacy of VA mental health services, including services for the
treatment of substance abuse disorders. VA's mental health strategic plan
was intended to help VA's leadership identify the actions and resources
needed to begin eliminating the gaps between mental health services VA
provided at the time of the plan's formulation and those additional
services VA anticipated that would be required to meet future needs.

VA indicated at a 2005 congressional hearing2 that it would provide $100
million above fiscal year 2004 levels for mental health strategic plan
initiatives in fiscal year 2005 from available resources. In addition, in
a 2005 executive decision memo, VA indicated its intent to increase its
fiscal year 2006 funding levels to $200 million above fiscal year 2004
levels for mental health strategic plan initiatives. This $200 million in
funds for fiscal year 2006 was to be composed of $100 million for a
continuation of fiscal year 2005 initiatives plus an additional $100
million included in the President's budget request for fiscal year 2006,
according to the executive decision memo. These additional funds
represented only a portion of the overall funds available to support VA
mental health services in those 2 fiscal years. VA's appropriation for
fiscal year 2006, for example, included more than $31.5 billion for its
medical programs,3 of which VA expected to spend more than $2 billion on
mental health services. VA headquarters allocates most of these resources
to VA's 21 regional health care networks4 through a general resource
allocation system and the networks in turn allocate resources to their
medical centers.

1The plan is known formally as A Comprehensive Veterans Health
Administration Strategic Plan for Mental Health Services. In this report,
we will refer to it as the mental health strategic plan.

2Full Committee Hearing on the Continuum of Care for Post Traumatic Stress
Disorder Before the House Comm. on Veterans' Affairs, 109th Cong. (July
27, 2005).

VA officials have stated that funds for mental health strategic plan
initiatives are to be used to address priorities such as the expansion of
PTSD services, postdeployment mental health services for veterans
returning from combat in Iraq and Afghanistan and other geographic
areas--Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF),
respectively, and the expansion of programs for the treatment of substance
abuse disorders. In recent years, VA's mental health services and budget
have come under increased scrutiny due to the potential for increased
demand for mental health services from veterans returning from combat in
Iraq and Afghanistan. In particular, concerns have been expressed by
members of Congress and others regarding the adequacy of resources that VA
is devoting to provide mental health care for these veterans while also
continuing to provide services for veterans who are currently receiving
mental health care.

You requested that we provide information on VA's allocation and spending
for mental health strategic plan initiatives in fiscal years 2005 and
2006, and the extent to which VA tracks the use of funding for plan
initiatives. In this report, we provide information on (1) how much of the
$100 million for mental health strategic plan initiatives in fiscal year
2005 was allocated and how those funds were used by selected medical
centers, (2) how much of the $200 million for mental health strategic plan
initiatives in fiscal year 2006 was allocated and how those funds were
used by selected medical centers, and (3) the adequacy of how VA tracked
funds spent for mental health strategic plan initiatives in fiscal years
2005 and 2006 and the extent to which allocated funds were spent for these
initiatives.

3Total includes medical care collections, but does not include certain
other amounts, such as appropriations for construction.

4VA headquarters delegates decision making regarding financing and service
delivery for health care services to its 21 health care networks,
including most budget and management responsibilities concerning medical
center operations. Medical centers typically include one or more hospitals
as well as other types of health care facilities such as outpatient
clinics and nursing homes.

To provide information on how much of the $100 million for fiscal year
2005 and $200 million for fiscal year 2006 for mental health strategic
plan initiatives was allocated to networks, medical centers, and certain
offices, we reviewed the plan itself as well as reports and other
documents related to the development, implementation, and funding of the
mental health strategic plan. We also conducted interviews with VA
headquarters officials with responsibilities related to mental health
services, budgeting, and the allocation of financial resources. We took
steps to ensure that the data VA provided to us on the funding allocated
in fiscal years 2005 and 2006 were sufficiently reliable for our purposes.
We reviewed the data for internal consistency and compared the data to
other VA information as well as information we obtained through interviews
with VA officials. We did not independently verify the accuracy of the
data. Nor did we independently determine the extent to which legislation
regarding VA health care expressly requires spending or authorizes various
types of mental health services but relied on VA's determination regarding
these services. To describe how funds were used by selected medical
centers, in May and June 2006, we conducted site visits to 2 of VA's 21
health care networks and three medical centers located in those networks,
and we also conducted phone interviews with officials in 2 other networks
and four medical centers located in those networks.5 We selected these 4
networks because VA had identified them as having gaps in substance abuse
and/or mental health services prior to the implementation of the mental
health strategic plan, and because they received varying levels of
funding--from relatively high to relatively low--in fiscal year 2005 for
mental health strategic plan initiatives. We interviewed clinical and
administrative officials at these networks and medical centers and at
three community-based outpatient clinics (CBOC)6 associated with these
medical centers and at five Vet Centers.7 We conducted these interviews in
May and June 2006. The findings from our site visits and phone interviews
with network and medical center officials cannot be generalized to other
medical centers or networks. For a list of VA health care networks and
medical centers included in our review, see appendix I. For a list of
selected VA mental health services discussed in this report, see appendix
II. This work expands upon the preliminary findings that we reported in
September 2006.8

5Throughout this report, the phrase "how funds were used by medical
centers" refers to information provided by medical center officials
regarding the hiring of staff, purchase of certain equipment, and other
purposes. These activities would be expected to result in obligations and
expenditures of funds either immediately or in the future.

To discuss how VA tracked funds spent for mental health strategic plan
initiatives in fiscal years 2005 and 2006 and the extent to which these
funds were spent for mental health strategic plan initiatives, we reviewed
documents related to VA's tracking efforts and interviewed VA headquarters
officials responsible for those efforts. We also requested from VA
headquarters information on the amount of funds returned by medical
centers to headquarters when medical centers were unable to spend all the
funds in a fiscal year. In addition, we requested information from VA
headquarters on the amount of funds medical centers spent on plan
initiatives. To gain further insights and perspectives on veterans' mental
health services generally, we reviewed our previous work on VA health
care, including those related to mental health and strategic planning (see
Related GAO Products at the end of this report), and interviewed officials
from selected veterans' service organizations and professional and
advocacy organizations. We focused on the allocation and use of funds
related to mental health strategic plan initiatives, and did not evaluate
the appropriateness of the mental health strategic plan, VA's efforts to
implement the initiatives outlined in the plan, or VA's allocation and use
of funding for mental health services generally. We performed our work
from January 2006 through November 2006 in accordance with generally
accepted government auditing standards.

6CBOCs provide medical services, which may include mental health services,
on an outpatient basis in local communities. As of December 2005, VA
operated over 700 freestanding CBOCs, in addition to other CBOCs that are
located in VA medical centers.

7Vet Centers provide mental health services, including readjustment
counseling and outreach services, to all veterans who served in any combat
zone. There are 207 such centers that operate in all 50 states, the
District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands.

8See GAO, VA Health Care: Preliminary Information on Resources Allocated
for Mental Health Strategic Plan Initiatives, [26]GAO-06-1119T
(Washington, D.C.: Sept. 28, 2006).

Results In Brief

VA headquarters allocated about $88 million of the $100 million VA
officials said would be used for VA mental health strategic plan
initiatives in fiscal year 2005 by using several approaches. VA allocated
about $53 million directly to medical centers and certain offices based on
proposals submitted for funding and other approaches targeted to specific
initiatives. VA headquarters solicited submissions from networks through
requests for proposals (RFP) for specific initiatives to be carried out at
networks' medical centers. In addition, VA headquarters officials said
that VA allocated $35 million for mental health strategic plan initiatives
through VA's general resource allocation system to its 21 health care
networks, which, in turn, could allocate these resources to individual
medical centers. VA's decision that $35 million of the funds allocated
through its general resource allocation system was for mental health
strategic plan initiatives was a retroactive decision, made several months
after these resources had been provided to networks through the general
resource allocation system. Moreover, VA did not notify networks and
medical centers that these funds were to be used for plan initiatives.
Network and medical center officials we interviewed in 4 networks told us
that they were unaware that any portion of their general allocation was to
be used specifically for mental health strategic plan initiatives. The
approximately $12 million remaining of the $100 million was not allocated
because, according to headquarters officials, there was not enough time
during the fiscal year to allocate the funds. Officials we interviewed
from seven medical centers in four networks reported using resources
allocated directly to their medical centers for plan initiatives for new
mental health services and more of the services they were already
providing. For example, one medical center used funding to develop a
program to help veterans with mental health diagnoses develop job skills
and find employment. Some medical center officials told us they had not
been able to use all of the funds provided for plan initiatives during the
fiscal year in part because of the length of time it took to hire new
staff.

