Military Sexual Trauma (MST)

1.  PURPOSE:  This Veterans Health Administration (VHA) Directive provides policy for
clinical care, monitoring, staff education, and informational outreach related to military sexual trauma (MST) counseling, care, and services.

2.  BACKGROUND

    a.  Based on Title 38 United States Code (U.S.C.) 1720D, the Department of Veterans Affairs (VA) provides counseling, care, and services to Veterans and certain other Servicemembers who may not have Veteran status, but who experienced sexual trauma while serving on active duty or active duty for training.  MST is defined as “psychological trauma, which in the judgment of a mental health professional employed by the Department, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was serving on active duty or active duty for training.”  Sexual harassment is further defined as “repeated, unsolicited verbal or physical contact of a sexual nature, which is threatening in character.”  MST-related care must be provided in a setting that is therapeutically appropriate, taking into account the circumstances that resulted in the need for such counseling.  Public Law 103-452 removed limits on the duration of this care and specified that it must be available to both male and female survivors of MST.  Public Law 108-422 made VA’s authorization to provide this care permanent.

    b.  VA has determined that because VA provides sexual trauma counseling and care pursuant to 38 U.S.C. Section 1720D only for sexual trauma-related disabilities that are incurred in service, there are no requirements for the condition to be adjudicated as service connected.  Length of service or income eligibility requirements do not apply in order to receive this benefit.  Veterans and eligible individuals who experienced MST while on active duty or active duty for training do not need to have filed a disability claim, be service connected, or provide evidence of the sexual trauma to receive MST-related care.  Veterans and eligible individuals who report experiences of MST, but who are deemed ineligible for other VA health care benefits or enrollment, may be provided MST-related care only.  This benefit extends to Reservists and members of the National Guard who were activated to full-time duty status in the Armed Forces.  Veterans and eligible individuals who received an “other than honorable” discharge may be able to receive free MST-related care with the Veterans Benefits Administration (VBA) Regional Office approval.  NOTE:  For purposes of this Directive, “eligible individual” means someone without Veteran status who experienced sexual trauma as described in subparagraph 2a while on active duty or active duty for training.  Because eligibility accrues as a result of events incurred in service and is not dependent on length of service some individuals may be eligible for MST-related care even if they do not have Veteran status.  

    c.  All health care for treatment of mental and physical health conditions related to MST, including medications, is provided free of charge.  Fee basis is available when it is clinically

THIS VHA DIRECTIVE EXPIRES JULY 31, 2015

inadvisable to provide counseling in a VA facility, when VA facilities are geographically inaccessible, or when VA facilities are unable to provide care in a timely manner.  Referral to the local Readjustment Counseling Service (Vet Center) may also be an appropriate option.  NOTE:  Policies specific to the availability of MST-related care in Community-based Outpatient Clinics (CBOCs) are specified in VHA Handbook 1160.01.

    d.  Staff training and informational outreach are important components of MST-related programming.  Mental health and other health care personnel must receive appropriate training on MST-related issues.  VA engages in efforts to ensure that Veterans and potentially eligible individuals are informed about MST-related services available through VHA.

3. POLICY:  It is VHA policy to provide Veterans and eligible individuals who report having experienced MST with free care for all physical and mental health conditions determined by their VA provider to be related to experiences of MST.

4.  ACTION  

    a.  Veterans Integrated Service Network (VISN) Director.  The VISN Director is responsible for ensuring:

    (1)  Appointment of MST VISN-level Point of Contact (POC).  Each VISN must have a designated MST VISN-level POC whose responsibilities are described in subparagraph 4b.  The VISN MST POC needs to be a professional knowledgeable about mental health and informed about MST and treatment of its after-effects.  This is a collateral position, but the MST POC needs to be given adequate protected time to fulfill the responsibilities of the role.  

    (2)  Access to Specialized Residential or Inpatient Care.  Veterans and eligible individuals must have access to residential or inpatient programs able to provide specialized MST-related mental health care, when clinically needed, for conditions resulting from MST.  VISNs or VA medical centers that do not have these programs need to develop Memoranda of Understanding with VISNs that do have these services.  NOTE:  At a national level there is a need to consider developing a number of these programs as national resources and to arrange processes for referral, discharge, and follow-up.  

    b.  VISN-level MST POC.  The VISN-level MST POC is responsible for:

    (1)  Monitoring and helping to ensure national and VISN-level policies related to MST are implemented at individual facilities and associated CBOCs within the VISN; 

    (2)  Providing support, assistance, and opportunities for communication and networking to MST Coordinators within the VISN; and 

    (3)  Communicating with national, VISN, and facility-level leadership and other stakeholders.  

    c.  Facility Director.  The Facility Director is responsible for ensuring:

    (1)  Appointment of an MST Coordinator.  Every facility must have a designated MST Coordinator whose responsibilities are described in subparagraph 4d.  The facility MST Coordinator needs to be a professional who is knowledgeable about trauma and mental health and who possesses expertise in issues specific to MST.  Given that part of the role of the MST Coordinator is to provide information and assistance to Veterans and eligible individuals in accessing MST-related care at the facility and associated CBOCs, the MST Coordinator must be sensitive to issues arising in the clinical care of MST survivors, in order to handle these contacts appropriately.  Although some facilities have established the MST Coordinator as a full-time position, it is permissible for the role to be assigned as a collateral duty.  If this is the case, care must be taken to ensure that the MST Coordinator is given adequate protected time to fulfill the responsibilities of the role.  Facility size and complexity, number of associated CBOCs, the size of the facility’s catchment area, and the size of the local MST population are to be considered in making this assessment.  NOTE:  Although the MST Coordinator may engage in the provision of clinical care to MST survivors as part of the MST Coordinator’s  primary position, the MST Coordinator role is defined by screening and treatment program development, monitoring, staff education and training, informational outreach to Veterans and potentially eligible individuals, and other administrative responsibilities. 

