How mental health providers spend their time: A survey of 10 Veterans Health Administration mental health services

South Central Mental Illness Research, Education, and Clinical Center, Department of Veterans Affairs, Little Rock, Arkansas, USA.
The Journal of Mental Health Policy and Economics (Impact Factor: 0.97). 07/2003; 6(2):89-97.
Source: PubMed


Allocation of provider time across clinical, administrative, educational, and research activities may influence job satisfaction, productivity, and quality of care, yet we know little about what determines time allocation.
To investigate factors associated with time allocation, we surveyed all mental health providers in one Veterans Health Administration (VHA) network. We hypothesized that both facility characteristics (academic affiliation, type of organization of services, serving as a hub for treatment of severely mentally ill, facility size) and individual provider characteristics (discipline, length of time in job, having an academic appointment) would influence time allocation.
Eligible providers were psychiatrists, psychologists, social workers, physician assistants, registered or licensed practical nurses or other providers (psychology technicians, addiction therapists, nursing assistants, rehabilitation, recreational, occupational therapists) who were providing care in mental health services. A brief self-report survey was collected from all eligible providers at ten VHA facilities in late 1998 (N = 997). Data regarding facility characteristics were obtained by site visits and interviews with managers. Multilevel modeling was used to examine factors associated with three dependent variables: (i) total time allocation by activity (clinical, administrative, educational, research); (ii) clinical time allocation by treatment setting (inpatient vs. outpatient); and (iii) clinical time allocation by type of care (mental vs. physical). Licensed Practical Nurses (LPNs) were used as the reference group for all analyses because LPNs were expected to spend the majority of their time on clinical activities.
Overall, providers spent most of their time on clinical activities (77%), followed by administrative (11%), and educational (10%). Surprisingly, research activities accounted for only 2% of their time. Multilevel analysis indicated none of the facility-level variables were significant in explaining facility variance in time allocation, but individual characteristics were associated with time allocation. The model for predicting time allocation by inpatient or outpatient settings explained 16-18% of the variance in the dependent variable. In all models, provider discipline and length of time in job played an important role. Having an academic appointment was important only in the model examining total time allocation by activity type.
These simple models explained only a small amount of variance in the three dependent variables which were intended to capture issues related to time allocation; and the low number of facilities limited our power to examine effects of facility-level factors. Our models performed better in predicting allocation of clinical time to treatment setting and type of treatment than in predicting overall time allocation. Discipline and length of time in job were significant across all models. In contrast, having an academic appointment was associated with allocating significantly less time to clinical activities and more time to administrative activities but not to any significant difference in time spent in either research or education.
While a gold standard of optimal time allocation does not exist, it is striking that research, a stated mission of the VHA, accounted for so little of providers' time. The lack of involvement of clinicians in research has implications for recruitment and retention of high-quality mental health providers in this network and for the education of future providers. Without involvement of clinicians, research conducted in the network by nonclinicians may be less relevant to "real-world" clinical issues. Reductions of funds available to mental health, coupled with increased clinical demands, may have prompted this pattern of time allocation, and these findings attest to the challenges faced by large institutions that are charged with balancing many often seemingly competing missions.