VA headquarters allocated about $158 million of the $200 million VA
planned for its mental health strategic plan initiatives in fiscal year
2006 directly to medical centers and certain offices by using several
approaches. VA allocated about $92 million of these funds to support new
mental health strategic plan initiatives, using RFPs and other approaches
targeted to specific initiatives. VA also allocated about $66 million to
support the recurring costs of continuing mental health strategic plan
initiatives that were funded in fiscal year 2005 through RFPs and other
targeted approaches. About $42 million of the $200 million for fiscal year
2006 was not allocated. A portion of the approximately $42 million not
allocated was a result of partial-year allocations made for projects that
were funded later in fiscal year 2006 and that are expected to receive
12-month allocations for fiscal year 2007, according to VA officials.
Officials we interviewed at seven medical centers said they had used funds
to implement plan initiatives. Such initiatives included a new mental
health intensive case management program at one medical center. However,
officials at some medical centers told us they were uncertain that they
would be able to use all of the funds for plan initiatives by the end of
the fiscal year.

VA tracking of spending for plan initiatives in fiscal years 2005 and 2006
was inadequate. In fiscal year 2005, VA headquarters did not track the
spending of allocated funds for mental health strategic plan initiatives.
In fiscal year 2006, VA began tracking information on mental health
strategic plan initiatives by developing a quarterly reporting system that
focused primarily on staffing but did not track dollars spent. In fiscal
year 2006, VA compiled information on allocated funds returned to
headquarters by medical centers that they could not spend in the fiscal
year. However, VA does not have information on whether the funds medical
centers retained were spent for plan initiatives. Available information
indicates that spending of allocations for plan initiatives was
substantially less than planned in both fiscal years 2005 and 2006. In
fiscal year 2005, about $12 million of the planned $100 million for plan
initiatives was not allocated for them and thus was not spent for them.
Thirty-five million dollars was allocated through VA's general resource
allocation system, but because VA headquarters did not specify that these
funds were for plan initiatives, it is likely that portions of this money
were not spent on them and VA officials said that they do not have
information on these funds being spent for plan initiatives. VA officials
also told us that they did not have information on the extent to which the
approximately $53 million allocated directly to medical centers and
certain offices was actually spent on plan initiatives. Officials at
medical centers we interviewed told us that they used some of these funds
on mental health activities other than the planned initiatives or carried
over funds until the next fiscal year. In fiscal year 2006, available
information indicates that the maximum amount of allocated funds that
could have been spent for plan initiatives also fell substantially below
what was planned. About $42 million of the $200 million that was planned
for allocation to plan initiatives was never allocated for these
initiatives, and thus, never spent for them. Also, about $46 million of
the approximately $158 million that was allocated was returned by medical
centers to headquarters because it had not been spent on plan initiatives
by the end of the fiscal year. However, all of the approximately $112
million in allocations that medical centers and offices retained was not
necessarily spent on plan initiatives as originally planned. VA instructed
medical centers in August 2006 to spend funds for other mental health
activities if they could not spend the funds for the plan initiatives for
which they were allocated by the end of the fiscal year. Moreover, VA did
not track specifically how these funds were spent.

To help provide information on how funds are spent for VA's mental health
strategic plan initiatives, we are recommending that VA track the extent
to which the resources allocated for plan initiatives are spent for those
initiatives.

VA did not provide agency comments on the contents of this report. We
offered VA the opportunity to review but not retain copies of this report
as part of a process to help safeguard the draft contents from
unauthorized disclosure. However, VA chose not to review the draft report
in this manner. VA had previously seen portions of this report that had
been included in a statement for the record prepared for a hearing of the
House Veterans' Affairs Committee, Subcommittee on Health, on September
28, 2006. We discussed the information in that statement with VA officials
who have responsibilities related to mental health services, budgeting,
and the allocation of financial resources, and they agreed that the data
in the statement were accurate. Further, we briefed VA staff on the new
material in this report on November 14, 2006.

Background

VA operates a national health care system that provides health care
services to over 5 million patients annually. As part of that system, VA
provides mental health services to veterans in inpatient and outpatient
settings in a variety of VA health care facilities, including medical
centers, CBOCs, and Vet Centers. Veterans receiving these services include
homeless veterans, veterans with serious mental illness, and veterans
returning from combat who are dealing with postdeployment readjustment
issues. Mental health services are provided for a range of conditions such
as depression, PTSD, and substance abuse disorders.

Organizational Structure and Funding of VA's Mental Health Services

VA's Under Secretary for Health heads VA health care programs and is
responsible for oversight of operations in VA's 21 health care networks,
which are structured to manage and allocate resources to more than 150 VA
medical centers. Mental health services are provided on an inpatient and
outpatient basis in medical centers and may also be provided on an
outpatient basis in CBOCs, which are associated with medical centers.
Within VA, the lead mental health expert is the Deputy Chief Patient Care
Services Officer for Mental Health. This position does not have direct
authority for operations, but instead serves as an advisor to VA networks
and medical centers on mental health services. In addition, the official
in this position is responsible for oversight of the Office of Mental
Health Services (OMHS) located at VA headquarters. OMHS includes various
clinical experts who provide consultation on mental health services,
including PTSD and substance abuse, to VA program officials in the
networks and medical centers.

VA headquarters allocates most of its medical program services budget each
year through a general resource allocation system to its 21 health care
networks. This system, the Veterans Equitable Resource Allocation (VERA)
system, uses a case-mix9 formula to allocate funding to the networks,
which in turn allocate funding to their medical centers. Although the VERA
system is used to allocate funds, it does not designate funds for specific
purposes or prescribe how those funds are to be used.10 Medical centers
also receive funding for specific purposes, such as prosthetics, from VA
headquarters that is not allocated through the VERA system. In addition,
VA medical center resources include collections from insurance
reimbursements, copayments, and deductibles for the care of some
veterans.11

VA's Mental Health Strategic Plan

In April 2002, President Bush established the President's New Freedom
Commission on Mental Health and directed the Commission to identify
policies that could be implemented by federal, state, and local
governments to improve the delivery of mental health care across the
country.12 In July 2003, the Commission released its final report and
recommendations for improving the American mental health care system.
After release of the report, VA's Under Secretary for Health formed a work
group of mental health and health care professionals charged with
reviewing the Commission's recommendations to determine if those
recommendations were relevant to VA's mental health program.

9Case mix is a classification of patients into categories based on their
health care needs and related costs.

10For a discussion of how VERA allocates resources to networks, see GAO,
VA Health Care: Allocation Changes Would Better Align Resources with
Workload, [27]GAO-02-338 (Washington, D.C.: Feb. 28, 2002).

11For a discussion of resource allocations to medical centers, see GAO, VA
Health Care: Resource Allocations to Medical Centers in the Mid South
Healthcare Network, [28]GAO-04-444 (Washington, D.C.: Apr. 21, 2004).

12For more information about the President's New Freedom Commission on
Mental Health, see, for example, [29]http://www.mentalhealthcommission.gov
.

Following that effort, in July 2004, VA completed its mental health
strategic plan for improving the delivery of mental health services within
its health care system. This plan was formally approved by the Secretary
of VA in November 2004. The mental health strategic plan contained
recommended initiatives for improving VA mental health services by
addressing a range of issues, including, for example, improving awareness
about mental illness and improving access to mental health services.
According to VA officials, the mental health strategic plan was designed
to address gaps in mental health services provided to veterans across the
country. Some of the service gaps identified by the VA were in treating
veterans with serious mental illness,13 female veterans, and veterans
returning from combat in Iraq and Afghanistan. The implementation of the
mental health strategic plan sought to ensure, for example, that mental
health services are provided in community-based outpatient settings; that
veterans have consistent access to mental health services across the
country; and that acute inpatient mental health services are coordinated
with other inpatient services provided to veterans.

Within VA, OMHS is responsible for coordinating with the networks and
medical centers on the overall implementation of the mental health
strategic plan. This includes formulating strategies for allocating funds
committed for the plan's implementation. Such strategies include, for
example, the use of RFPs solicited from networks for specific initiatives
to be carried out at their individual medical centers. In addition to
making these funding decisions, OMHS is also responsible for tracking the
use of funds allocated for implementing the mental health strategic plan.

While VA initially attempted to develop an estimate of the cost to fully
implement the mental health strategic plan, VA has since decided that a
comprehensive cost estimate is inappropriate. According to VA, a
full-implementation cost estimate is inappropriate because the plan is a
"living document" that will continue to change over time as it is
implemented, and thus, the costs will change as well. VA, working with an
actuarial firm that used certain assumptions provided by VA, developed
both a long-term and a shorter-term "unofficial" estimate of
implementation costs for the initiatives included in the plan because VA
wished to have a "rough estimate" of what might be entailed in providing
all services that might be needed if capacity were not a constraint,
according to VA officials. VA and the actuary it used concluded, however,
that the methodology used to develop these estimates was problematic. For
example, the estimates used incorrect projections for utilization of
mental health services, in part, because VA's population and mental health
services are different from those in the private sector. VA officials said
that more current and accurate data are becoming available for use in
projecting the number of OIF and OEF veterans who would be entering the
system and need such services, and that such data and improvements in
projecting demand were used in development of the President's budget
request for fiscal years 2006 and 2007.

13For the purposes of the mental health strategic plan, VA defined
veterans with serious mental illness to be "those who currently or at any
time during the past year: 1) have a diagnosed mental, behavioral or
emotional disorder of sufficient duration to meet the Diagnostic and
Statistical Manual of Mental Disorders (Fourth Edition) criteria, that 2)
results in a disability (i.e. functional impairment that substantially
interferes with or limits one or more major life activities)." This
definition included adults who would meet these criteria during the year
without the benefit of treatment or support services.

