VHA GAF Directive
Department of Veterans Affairs
VHA Directive 97-059
Veterans Health Administration
Washington, DC 20420
November 25, 1997
INSTITUTING GLOBAL ASSESSMENT OF FUNCTION (GAF)
SCORES IN AXIS V FOR MENTAL HEALTH PATIENTS
1. PURPOSE: This Veterans Health Administration (VHA) Directive describes new policy and procedures for determining and capturing the Axis V, Global Assessment of Functioning (GAF) scale for all mental health patients.
2. BACKGROUND
a. As part of the Government Performance Results Act (GPRA), the Department of Veterans Affairs (VA) has been given two performance goals with regard to seriously mentally ill (SMI) veterans:
- Goal 1. VHA is to evaluate every mental health patient using the Global Assessment of Functioning (GAF) scale at least once, define those who are seriously mentally ill, and calculate the GAF index for the SMI population in FY 1998. The GAF is taken directly from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), p. 32, except that VHA only includes scores from 1 to 100, excluding 0 (insufficient information).
- Goal 2. VHA will raise the average GAF index over the Fiscal Year (FY) 1998 baseline for the SMI pool of enrollees by five percent between FY 1999 and FY 2003.
b. Public Law 104-262, the Veterans Eligibility Reform Act of 1996, requires that VA will maintain its capacity to provide for the specialized treatment and rehabilitative needs of disabled veterans (including veterans with spinal cord dysfunction, blindness, amputations, and mental illness) within distinct programs or facilities of the Department. In order to define the population of disabled mentally ill veterans so as to preserve VA’s capacity to treat them, VHA is committed to using the GAF, as described in the GPRA Goal 1, in paragraph 2.a.
c. For many years, the American Psychiatric Association’s multi-Axis diagnostic system described in DSM-IV, and its earlier editions, have been recommended as a preferred system for VA Mental Health Programs. DSM-IV and its earlier editions are compatible with the International Classification of Diseases, Ninth Edition (ICD-9-CM) used for all other VHA diagnoses.
d. In this system, Axis I includes the clinical [mental] disorders including other [mental] conditions that may be a focus of clinical attention; Axis II records personality disorders; Axis III includes all general medical conditions; Axis IV addresses psychosocial and environmental problems; and Axis V is the Global Assessment of Functioning. While VHA has encouraged use of all five Axes, we currently have no way or special reason for capturing Axis IV for analysis. As we move toward a primary care mental health approach, the medical (Axis III) diagnoses increase in importance.
e. Since 1991, VHA mental health clinicians at many facilities have been routinely recording Axis V GAF scores on all inpatient discharges from psychiatric specialty bed sections as part of the discharge summary. A clerk from Medical Administration Service later codes the diagnoses and enters the GAF scores into the facility’s Patient Treatment File. VA Domiciliaries and Nursing Homes are excluded, even though psychiatric patients are discharged from these and other non-psychiatric bed sections.
f. In FY 1997, new AICS (Automated Information Collection System) software, for the first time permitted the recording of outpatient diagnoses captured from patient encounter forms prepared by clinicians at each visit.
g. The Mental Health Package (MHP), which can be used to record and store GAF scores, is installed at all facilities which have any patients receiving mental health care. NOTE: Some staff at most facilities use the Mental Health Package and are familiar with it.
3. POLICY
a. It is VHA policy that, starting in FY 1998, as part of the diagnosis, mental health clinicians are required to record at least one GAF score in Axis V reflecting the "current level of functioning" for each veteran patient seen at any VHA mental health inpatient or outpatient setting.
(1). Outpatients seen in a mental health clinic or program who have not had a GAF score for 90 days will require an update. "Mental health clinics or programs" are defined as those for which a 500 series stop code, now also called Decision Support System (DSS) Identifier, is generated (with the exception of the telephone stop codes numbers 526, 527, 528, 542, 545, and 546).
(2). At least one GAF score in Axis V will now be required for all patients discharged from psychiatric bed sections. A zero score indicating "insufficient information" will no longer be permitted.
(3). GAF scores for all patients included in the Annual Patient Census will be required before September 30, 1998.
b. Responsibility
(1). The Chief Information Officer. The Chief Information Officer will oversee development of software described in this Directive in a timely manner.
(2). VISN Directors. VISN Directors are to ensure that medical facilities within their area of responsibility initiate the policy found in this Directive immediately.