Download full-text


Available from: Snigdha Mukherjee,
  • Source
    • "Mental health services are coordinated by the network mental health product line manager and the advisory council comprised of the Directors of Mental Health at ten medical centers. These ten medical centers offer both inpatient and outpatient care, provided by more than 1,000 mental health clinicians of various disciplines [4]. There is considerable variation in the organization of the ten mental health services. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Implementing clinical training in a complex health care system is challenging. This report describes two successive training programs in one Veterans Affairs healthcare network and the lessons we drew from their success and failures. The first training experience led us to appreciate the value of careful implementation planning while the second suggested that use of an external facilitator might be an especially effective implementation component. We also describe a third training intervention in which we expect to more rigorously test our hypothesis regarding the value of external facilitation. Our experiences appear to be consonant with the implementation model proposed by Fixsen. In this paper we offer a modified version of the Fixsen model with separate components related to training and implementation. This report further reinforces what others have noted, namely that educational interventions intended to change clinical practice should employ a multilevel approach if patients are to truly benefit from new skills gained by clinicians. We utilize an implementation research model to illustrate how the aims of the second intervention were realized and sustained over the 12-month follow-up period, and to suggest directions for future implementation research. The present report attests to the validity of, and contributes to, the emerging literature on implementation research.
    Implementation Science 06/2008; 3(1):33. DOI:10.1186/1748-5908-3-33 · 4.12 Impact Factor
  • Source
    • "The main apportionment of waking time is roughly similar when compared with previous studies: first clinical activities then further education and paper work for all professionals, even if this survey did not preclude biased recall of retrospective agendas, as did the survey using a hand-held computer[32]. The present results revealed that physicians without an academic inscription had less time for education and research than other European general physicians in academic departments, American residents or American psychiatrists [32-35]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Providing care for mental health problems concerns General Practitioners (GPs), Private Psychiatrists (PrPs) and Public Psychiatrists (PuPs). As patient distribution and patterns of practice among these professionals are not well known, a survey was planned prior to a re-organisation of mental health services in an area close to Paris All GPs (n = 492), PrPs (n = 82) and PuPs (n = 78) in the South-Yvelines area in France were informed of the implementation of a local mental health program. Practitioners interested in taking part were invited to include prospectively all patients with mental health problem they saw over an 8-day period and to complete a 6-month retrospective questionnaire on their mental health practice. 180 GPs (36.6%), 45 PrPs (54.9%) and 63 PuPs (84.0%) responded. GPs and PrPs were very similar but very different from PuPs for the proportion of patients with anxious or depressive disorders (70% v. 65% v. 38%, p < .001), psychotic disorders (5% v. 7% v. 30%, p < .001), previous psychiatric hospitalization (22% v. 26 v. 61%, p < .001) and receiving disability allowance (16% v. 18% v. 52%, p < .001). GPs had fewer patients with long-standing psychiatric disorders than PrPs and PuPs (52%, 64% v. 63%, p < .001). Time-lapse between consultations was longest for GPs, intermediate for PuPs and shortest for PrPs (36 days v. 26 v. 18, p < .001). Access to care had been delayed longer for Psychiatrists (PrPs, PuPs) than for GPs (61% v. 53% v. 25%, p < .001). GPs and PuPs frequently felt a need for collaboration for their patients, PrPs rarely (42% v. 61%. v. 10%, p < .001). Satisfaction with mental health practice was low for all categories of physicians (42.6% encountered difficulties hospitalizing patients and 61.4% had patients they would prefer not to cater for). GPs more often reported unsatisfactory relationships with mental health professionals than did PrPs and PuPs (54% v. 15% v. 8%, p < .001). GP patients with mental health problems are very similar to patients of private psychiatrists; there is a lack of the collaboration felt to be necessary, because of psychiatrists' workload, and because GPs have specific needs in this respect. The "Yvelines-Sud Mental Health Network" has been created to enhance collaboration.
    BMC Public Health 10/2005; 5(1):104. DOI:10.1186/1471-2458-5-104 · 2.26 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Medications to treat depression, anxiety, sleep problems; and smoking cessation are often prescribed to people with heart disease by their primary care physicians or cardiologists. These categories of medication are commonly encountered by therapists working with a cardiac population arid are thus the focus of this chapter. The relative advantages of pharmacotherapy combined with psychotherapy have been demonstrated in many clinical trials (I. W. Miller & Keitner; 1996). A basic working knowledge of psychotropic medications commonly used in cardiac patients can be helpful to therapists. Patients often have a difficult time discriminating between somatic symptoms that may be caused by psychological distress, heart problems, a side effect bf medication, of some combination of these factors. Pharmacological treatment for psychological problems in people with heart disease is complex and requires attention to the effect that the medication will have on cardiac function, potential to improve psychological well-being, severity of the psychological problem, and the patient's history of compliance with other medical regimens. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Show more