VA Allocated about $88 Million of the $100 Million Planned for Mental Health
Strategic Plan Initiatives in Fiscal Year 2005, but Officials Reported That Not
All Allocated Funds Were Used for Plan Initiatives

VA headquarters allocated about $88 million of the $100 million that VA
officials said would be allocated for VA mental health strategic plan
initiatives in fiscal year 2005 by using several approaches. About $53
million was allocated directly to medical centers and certain offices and
$35 million was allocated through VA's general resource allocation system
to its health care networks, according to VA officials. The approximately
$12 million remaining of the $100 million was not allocated by any
approach, headquarters officials said, because there was not enough time
during the fiscal year to allocate the funds. Officials we interviewed at
seven medical centers in four networks reported using allocated funds to
provide new mental health services and to provide more of existing
services. However, some medical center officials reported that they did
not use all allocated funds for plan initiatives by the end of fiscal
year, due in part to the length of time it took to hire new staff.

VA Allocated Approximately $53 Million Directly to Medical Centers and Certain
Offices

VA headquarters allocated about $53 million directly to medical centers
and certain offices based on proposals submitted for funding and other
approaches targeted to specific initiatives related to the mental health
strategic plan in fiscal year 2005. (See table 1.) VA headquarters
developed RFPs and solicited submissions from networks for specific
initiatives to be carried out at their individual medical centers through
these RFPs. VA allocated resources through this and other targeted
approaches to support a range of mental health services, based, in part,
on the priorities of VA leadership and legislation for programs related to
PTSD, substance abuse, and other mental health areas,14 according to VA
headquarters officials. VA headquarters officials told us that the
Secretary of VA had identified several areas of the mental health
strategic plan that were to be priorities for implementation, including
those related to substance abuse, PTSD, services for veterans of OIF/OEF,
mental health in CBOCs, and homelessness. Nearly $20 million of the
approximately $53 million allocated by using RFPs and other targeted
approaches was for mental health services related to legislation that
expressly required spending or authorized such services, according to VA
officials. In addition, nearly $33 million was allocated for mental health
services not directly related to such legislation.

Table 1: Summary of VA Information on Mental Health Strategic Plan
Allocations to Medical Centers and Certain Offices by Type of Mental
Health Service, Fiscal Year 2005

Type of mental health service                    Amount allocated(dollars) 
Allocations related to legislation that                                    
expressly required spending or authorized                                  
services                                                                   
Domiciliary expansiona                                          $5,999,971 
Compensated work therapy/supported employment                              
mentoring sitesb                                                 4,535,738 
PTSDb                                                            2,726,840 
Operation Iraqi Freedom (OIF) and Operation                                
Enduring Freedom (OEF)b                                          2,445,554 
Substance abuseb                                                 2,175,367 
Psychosocial rehabilitation for veterans with                              
serious mental illnessb                                          1,786,414 
Subtotal                                                       $19,669,884 
Allocations not directly related to legislation                            
that expressly required spending or authorized                             
servicesc                                                                  
PTSD and OEF/OIF                                                12,899,611 
Compensated work therapy enhancement and                                   
expansion                                                        4,972,784 
Grant and per diem liaisons                                      4,500,000 
Mental health services in nursing homes                         4,000,000d 
Community-based outpatient clinic mental health                  1,997,653 
Substance abuse                                                  2,998,911 
Mental health intensive case management teams                      999,824 
Development of educational programs                               600,000e 
Subtotal                                                       $32,968,783 
Total                                                          $52,638,667 

14The Veterans Health Care, Capital Asset, and Business Improvement Act of
2003, Pub. L. No. 108-170, S 108, 117 Stat. 2042, 2046-47, required VA to
allocate a minimum of $25 million in each of fiscal years 2004, 2005, and
2006 to carry out a program to expand and improve the provision of
specialty mental health services for veterans, including PTSD and
substance abuse services. Congress also required VA to ensure that after
these allocations, total expenditures related to treatment of substance
abuse and PTSD were not less than $25 million above the total expenditures
on such programs in fiscal year 2003, adjusted for increases in the costs
of delivering those services. The Homeless Veterans Comprehensive
Assistance Act of 2001, Pub. L. No. 107-95, S 2043, 115 Stat. 903, 913,
authorized VA to establish up to 10 new domiciliary programs for homeless
veterans.

Source: GAO summary of VA information.

Notes: A total of $48 million was allocated to medical centers to use for
their mental health services. In addition, $4 million was allocated to
VA's Office of Geriatrics and Extended Care and $600,000 was allocated to
the Employee Education System. GAO did not independently determine the
extent to which legislation regarding VA health care expressly requires
spending or authorizes these services but relied on VA's determination
regarding these services.

aRelated to the Homeless Veterans Comprehensive Assistance Act of 2001,
which authorized VA to establish up to 10 new domiciliary programs for
homeless veterans, and authorized appropriations of $5 million in fiscal
years 2003 and 2004 for any such domiciliaries. See Pub. L. No. 107-95, S
2043, 115 Stat. 903, 913.

bRelated to the Veterans Health Care, Capital Asset, and Business
Improvement Act of 2003, in which Congress required VA to allocate a
minimum of $25 million in each of fiscal years 2004, 2005, and 2006 to
carry out a program to expand and improve the provision of specialized
mental health services for veterans, including PTSD and substance abuse
services. Congress also required VA to ensure that after these
allocations, total expenditures related to treatment of substance abuse
and PTSD were not less than $25 million above the total expenditures on
such programs in fiscal year 2003, adjusted for increases in the costs of
delivering those services. See Pub. L. No 108-170 S 108, 117 Stat. 2042,
2046-47.

cFor some mental health services, such as substance abuse, VA planned to
allocate some funds that were related to legislation expressly requiring
spending or authorizing those services as well as other funds that were
not.

dThis amount was allocated to VA's Office of Geriatrics and Extended Care.

eThis amount was allocated to VA's Employee Education System.

Most of the approximately $53 million allocated--about $48 million--went
to VA medical centers. PTSD services and OEF/OIF veterans' mental health
care received combined allocations of about $18 million. In addition,
combined allocations for Compensated Work Therapy (CWT) totaled nearly $10
million. Other initiatives receiving funding included substance abuse
services, domiciliary expansion, and psychosocial rehabilitation for
veterans with serious mental illness. In addition, VA allocated $4 million
that was initially planned for CWT programs to VA's Office of Geriatrics
and Extended Care to support development of a new nursing home care model.
This shift occurred toward the end of the fiscal year, when it appeared
that not all mental health strategic plan funding would be allocated that
year. VA officials noted that the nursing home model was aligned with
initiatives in the mental health strategic plan related to the needs of
veterans in long-term care settings. The remaining funds--$600,000--were
allocated to VA's Employee Education System to develop educational
programs.

VA headquarters officials issued five RFPs from October 2004 to January
2005 that described the specific types of services for which mental health
strategic plan funding was available. The RFPs related to PTSD, veterans
of OIF and OEF, substance abuse, and psychosocial rehabilitation services
were issued in October 2004; the domiciliary RFP was issued in January
2005. All of the RFPs noted that funding would be provided to address
unmet needs or gaps in services. Review panels headed by mental health
experts within VA reviewed the proposals submitted by networks, ranked
them, and provided their rankings to VA's leadership who made the
allocation decisions.15 VA then allocated funding directly to medical
centers for the mental health strategic plan initiatives beginning in
February 2005 and continuing throughout fiscal year 2005.

In addition to RFPs, VA also used other approaches targeted to specific
initiatives based on identified needs. For example, VA headquarters
officials used a targeted approach to allocate funding to medical centers
to expand mental health services at CBOCs that had fewer mental health
visits than a standard that VA identified for this purpose.16 In addition,
VA headquarters allocated funds to support the creation of CWT-supported
employment mentor sites in each network. The medical centers selected at
those sites were expected to provide training and support for existing and
future CWT programs aimed at helping veterans with serious mental illness
find and maintain employment. VA headquarters also used targeted funding
approaches to allocate funds to medical centers to enhance existing CWT
programs through the addition of new staff and to establish CWT programs
at medical centers without such programs. VA headquarters used targeted
approaches to allocate funding for new and expanded mental health
intensive case management teams; grant and per diem liaisons for homeless
veterans; and PTSD, OIF and OEF veterans', and substance abuse services.

15According to the network and medical center staff we spoke with, even
though the proposals were formally submitted by the networks, medical
center staff had a significant amount of input into the proposals.

16VA's performance measure was that for each network, in at least 85
percent of all CBOCs with 1,500 or more patients, mental health visits
would account for at least 10 percent of all visits. VA targeted funds to
CBOCs that had no mental health providers or that needed additional
providers to meet the performance measure of 10 percent.