(3). Mental Health Strategic Healthcare Group. The Mental Health Strategic Healthcare Group (116) will be responsible for retrieving GAF information, analyzing the information and creating national, VISN, and facility-level reports as needed.
4. ACTION:
a. Starting Oct. 1, 1997, each veteran patient seen at any VHA mental health inpatient or outpatient setting will be assessed using the GAF score in Axis V. All GAF scores will be stored at each facility within the Mental Health Package (MHP) of the Veterans Health Information System and Technology Architecture (VISTA) (formerly the Decentralized Hospital Computer Program (DHCP)).
b. The Office of the Chief Information Officer (OCIO) will expedite preparation of outpatient encounter forms that include GAF scores at each facility, and insure that mechanisms exist to transfer such scores from the encounter forms into the appropriate VISTA software package. Until such time as facilities have the new encounter form scanning technology, this, like coding the diagnosis and any other information from the encounter form, will have to be performed manually.
c. The OCIO will develop software for each facility during early in FY 1998 that will automatically take GAF scores from the (inpatient) Patient Treatment File and enter them into the appropriate VISTA software package.
d. As soon as feasible this Fiscal Year, the OCIO will develop additional software for the Patient Care Encounter (PCE) and Scheduling software that will integrate the GAF into current coding of outpatient information and automatically transfer such data into the appropriate VISTA software package.
e. This Fiscal Year, the OCIO will modify the Automated Information Collection System (AICS) to scan the outpatient encounter forms and enter that data into appropriate files, including transferring the GAF into the appropriate VISTA software package.
f. This Fiscal Year, the OCIO will determine which Austin file will contain the roll-up of all GAF scores and provide software that will transfer GAF scores from VISTA files to Austin (VHA’s national database).
5. REFERENCES
a. Public Law 104-262, the Veterans Eligibility Reform Act of 1996.
b. Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (DSM-IV). American Psychiatric Association, Washington, DC, 1996.
6. FOLLOW-UP RESPONSIBILILTY: The Mental Health Strategic Healthcare Group (116) is responsibility for the content of this Directive.
7. RESCISSIONS: This Directive will expire on November 25, 2002.
(signed)
Kenneth W. Kizer, M.D., M.P.H.
Under Secretary for Health
DISTRIBUTION: CO: E-mailed 11/26/97
FLD: VISN, MA, DO, OC, OCRO and 200 - FAX 11/26/97
EX: Boxes 104, 88, 63, 60, 54, 52, 47 and 44 - FAX
11/26/97
PURPOSE: This Veterans Health Administration (VHA) Directive describes new policy and procedures for determining and capturing the Axis V, Global Assessment of Functioning (GAF) scale for all mental health patients as required by law.
BACKGROUND:
1. As part of the Government Performance Results Act (GPRA), the Department of Veterans Affairs (VA) has been given a goal to evaluate every mental health patient using the Global Assessment of Functioning (GAF) scale at least once, define those who are seriously mentally ill, and calculate the GAF index for the SMI population in FY 1998 [and thereafter]. In addition, the Veterans Eligibility Reform Act of 1996, requires that VA will maintain its capacity to provide for the specialized treatment and rehabilitative needs of disabled mentally ill veterans, as defined by the GPRA criteria.
2. VHA has had no mechanism to perform, record, or retrieve the GAF scores in our outpatient settings. The Mental Health Strategic Healthcare Group has been working with mental health field staff and with the Office of the Chief Information Officer since last January to prepare the necessary software and advise our respective staffs how to respond. We have had numerous discussions on FORUM and on MHSHG’s monthly conference calls about best ways to meet the October 1 starting time and still prepare needed software. A compromise was reached among our need for sufficient data, the time generally required for a significant change in GAF scores to occur, and the added workload imposed on clinicians (generally less than a minute per patient). The resulting policy states that outpatients reporting for treatment who have not had a GAF score for 90 days, will require an update. Patients shall clearly not be called in just for a GAF rating.
3. GAF scores have been required on all discharges from psychiatric bed sections since October, 1991. Compliance was mandated by software that would not permit a record to be signed out without a GAF score. However, noncompliance in spirit has been achieved by permitting a "0" score, indicating "insufficient information," which was used in the great majority of records. Since there are now consequences for non-compliance under GPRA and PL104-262, we are omitting the "0" score.
IMPLICATIONS: VHA will be in compliance with both GPRA and Public Law 104-262 if we initiate this Directive immediately. VISN and Medical Center Directors will need as much time as possible to initiate necessary procedures.
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* Modified in response to concerns by the Chief Network Officer.