VA headquarters officials said that allocations made for initiatives in
fiscal year 2005 through RFPs and other approaches targeted to specific
initiatives would be made for a total of 2 to 3 fiscal years. These
officials said they anticipated that medical centers would hire permanent
staff whose positions would need to be funded for more than 1 year. The
expectation of VA leadership was that after funds allocated through these
approaches were no longer available, medical centers would continue to
support these programs using their general operating funds received
through VA's general resource allocation system.

VA Allocated $35 Million through Its General Resource Allocation System to Its
Health Care Networks on a Retrospective Basis

VA allocated $35 million for mental health strategic plan initiatives in
fiscal year 2005 through its general resource allocation system17 to its
health care networks, according to VA headquarters officials. The decision
to allocate these resources to VA's networks for mental health strategic
plan initiatives was retrospective and VA did not notify networks and
medical centers of this decision. Although VA headquarters made fiscal
year 2005 general resource allocations to the networks in December 2004,18
the decision that $35 million in funds allocated at that time was for
mental health strategic plan initiatives was not finalized until April
2005, several months after the general allocation had been made. VA
headquarters officials said that they made the decision to allocate $35
million from the general resource allocation system because these
resources would be more rapidly allocated than if they had been allocated
through RFPs. However, other VA headquarters officials told us that the
decision was also made, in part, because VA did not have sufficient
unallocated funds remaining after the December 2004 general allocation to
fund $100 million for the mental health strategic plan through RFPs and
other targeted approaches.

17This allocation system is known as the Veterans Equitable Resource
Allocation (VERA) system. In fiscal year 2005, VA headquarters used VERA
to allocate about 85 percent of its medical care appropriations to its 21
health care networks, which in turn allocated resources to their medical
centers. VERA allocates resources primarily on the basis of patient
workload and case mix where workload is the number of veterans treated and
case mix is a classification of patients into categories based on their
health care needs and related costs. See [30]GAO-02-338 and [31]GAO-04-444
.

18Fiscal year 2005 covered the period of October 1, 2004, through
September 30, 2005.

VA headquarters officials, as well as network and medical center
officials, indicated that there was no guidance to the networks and
medical centers instructing them to use specific amounts from their
general fiscal year allocation for mental health strategic plan
initiatives. Network and medical center officials we spoke with in four
networks were unaware that any specific portion of their general
allocation was intended by headquarters officials to be used for mental
health strategic plan initiatives. Several VA medical center officials
noted, however, that some of the funds in their general allocation were
used to support mental health programs generally, as part of their routine
operations. However, because network and medical center officials we
interviewed did not know that funds had been allocated for mental health
strategic plan initiatives through VA's general resource allocation
system, nor did VA headquarters notify networks and medical centers
throughout VA of this retrospective allocation, it is likely that some of
these funds were not used for plan initiatives.

VA Did Not Allocate about $12 Million Planned for Mental Health Strategic Plan
Initiatives

VA did not allocate approximately $12 million remaining of the $100
million planned for mental health strategic plan initiatives in fiscal
year 2005 because, according to VA headquarters officials, there was not
enough time during the fiscal year to allocate the funds through the RFP
process or other approaches targeted to specific initiatives. In addition,
officials said that when resources were allocated later in the fiscal year
through an RFP, rather than at the beginning of the year, the amount
allocated was only a portion of the annualized cost. For example, if funds
for a project with an annual cost of $4 million were allocated midway
through the fiscal year, only half the annual cost was allocated at that
time--$2 million. The expectation was that the full $4 million would be
made available for the project over the 12 months in the next fiscal year.
The approximately $12 million in unallocated funds in fiscal year 2005 was
intended for mental health strategic plan initiatives based on an
allocation plan developed by VA. (See table 2.) About $11 million of the
resources not allocated was for services related to legislation that
expressly required spending or authorized such services, according to VA
officials. VA headquarters officials said that the funds not allocated for
mental health strategic plan initiatives were allocated for other health
care services.

Table 2: Summary of VA Information on Planned Funding for Mental Health
Strategic Plan Initiatives Not Allocated by Type of Mental Health Service,
Fiscal Year 2005

                                                 Planned amount not allocated 
Type of mental health service                                    (dollars) 
Related to legislation that expressly                                      
required spending or authorized services                                   
Substance abusea                                                $2,824,633 
Operation Iraqi Freedom (OIF) and Operation                                
Enduring Freedom (OEF)a                                          2,554,446 
PTSDa                                                            2,273,160 
Psychosocial rehabilitation for veterans with                              
serious mental illnessa                                          2,213,586 
Compensated work therapy/supported employment                              
mentoring sitesa                                                 1,464,262 
Subtotal                                                      $11,330,116b 
Not directly related to legislation that                                   
expressly required spending or authorized                                  
servicesc                                                                  
Compensated work therapy enhancement and                                   
expansion                                                        1,027,216 
Subtotal                                                       $1,031,217d 
Total                                                          $12,361,333 

Source: GAO summary of VA information.

Notes: GAO did not independently determine the extent to which legislation
regarding VA health care expressly requires spending or authorizes these
services but relied on VA's determination regarding these services.

aRelated to the Veterans Health Care, Capital Asset, and Business
Improvement Act of 2003, in which Congress required VA to allocate a
minimum of $25 million in each of fiscal years 2004, 2005, and 2006 to
carry out a program to expand and improve the provision of specialized
mental health services for veterans, including PTSD and substance abuse
services. Congress also required VA to ensure that after these
allocations, total expenditures related to treatment of substance abuse
and PTSD were not less than $25 million above the total expenditures on
such programs in fiscal year 2003, adjusted for increases in the costs of
delivering those services. See Pub. L. No 108-170 S 108, 117 Stat. 2042,
2046-47.

bIncluded in this subtotal is less than $100 that was not allocated for
domiciliary expansion. The Homeless Veterans Comprehensive Assistance Act
of 2001 authorized VA to establish up to 10 new domiciliary programs for
homeless veterans. See Pub. L. No.107-95, S 2043, 115 Stat. 903, 913.

cFor some mental health services, such as substance abuse, VA planned to
allocate some funds that related to legislation expressly requiring
spending or authorizing those services as well as other funds that were
not.

dIncluded in this subtotal is approximately $4,000 that was not allocated
for community-based outpatient clinic mental health, substance abuse,
PTSD, and OIF/OEF services, as well as for mental health intensive case
management teams.

Medical Center Officials Reported Using Allocated Funds for Mental Health
Strategic Plan Initiatives, but Not Using All Funds Allocated for Plan
Initiatives

Officials we interviewed from seven medical centers in four networks
reported using the funds allocated to them for mental health strategic
plan initiatives through RFPs and other targeted approaches, but some
officials said that some of these funds were not used for plan initiatives
in fiscal year 2005. Officials said they used funds allocated to provide
new mental health services and to provide more of existing mental health
services included in plan initiatives. For example, officials at medical
centers in Bay Pines and the Tennessee Valley Healthcare System reported
using funds to increase the number of mental health providers at CBOCs,
some of which previously had no mental health providers available to see
veterans. The Albuquerque medical center used funds to develop a
CWT-supported employment program to help veterans with mental health
diagnoses develop job skills and find employment. The Tennessee Valley
Healthcare System also implemented a new 6-week PTSD day treatment program
in which veterans live in the community but come to the medical center
during the day for counseling, group therapy, and other services. The
Tampa medical center funded new mental health staff to work with veterans
being treated in its Polytrauma Rehabilitation Center. The Tuscaloosa
medical center opened a new domiciliary for homeless veterans and the
Phoenix medical center hired a new grant and per diem liaison for its
homeless program. The medical centers in our review used the mental health
strategic plan funds for recurring uses, such as hiring staff, and for
nonrecurring uses. Nonrecurring uses included acquisition of furniture and
equipment as well as building renovation.

Officials at four medical centers reported that they were not able to use
all of their fiscal year 2005 funding by the end of the fiscal year as
planned and cited several factors that contributed to this situation. The
length of time it takes to recruit new staff in general and the special
problems of hiring specialized staff such as psychiatrists were cited.
Officials at two medical centers noted that they received funding for
multiple new positions, but that it was difficult for the medical center
to recruit and hire for so many positions in a relatively short period of
time. In addition, in some cases the need to locate or renovate space for
mental health programs contributed to delays in using funds. For example,
officials at the Albuquerque medical center reported that although it
received funding for staff for a new residential program, it took some
time to renovate the space needed for that program, which limited the
amount of funding for staff they were actually able to spend in fiscal
year 2005.

Medical centers varied in how they treated fiscal year 2005 funds that
were allocated by VA for mental health strategic plan initiatives but not
used for those initiatives. Officials at three medical centers reported
that they carried over the funds for use in the next fiscal year.19 For
example, officials at the Phoenix medical center reported carrying over
unused funding for a substance abuse residential rehabilitation program.
Officials at two medical centers reported that they used these funds for
other health care purposes. For example, officials at the Albuquerque
medical center said that funding that was not used for staffing due to
difficulties with hiring was made available to meet other needs in the
medical center for that fiscal year. Officials at another medical center,
the Tennessee Valley Health Care System, reported having unused fiscal
year 2005 funding due to difficulties with hiring, and using this funding
to support other mental health programs, in particular to hire mental
health staff for its CBOCs. VA headquarters officials advised participants
from networks and medical centers in a weekly conference call in August
2005 that if they were unable to hire staff for initiatives in fiscal year
2005, they should use the funds allocated only for mental health services.

VA Allocated about $158 Million of the $200 Million Planned for Mental Health
Strategic Plan Initiatives in Fiscal Year 2006, but Some Officials Were
Uncertain If All Funds Would Be Used for Plan Initiatives

VA headquarters allocated about $158 million of the $200 million to be
used for VA mental health strategic plan initiatives in fiscal year 2006
directly to medical centers and certain offices by using several
approaches. About $92 million of these funds was allocated to support new
mental health strategic plan initiatives for fiscal year 2006. VA also
allocated about $66 million to support the recurring costs of the
continuing mental health strategic plan initiatives that were funded in
fiscal year 2005. The remaining approximately $42 million was not
allocated. Officials at some medical centers expected to use all the
allocations they received during fiscal year 2006. However, officials at
other medical centers were uncertain that they would use all their
allocated funds for plan initiatives during the fiscal year.

19VA may carry over from one fiscal year to the next unobligated balances
of funds made available without fiscal year limitation and other funds
appropriated for multiple fiscal years.

VA Allocated about $158 Million Directly to Medical Centers and Certain Offices

VA headquarters allocated about $158 million directly to medical centers
and certain offices through RFPs and other approaches targeted to specific
initiatives related to the mental health strategic plan in fiscal year
2006. (See table 3.) About $92 million was for new mental health strategic
plan activities, and about $66 million was to support the recurring costs
of continuing mental health strategic plan initiatives that were first
funded in fiscal year 2005. As in fiscal year 2005, the new resources went
to support a range of mental health services in line with priorities of
VA's leadership and legislation, according to VA officials. Funding for
services for PTSD, OIF and OEF veterans, substance abuse, and CBOC mental
health services accounted for nearly three-fifths of the funds allocated
for new initiatives. VA did not allocate resources in fiscal year 2006 for
mental health strategic plan initiatives through its general resource
allocation system, according to VA officials.

Table 3: Summary of VA Information on Mental Health Strategic Plan
Allocations to Medical Centers and Certain Offices by Type of Mental
Health Service, Fiscal Year 2006

Type of mental health service                    Amount allocated(dollars) 
New fiscal year 2006 initiatives                                           
Allocations related to legislation that                                    
expressly required spending or authorized                                  
services                                                                   
Domiciliary expansiona                                          $7,437,593 
Allocations not directly related to legislation                            
that expressly required spending or authorized                             
services                                                                   
PTSD and OEF/OIF                                                18,772,089 
Substance abuse                                                 16,887,550 
Community-based outpatient clinic mental health                 16,782,344 
Psychosocial and recovery-oriented services                      6,249,025 
Telemental health programs to provide mental                               
health services through videoconferencing                        5,063,987 
Web-based support tools for veterans with mental                           
health concerns                                                  5,000,000 
Grant and per diem liaisons                                      4,700,000 
Mental health intensive case management teams                    3,749,029 
Suicide prevention and residential                                         
rehabilitation treatment program infrastructure                            
improvements                                                     1,803,853 
Inpatient mental health services at two VA                                 
facilities in Tennessee                                          1,629,657 
Support for Gulf Coast mental health programs                              
affected by Hurricane Katrina                                    1,610,643 
Educational programs                                             1,391,208 
Stand Down events for homeless veterans                            467,665 
Pilot program for incarcerated veterans with                               
mental illness                                                     233,334 
Peer housing assistance pilot program for                                  
homeless veterans                                                  168,980 
Initiative for mentally ill chemically-addicted                            
veterans                                                            69,517 
Subtotal--new fiscal year 2006 initiatives                     $92,016,474 
Initiatives initially funded in fiscal year 2005                65,675,513 
Total                                                         $157,691,987 

Source: GAO summary of VA information.

Notes: GAO did not independently determine the extent to which legislation
regarding VA health care expressly requires spending or authorizes these
services but relied on VA's determination regarding these services.

aRelated to the Homeless Veterans Comprehensive Assistance Act of 2001,
which authorized VA to establish up to 10 new domiciliary programs for
homeless veterans. See Pub. L. No. 107-95, S 2043, 115 Stat. 903, 913.

VA headquarters officials used RFPs and other approaches targeted to
specific initiatives to determine which medical centers would receive
funding for new mental health strategic plan initiatives in fiscal year
2006. In November 2005, for example, VA issued an RFP that covered six
mental health areas: PTSD services, including residential services; health
promotion and preventive care services for veterans returning from OEF and
OIF; specialized substance abuse treatment programs; new mental health
residential rehabilitation and treatment programs;20 enhanced or new CBOC
mental health services; and new telemental health programs to provide
mental health services through videoconferencing. VA also used other
approaches to target funds to medical centers for grant and per diem
program liaisons, new or expanded mental health intensive case management
teams, and expanded inpatient services at the Tennessee Valley Healthcare
System medical center. Further, VA allocated funding for medical supplies,
equipment, and office furniture for Gulf Coast mental health programs
affected by Hurricane Katrina. As in fiscal year 2005, VA allocated
funding to the Employee Education System to support educational programs.
VA also allocated funding to support additional mental health initiatives
such as the development of web-based support tools for veterans with
mental health concerns, infrastructure improvements at residential
rehabilitation treatment facilities, suicide prevention efforts, and Stand
Down events to provide services such as counseling and health screenings
for homeless veterans.

20These could include homeless domiciliary programs, psychosocial
programs, substance abuse programs, PTSD programs, or other general
programs.

VA Did Not Allocate about $42 Million for Mental Health Strategic Plan
Initiatives

VA did not allocate about $42 million of the $200 million planned for
mental health strategic plan initiatives in fiscal year 2006 by any
approach. The approximately $42 million in unallocated funds were intended
for certain mental health strategic plan initiatives based on an
allocation plan developed by VA. According to VA officials, VA was unable
to allocate all the $200 million, in part, because of the delayed
implementation of three new Centers of Excellence, focusing on veterans'
mental health issues, including PTSD, for which VA planned allocations
totaling $4.5 million.21 VA officials also cited the unanticipated length
of time required to refine the processes for implementation of initiatives
related to the provision of mental health services in primary care
settings. VA had solicited proposals related to primary care mental health
services through a May 2006 RFP22 and had anticipated allocating about $11
million for such services from funds reserved for emerging needs related
to the mental health strategic plan. In addition, VA officials reported
that a portion of the funds were unallocated for reasons related to the
timing of allocations that were made for plan initiatives through RFPs and
other funds targeted to medical centers. Specifically, some of these
allocations were made well into the fiscal year. VA allocated only the
amount of funds through these approaches for fiscal year 2006 that would
fund the projects through the end of the fiscal year, and not the full
12-month costs, which VA expects to fund in fiscal year 2007. VA officials
said they anticipated that the full 12-month allocation would be available
for these projects in fiscal year 2007. Most of the unallocated funds had
been planned for initiatives to provide services that VA identified as not
directly in response to legislation that expressly required spending or
authorized such services. (See table 4.)

21In the Conference Report accompanying the Military Quality of Life and
Veterans Affairs Appropriations Act of 2006, Pub. L. No. 109-114, the
Conference Committee stated that VA should consider designating
specialized medical treatment facilities for mental health and PTSD as
Centers of Excellence, and directed VA to establish three specific
centers. These centers are to be located at VA facilities in Canandaigua,
New York; Waco, Texas; and San Diego, California. See H.R. Conf. Rep. No.
109-305, at 39 (2005).

22Through the RFP, funds were available for programs that promote
effective treatment of common mental health conditions in primary care
settings, in order to integrate care for veterans' physical and mental
health and allow mental health specialists to focus on veterans with more
severe illnesses. Funds were also available for related education and
training.

Table 4: Summary of VA Information on Planned Funding for Mental Health
Strategic Plan Initiatives Not Allocated by Type of Mental Health Service,
Fiscal Year 2006

                                                           Planned Amount Not 
Type of Mental Health Service                           Allocated(dollars) 
Related to legislation that expressly required spending                    
or authorized services                                                     
Centers of Excellencea                                          $4,500,000 
Domiciliary expansionb                                               8,804 
Not directly related to legislation that expressly                         
required spending or authorized services                                   
PTSD and OEF/OIF                                                10,690,920 
Psychosocial and recovery-oriented services                      5,652,638 
Telemental health programs to provide mental health                        
services through videoconferencing                               3,936,013 
Substance abuse                                                  3,112,450 
Mental health program review                                     1,000,000 
Inpatient mental health services at two VA facilities                      
in Tennessee                                                       773,503 
Mental health intensive case management teams                      539,419 
Community-based outpatient clinic mental health                    194,266 
Reserved for emerging needs                                     11,900,000 
Total                                                          $42,308,013 

Source: GAO summary of VA information.

Notes: GAO did not independently determine the extent to which legislation
regarding VA health care expressly requires spending or authorizes these
services but relied on VA's determination regarding these services.

aIn the Conference Report accompanying the Military Quality of Life and
Veterans Affairs Appropriations Act of 2006, the Conference Committee
stated that VA should consider designating specialized medical treatment
facilities for mental health and PTSD as Centers of Excellence, and
directed VA to establish three specific centers. See H.R. Conf. Rep. No.
109-305, at 39 (2005).

bRelated to the Homeless Veterans Comprehensive Assistance Act of 2001,
which authorized VA to establish up to 10 new domiciliary programs for
homeless veterans. See Pub. L. No. 107-95, S 2043, 115 Stat. 903, 913.

Medical Center Officials Reported Using Allocated Funds for Mental Health
Strategic Plan Initiatives, but Were Uncertain Whether All Funds Allocated Would
Be Used for Plan Initiatives

Officials at seven medical centers we interviewed in May and June of 2006
reported using funds allocated to them through RFPs and other approaches
to support new 2006 initiatives and to continue to support initiatives
funded in fiscal year 2005. Officials at four of these medical centers
told us that they were using these funds to support expanded mental health
services. For example, officials at several medical centers, including Bay
Pines, Decatur, and the Tennessee Valley Healthcare System, reported using
fiscal year 2006 funding to expand mental health services in their CBOCs
by adding clinical staff. As part of this expansion of services, the Tampa
medical center used funding for a new mental health intensive case
management program. Five medical centers had received funding for expanded
mental health services, but had not yet used all of the allocated funds.
The Albuquerque medical center, for example, had received funding for a
new substance abuse program for geriatric patients and a new case
management program for veterans with PTSD. As of May 2006, both programs
were still being developed and positions had been advertised but had not
yet been filled.

Officials at two medical centers reported that they did not anticipate
problems using all of the funds they had received in fiscal year 2006.
However, officials at four other medical centers were less certain they
would be able to use all of the funds. Officials at two of these medical
centers were not sure whether they would be able to hire all of their new
staff by the end of the fiscal year. In addition, officials at the Bay
Pines and Phoenix medical centers noted that they had not yet learned
whether proposals they submitted in response to fiscal year 2006 RFPs
would be funded; as a result, officials at those medical centers were
uncertain whether they would be able to use all of their fiscal year 2006
funds for plan initiatives by the end of the fiscal year.

VA Tracking of Funds Spent for Mental Health Strategic Plan Initiatives Was
Inadequate, but Available Information Indicates That Spending for These
Initiatives Was Substantially Less Than Planned

VA tracking of spending for mental health strategic plan initiatives was
inadequate for fiscal years 2005 and 2006. In fiscal year 2005, VA
headquarters did not track spending on mental health strategic plan
initiatives. In fiscal year 2006, VA began to track some information on
medical centers' mental health strategic plan initiatives, but did not
track the amount of allocated funds that was spent for them.23 VA
headquarters officials used this newly instituted tracking system to
gather implementation information reported by networks and medical centers
on a quarterly basis. The tracked information was primarily related to
positions to be filled, the schedule for filling them, and when they were
filled. Headquarters officials said that this tracking was intended, in
part, to measure medical centers' progress in implementing plan
initiatives. Officials told us that they believe that tracking of hiring
provides information on how funds were spent because most costs of
initiatives are personnel costs. However, the data on hiring did not
include information on the individual salaries of staff, associated
benefits, the portion of the fiscal year for which staff are employed,
equipment, supplies, rent, or renovation of facilities. As a result the
quarterly reports do not allow VA to determine how much was spent on plan
initiatives. In fiscal year 2006, VA headquarters officials compiled
information on the amount of funds returned to headquarters that medical
centers could not spend during the fiscal year. However, VA does not have
information on whether the funds medical centers retained were spent for
plan initiatives.

Available information indicates that spending of allocations for mental
health strategic plan initiatives was substantially less than planned in
both fiscal years 2005 and 2006. In fiscal year 2005, approximately $12
million of the planned $100 million for plan initiatives was not allocated
for plan initiatives and thus was not spent on them. Thirty-five million
dollars was allocated through VA's general resource allocation system, but
because VA headquarters did not specify that these funds were for mental
health strategic plan initiatives, it is likely that portions of this
money were not spent on them, and VA officials said they do not have
information on these funds being spent for plan initiatives. In addition,
VA officials told us that they did not have information on the extent to
which the approximately $53 million in funds that were allocated directly
to medical centers and certain offices was actually spent on plan
initiatives. Officials at medical centers we interviewed told us that they
used some of these funds on mental health activities other than the
planned initiatives or carried over funds until the next fiscal year.

23Although VA headquarters' tracking system did not track spending for
plan initiatives in fiscal year 2005, some network and medical center
staff we spoke with reported on separate efforts to track medical centers'
use of funds for mental health strategic plan initiatives. Some network
staff told us that they developed their own tracking processes because
they anticipated that they would eventually have to account for the use of
funds allocated for mental health strategic plan initiatives.

In fiscal year 2006, available information indicates that the maximum
amount of allocated funds that could have been spent for plan initiatives
in fiscal year 2006 also fell substantially below what was planned. About
$42 million of the $200 million that was planned for allocation to mental
health strategic plan initiatives was never allocated for them, and thus,
never spent for plan initiatives. Additionally, about $46 million of the
approximately $158 million that was allocated was returned by medical
centers to headquarters because it had not been spent for plan initiatives
before the end of the fiscal year.24 However, all of the remaining
approximately $112 million of funds allocated to and retained by medical
centers and offices was not necessarily spent on plan initiatives as
originally planned. VA officials provided written guidance to medical
centers in August 2006 instructing them to spend funds for other mental
health activities if they could not spend them for the planned initiatives
before the end of the fiscal year. VA officials told us that because they
had provided instructions to spend the funds on mental health activities
that such activities would constitute spending on mental health strategic
plan activities. VA's guidance, however, did not specify that funds be
used for the plan initiatives or alternative initiatives. Moreover, VA did
not track specifically how these funds were spent. As a consequence, VA
cannot determine how much of the approximately $112 million that was
allocated for plan initiatives and not returned to headquarters was spent
on plan initiatives.

Conclusion

VA allocated additional resources for mental health strategic plan
initiatives in fiscal years 2005 and 2006 to help address identified gaps
in VA's mental health services for veterans. The allocations that were
made resulted in some new and expanded mental health services for plan
initiatives according to officials at selected medical centers. However,
in fiscal year 2005, lack of adequate time for headquarters to allocate
funds for plan initiatives to medical centers, late-in-the-year
allocations that hampered medical center efforts to bring staff on board
during the fiscal year, and a lack of guidance concerning allocations for
plan initiatives made through VA's general resource allocation system
resulted in spending on initiatives falling short of what was planned. In
fiscal year 2006, a larger amount, approximately $158 million of the
planned $200 million for plan initiatives, was allocated to medical
centers and other offices than in fiscal year 2005. However, at the end of
the fiscal year about $46 million was returned to VA headquarters that had
not been spent on mental health strategic plan initiatives, and some funds
that remained with medical centers and other offices may have been
directed towards mental health activities other than plan initiatives.

24Officials told us that unspent fiscal year 2006 funds returned to
headquarters were placed in a reserve fund for use in fiscal year 2007 and
would be used for plan initiatives in that fiscal year. These officials
said that the reserve fund is composed of appropriations that do not have
to be obligated within a single fiscal year.

Although available information shows that a substantial portion of the
resources intended for plan initiatives in fiscal years 2005 and 2006 was
not spent on these initiatives, VA does not know the amount of allocated
funds actually spent on them. The extent of spending is unknown because VA
did not track spending of these funds. Although some tracking of mental
health strategic plan initiatives was started in fiscal year 2006, data
were not collected that would allow an assessment of spending. Tracking
the extent to which allocations for plan initiatives are spent for these
initiatives is important as VA continues to allocate resources for future
plan initiatives. This would help to ensure that the money is being spent
as planned, and that VA is in fact addressing gaps that it has identified
in mental health services for veterans.

Recommendation for Executive Action

To provide information for improved management and oversight of how funds
VA allocates are spent to fill identified gaps in mental health services
for veterans, we recommend that the Secretary of Veterans Affairs direct
the Under Secretary for Health to take the following action:

Track the extent to which the resources allocated for mental health
strategic plan initiatives are spent for plan initiatives.

Agency Comments

VA did not provide agency comments on the contents of this report. We
offered VA the opportunity to review and comment on the report, but not
retain copies of the draft as part of a process to help safeguard the
contents from unauthorized disclosure. VA in a written response
(reproduced in app. III) said that it was unable to provide comments on
the draft report because VA was not provided a copy of the report for
appropriate staffing to include review and analysis. VA further stated
that while it respected our desire to maintain the integrity of GAO draft
reports by preventing improper disclosure of draft contents, that this did
not outweigh the need for VA staff to have a copy of the draft report for
review and analysis. We have provided similar report review opportunities
to other agencies for other reports, and have received agency comments in
those circumstances.

We met with VA officials on November 14, 2006, and provided them with an
oral briefing covering the contents of the draft report. Further, a
portion of the contents of this report had previously been released as a
statement for the record at a hearing held by the House Veterans' Affairs
Committee, Subcommittee on Health, on September 28, 2006. We discussed the
information in that statement with VA officials who have responsibilities
related to mental health services, budgeting, and the allocation of
financial resources, and they agreed that the data in the statement were
accurate. As a result, VA is aware of the report's contents.

As agreed with your office, unless you publicly announce the contents of
this report earlier, we plan no further distribution of it until 30 days
from the date of this report. At that time, we will send copies to the
Secretary of Veterans Affairs, appropriate congressional committees, and
other interested parties. We will also make copies available to others
upon request. In addition, the report will also be available at no charge
on the GAO Web site at http://www.gao.gov . If you or your staff have
any questions about this report, please contact me at (202) 512-7101 or
[email protected] . Contact points for our Offices of Congressional
Relations and Public Affairs may be found on the last page of this report.
GAO staff who made major contributions to this report are listed in
appendix IV.

Laurie E. Ekstrand
Director, Health Care

Appendix I: Department of Veterans Affairs (VA) Health Care Networks,
Medical Centers, and Other Facilities GAO Selected for Review

                              Site visits or   Medical centers and other      
VA health care network     phone interviews facilities                     
Network 7 (Atlanta,        Phone interviews    o Decatur, Ga., medical     
Ga.)--Southeast Network                        center                      
                                                  o Tuscaloosa, Ala., medical 
                                                  center                      
                                                  o Birmingham, Ala., Vet     
                                                  Center                      
Network 8 (Bay Pines,      Site visits         o Bay Pines, Fla., medical  
Fla.)--Sunshine Healthcare                     center                      
Network                                        o Tampa, Fla., medical      
                                                  center                      
                                                  o Dunedin, Fla.,            
                                                  community-based outpatient  
                                                  clinic (CBOC)               
                                                  o Lakeland, Fla., CBOC      
                                                  o St. Petersburg, Fla., Vet 
                                                  Center                      
                                                  o Tampa, Fla., Vet Center   
Network 9 (Nashville,      Site visits         o Tennessee Valley          
Tenn.)--Mid South                              Healthcare Systema          
Healthcare Network                             (Nashville, Tenn., and      
                                                  Murfreesboro, Tenn.,        
                                                  campuses) medical center    
                                                  o Clarksville, Tenn., CBOC  
                                                  o Chattanooga, Tenn., Vet   
                                                  Center                      
Network 18 (Phoenix,       Phone interviews    o Albuquerque, N.M.,        
Ariz.)--Southwest Health                       medical center              
Care Network                                   o Phoenix, Ariz., medical   
                                                  center                      
                                                  o Albuquerque, N.M., Vet    
                                                  Center                      

Source: GAO.

aThe Tennessee Valley Healthcare System is a medical center that has two
locations.

Appendix II: Description of Selected Department of Veterans Affairs (VA)
Mental Health Services

VA Mental Health Service     Description                                   
Community-based outpatient   CBOCs provide medical services, which can     
clinics (CBOC)               include mental health, on an outpatient basis 
                                in a community setting. CBOCs are affiliated  
                                with a VA medical center.                     
Compensated Work Therapy     CWT is a therapeutic work-for-pay program     
(CWT)                        that (1) uses remunerative work to maximize a 
                                veteran's level of functioning, (2) prepares  
                                veterans for successful reentry into the      
                                community, and (3) provides a structured      
                                daily activity to those veterans with severe  
                                and chronic disabling physical and/or mental  
                                conditions.                                   
Domiciliary program          Domiciliary residential rehabilitation and    
                                treatment programs for homeless veterans,     
                                providing coordinated, integrated             
                                rehabilitative and restorative clinical care  
                                in a bed-based program, with the goal of      
                                helping eligible veterans achieve and         
                                maintain the highest level of functioning and 
                                independence possible.                        
Grant and Per Diem program   VA offers grants to non-VA organizations in   
                                the community to provide supportive housing   
                                programs and supportive service centers for   
                                homeless veterans. Once programs are          
                                established, VA provides per diem payments to 
                                help offset operational expenses of the       
                                program. Grant and per diem liaisons oversee  
                                services provided by these organizations.     
Mental health intensive case Mental health intensive case management teams 
management                   are designed to deliver high-quality services 
                                that: (1) provide intensive, flexible         
                                community support; (2) improve health status  
                                (reduce psychiatric symptoms and substance    
                                abuse); (3) reduce psychiatric inpatient      
                                hospital use and dependency; (4) improve      
                                community adjustment, functioning, and        
                                quality of life; (5) enhance satisfaction     
                                with services; and (6) reduce treatment       
                                costs.                                        
Mentally ill                 The Mentally Ill Chemically Addicted program, 
chemically-addicted veterans intended to assist underserved veterans with  
initiative                   serious and persistent mental illnesses,      
                                involves recovery- and                        
                                rehabilitation-oriented services in Network   
                                17 as well as training on the recovery model  
                                and psychosocial rehabilitation concepts and  
                                skills.                                       
Operation Iraqi Freedom      Assessment, preventative, and early           
(OIF) and Operation Enduring intervention mental health services for       
Freedom (OEF)                veterans returning from combat in Iraq,       
                                Afghanistan, and other areas. These services  
                                involve outreach and education efforts, as    
                                well as a range of psychosocial support       
                                services.                                     
Peer housing assistance      The Peer Housing Location Assistance Group    
pilot program for homeless   pilot program is a recovery-oriented program  
veterans                     that encourages and enables each veteran to   
                                take responsibility and initiative to choose  
                                and apply for as many housing opportunities   
                                as his or her eligibility characteristics,    
                                preferences, and motivation permit. The       
                                program aims to help participants manage the  
                                process and frustrations of finding and       
                                maintaining safe and secure housing through a 
                                combination of information, problem-solving,  
                                encouragement, professional assistance, and   
                                peer support.                                 
Pilot program for            A collaborative venture between the North     
incarcerated veterans with   Texas Health Care System and the Texas        
mental illness               Correctional Office on Offenders with Medical 
                                and Mental Impairments that provides active   
                                outreach and case management services to      
                                veterans with diagnosed mental illness being  
                                released from the Texas prisons and involves  
                                work with the Texas diversion courts for      
                                mentally ill offenders to provide outreach    
                                and case management services for veterans     
                                convicted of minor offences who have been     
                                diagnosed with mental illness.                
Polytrauma Rehabilitation    Polytrauma Rehabilitation Centers provide     
Centers                      comprehensive interdisciplinary               
                                rehabilitation and coordinated complex        
                                medical, surgical, and mental health care, as 
                                well as long-term follow-up, to veterans of   
                                OIF and OEF who have sustained severe         
                                injuries and have complex rehabilitation      
                                needs.                                        
Post-traumatic stress        Specialized services for veterans returning   
disorder (PTSD)              from Iraq and Afghanistan, as well as         
                                veterans from past service eras, including    
                                the Vietnam War. As part of VA's overall      
                                coordination of postdeployment programs, PTSD 
                                services are focused on veterans who are      
                                survivors of traumatic events and require     
                                comprehensive treatment.                      
Psychosocial rehabilitation  A comprehensive approach to restoring a       
for veterans with serious    veteran's full potential following the onset  
mental illness               of serious mental illness. This approach      
                                involves assisting the veteran in all aspects 
                                of normal life to attain the highest level of 
                                functioning in the community; it includes     
                                such components as patient and family         
                                education; enhancement of residential,        
                                social, and work skills; cognitive behavioral 
                                therapy; motivational interviewing,           
                                integrated dual diagnosis treatment, and      
                                provision of intensive case management when   
                                needed.                                       
Residential rehabilitation   Safety, security, privacy, access, and        
treatment program            infrastructure improvements to domiciliary    
infrastructure improvements  and residential rehabilitation treatment      
                                programs, including repairs, renovations,     
                                furnishings, appliances, equipments,          
                                household goods, and program supplies and     
                                materials. A special emphasis for a component 
                                of these funds was improving access to these  
                                mental health residential programs for women  
                                veterans.                                     
Stand Downs                  Stand Downs are typically 1 to 3 day events   
                                that provide services to homeless veterans    
                                such as food, clothing, health screenings, VA 
                                and Social Security benefits counseling, and  
                                referrals to a variety of other supportive    
                                services such as housing, employment, and     
                                substance abuse treatment. Stand Downs are    
                                collaborative events that are coordinated     
                                between local VA facilities, other government 
                                agencies, and community agencies that serve   
                                the homeless.                                 
Substance abuse              Specialized services for veterans with        
                                substance abuse disorders such as alcoholism  
                                and drug addictions. These services, for      
                                example, are provided in residential          
                                rehabilitation treatment programs.            
Suicide prevention           Initiative designed to obtain causes of death 
initiative                   for veterans who have died in recent years,   
                                to identify those who have died from suicide  
                                and related causes, to identify risk factors, 
                                and to evaluate regional and local            
                                variability in rates and risk factors. The    
                                goal is to obtain information that can guide  
                                evidence-based efforts at suicide prevention, 
                                nationally and at other levels.               
Support for Gulf Coast       Special needs funding for medical supplies,   
mental health programs       equipment, office furniture, and modular      
affected by Hurricane        buildings for Gulf Coast VA mental health     
Katrina                      programs that sustained damage due to         
                                Hurricane Katrina.                            
Telemental health            Telemental health uses electronic             
                                communications and information technology to  
                                provide and support mental health care where  
                                geographic distance separates the clinicians  
                                and patients. These services are often used   
                                in rural areas where the availability of      
                                mental health providers is limited.           
Web-based support tools for  Initiative to develop an interactive set of   
veterans with mental health  web-based tools to allow veterans who have    
concerns                     behavioral or mental health concerns to track 
                                important aspects of their self-care and      
                                professional care.                            

Source: GAO summary of VA information.

Appendix III: Comments from the Department of Veterans Affairs

Appendix IV: GAO Contact and Staff Acknowledgments

GAO Contact

Laurie E. Ekstrand, (202) 512-7101 or [email protected]

Acknowledgments

In addition to the contact named above, Debra Draper, Assistant Director;
James Musselwhite, Assistant Director; Jennie Apter; Robin Burke; and
Steven Gregory made key contributions to this report.

Related GAO Products

VA Health Care: Preliminary Information on Resources Allocated for Mental
Health Strategic Plan Initiatives. [35]GAO-06-1119T . Washington, D.C.:
September 28, 2006.

VA Health Care: Budget Formulation and Reporting on Budget Execution Need
Improvement. [36]GAO-06-958 . Washington, D.C.: September 20, 2006.

VA Long-Term Care: Data Gaps Impede Strategic Planning for and Oversight
of State Veterans' Nursing Homes. [37]GAO-06-264 . Washington, D.C.: March
31, 2006.

VA Long-Term Care: Trends and Planning Challenges in Providing Nursing
Home Care to Veterans. [38]GAO-06-333T . Washington, D.C.: January 9,
2006.

VA Health Care: VA Should Expedite the Implementation of Recommendations
Needed to Improve Post-Traumatic Stress Disorder Services. [39]GAO-05-287
. Washington, D.C.: February 14, 2005.

VA Long-Term Care: Oversight of Nursing Home Program Impeded by Data Gaps.
[40]GAO-05-65 . Washington, D.C.: November 10, 2004.

VA and Defense Health Care: More Information Needed to Determine If VA Can
Meet an Increase in Demand for Post-Traumatic Stress Disorder Services.
[41]GAO-04-1069 . Washington, D.C.: September 20, 2004.

VA Health Care: Resource Allocations to Medical Centers in the Mid South
Healthcare Network. [42]GAO-04-444 . Washington, D.C.: April 21, 2004.

Department of Veterans Affairs: Key Management Challenges in Health and
Disability Programs. [43]GAO-03-756T . Washington, D.C.: May 8, 2003.

VA Health Care: Allocation Changes Would Better Align Resources with
Workload. [44]GAO-02-338 . February 28, 2002.

Agencies' Annual Performance Plans Under the Results Act: An Assessment
Guide to Facilitate Congressional Decisionmaking, Version 1.
[45]GAO/GGD/AIMD-10.1.18. Washington, D.C.: February 1998.

[46]Managing for Results: Critical Issues for Improving Federal Agencies'
Strategic Plans. GAO/GGD-97-180 . Washington, D.C.: September 16, 1997.

Business Process Reengineering Assessment Guide, Version 3.
GAO/AIMD-10.1.15. Washington, D.C.: May 1997.

Agencies' Strategic Plans Under GPRA: Key Questions to Facilitate
Congressional Review, Version 1. GAO/GGD-10.1.16. Washington, D.C.: May
1997.

(290522)

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Highlights of [54]GAO-07-66 , a report to congressional requesters

November 2006

VA HEALTH CARE

Spending for Mental Health Strategic Plan Initiatives Was Substantially
Less Than Planned

The Department of Veterans Affairs (VA) provides mental health services to
veterans with conditions such as post-traumatic stress disorder (PTSD) and
substance abuse disorders. To address gaps in services needed by veterans,
VA approved a mental health strategic plan in 2004. VA planned to increase
its fiscal year 2005 allocations for plan initiatives by $100 million
above fiscal year 2004 levels and its fiscal year 2006 allocations for
plan initiatives by $200 million above fiscal year 2004 levels.

GAO was asked to provide information on VA's allocation and use of funding
for mental health strategic plan initiatives in fiscal years 2005 and
2006, and to examine the adequacy of how VA tracked spending and the
extent of spending for plan initiatives.

GAO reviewed VA reports and documents on plan initiatives and conducted
interviews with VA officials at headquarters, 4 of 21 health care
networks, and seven medical centers. VA networks provide oversight of
medical center operations and most medical center resources.

[55]What GAO Recommends

GAO recommends that VA track the extent to which the resources allocated
for strategic plan initiatives are spent for these initiatives. VA did not
comment on the content of this report.

In fiscal year 2005, VA headquarters allocated about $88 million of the
$100 million above fiscal year 2004 levels that VA officials intended for
mental health strategic plan initiatives. VA allocated about $53 million
directly to medical centers and certain offices based on proposals
submitted for funding and other approaches targeted to specific
initiatives. VA solicited proposals from networks for initiatives to be
carried out at medical centers through requests for proposals (RFP). In
addition, VA headquarters officials said that VA allocated $35 million for
plan initiatives through VA's general resource allocation system to its 21
health care networks on a retrospective basis, several months after
resources had been provided to the networks though the general resource
allocation system. VA did not notify network and medical center officials
that these funds were to be used for plan initiatives. Network and medical
center officials interviewed told GAO that they were not aware these
allocations had been made. As a result, it is likely that some of these
funds were not used for plan initiatives. VA did not allocate the
approximately $12 million remaining of the $100 million for fiscal year
2005 because, according to VA officials, there was not enough time during
the fiscal year to do so. Medical center officials said they used funds
allocated for plan initiatives for new services and for enhancement of
existing services. For example, two medical centers increased the number
of mental health providers at community-based outpatient clinics. However,
some medical center officials reported they did not use all funds
allocated by the end of the fiscal year, due in part to the time it took
to hire staff.

In fiscal year 2006, VA headquarters allocated about $158 million of the
$200 million above fiscal year 2004 levels intended for mental health
strategic plan initiatives directly to medical centers and certain
offices. VA allocated about $92 million of these funds to support new
initiatives, using RFPs and other targeted funding approaches. VA also
allocated about $66 million to support recurring costs of continuing
initiatives from the prior fiscal year. About $42 million of the $200
million for fiscal year 2006 was not allocated. Officials from seven
medical centers GAO interviewed reported they had used funds for plan
initiatives, such as the creation of a new case management program.
Officials at some medical centers reported they did not anticipate
problems using all of the funds allocated within the fiscal year;however,
officials at other medical centers were less certain they would be able to
do so.

VA tracking of spending for plan initiatives was inadequate. In fiscal
year 2005, VA did not track such spending. In fiscal year 2006, VA tracked
aspects of plan initiatives but not dollars spent. However, available
information indicates that VA spending for plan initiatives was
substantially less than planned. In fiscal year 2006, VA medical centers
returned to headquarters about $46 million of about $158 million allocated
for plan initiatives because they could not spend the funds that year.
However, VA cannot determine to what extent the approximately $112 million
remaining was spent on plan initiatives because it did not track
specifically how these funds were spent.

References

Visible links
  26. http://www.gao.gov/cgi-bin/getrpt?GAO-06-1119T
  27. http://www.gao.gov/cgi-bin/getrpt?GAO-02-338
  28. http://www.gao.gov/cgi-bin/getrpt?GAO-04-444
  29. http://www.mentalhealthcommission.gov/
  30. http://www.gao.gov/cgi-bin/getrpt?GAO-02-338
  31. http://www.gao.gov/cgi-bin/getrpt?GAO-04-444
  35. http://www.gao.gov/cgi-bin/getrpt?GAO-06-1119T
  36. http://www.gao.gov/cgi-bin/getrpt?GAO-06-958
  37. http://www.gao.gov/cgi-bin/getrpt?GAO-06-264
  38. http://www.gao.gov/cgi-bin/getrpt?GAO-06-333T
  39. http://www.gao.gov/cgi-bin/getrpt?GAO-05-287
  40. http://www.gao.gov/cgi-bin/getrpt?GAO-05-65
  41. http://www.gao.gov/cgi-bin/getrpt?GAO-04-1069
  42. http://www.gao.gov/cgi-bin/getrpt?GAO-04-444
  43. http://www.gao.gov/cgi-bin/getrpt?GAO-03-756T
  44. http://www.gao.gov/cgi-bin/getrpt?GAO-02-338
  45. http://www.gao.gov/cgi-bin/getrpt?GAO/GGD/AIMD-10.1.18
  46. http://www.gao.gov/archive/1997/gg97180.pdf
  54. http://www.gao.gov/cgi-bin/getrpt?GAO-07-66
*** End of document. ***