    (2)  Universal Screening.  All Veterans and potentially eligible individuals seen in VHA facilities and associated CBOCs must be screened for experiences of MST.  This must be done using the MST Clinical Reminder in the Computerized Patient Record System (CPRS), (see subpar. 4c(5)).  Screening is to be conducted in appropriate clinical settings by providers with an appropriate level of clinical training; screenings are not to be conducted by clerks or health technicians.

    (3)  Availability of MST-related Care.  Facilities and associated CBOCs must have appropriate physical and mental health care available for conditions related to MST.  NOTE:  Policies specific to the availability of MST-related care in CBOCs are specified in VHA Handbook 1160.01.  Care must be delivered by staff with appropriate qualifications and training.  Facilities must ensure that there is a sufficient number of clinicians trained in the provision of specialized mental health care related to MST to adequately meet the demand for care.  Scheduling priority for outpatient sexual trauma counseling, care, and services is consistent with VHA performance standards for scheduling clinics.  NOTE:  When clinically indicated, facilities are strongly encouraged to accommodate the requests of Veterans and eligible individuals for a provider of a particular sex for their care for conditions related to MST.

    (4)  Co-payments.  Veterans and eligible individuals are provided free care, with no inpatient, outpatient, or pharmacy co-payments, for mental and physical health conditions resulting from their experiences of MST.  The provider of services makes the determination of whether the visit involved care related to a Veteran’s experiences of MST and must indicate this by checking the MST checkbox on the encounter form for the visit. Neither individuals nor health insurance plans are billed co-payments for MST-related inpatient, outpatient, or pharmaceutical treatment; however, applicable co-payments may be charged for services not related to MST.  Facilities and associated CBOCs must have mechanisms in place to ensure that Veterans and potentially eligible individuals who may have conditions related to MST that require care, but who are not eligible for other VHA care, are able to be evaluated by a clinician to determine the applicability of the free care benefit.

    (5)  Monitoring of Screening, Referral, and Treatment.  To ensure that national data on MST-related screening, referral, and treatment is accurate, the national MST software application must be installed and function properly at every facility and associated CBOCs.  The national MST software application activates both the MST Clinical Reminder and, when applicable, the MST-related care encounter form checkbox in CPRS.  The MST Clinical Reminder must be activated for all Veterans and potentially eligible individuals.  Veterans and eligible individuals who screen positive for MST must have the MST-related care checkbox activated on their encounter forms and all MST-related care must be indicated by checking this box on the encounter form for the visit.  Purpose of visit code 55, of the fee package, is recommended to indicate fee basis MST-related care.  Because MST is an experience and not a diagnosis and because patients who report MST are provided free care for both physical and mental health conditions related to MST, care is often provided through a variety of clinics identified by a range of clinic stop codes.  NOTE:  Although some facilities have historically used clinic stop code 524 (Active Duty Sexual Trauma) as an indicator for MST-related care, this is not recommended as it cannot capture the full range of services for which patients are eligible. 

    (6)  Education.  Staff must receive education and training about MST-related issues appropriate to their role with Veterans and potentially eligible individuals.  Providers of clinical services must be aware of the requirement to screen for MST and know how to screen sensitively, when appropriate to their role.  They must also be aware of referral processes for treatment and recognize how a history of MST may affect their provision of care.  

    (7)  Informational Outreach to Veterans.  Information regarding VA’s services related to MST must be made available through appropriate public information services and must be visibly posted or displayed in appropriate places within the facility.

    d.  Facility MST Coordinator.  The facility MST Coordinator is responsible for:

    (1)  Monitoring and helping to ensure national and VISN-level policies related to MST screening and treatment to ensure they are implemented at the facility and associated CBOCs.  For example, MST has unique eligibility guidelines and monitoring requirements that MST Coordinators must help ensure are implemented.  The MST Coordinator establishes and monitors mechanisms to ensure that all Veterans and potentially eligible individuals receiving VHA health care are screened for experiences of MST using the clinical reminder in CPRS, that those who screen positive have expedient access to a continuum of appropriate MST-related care, and that this care is provided free of charge.  The MST Coordinator monitors local MST-related programming and, as needed, makes efforts to expand the program’s scope.  MST survivors often have complex clinical needs and may be high utilizers of care; depending upon local needs and resources, programming may involve development of a specialized MST treatment team to ensure adequate coordination of care.  

    (2)  Monitoring and helping to ensure that national and VISN-level policies about staff education related to MST are implemented at the facility and associated CBOCs.  The MST Coordinator directly provides or establishes and monitors mechanisms to ensure that staff at the facility and associated CBOCs receive legally-mandated education and training related to MST.  Given VA policy of universal MST screening and the tendency for MST survivors to present with multiple mental and physical health comorbidities, education must occur in clinics throughout the facility and associated CBOCs.  Depending upon a staff member’s role and level of contact with MST survivors, training needs to cover such topics as:  sensitivity and confidentiality; treatment options; importance of, and rationale for, screening; potential impact of an MST history on provision of care; and background information on MST (e.g., prevalence of MST, impact of sexual trauma, etc.).  

    (3)  Monitoring and helping to ensure that national and VISN-level policies about informational outreach related to MST are implemented at the facility and associated CBOCs.  The MST Coordinator directly engages in and establishes and monitors mechanisms to provide informational outreach to Veterans and potentially eligible individuals and facilitates their engagement in care.  The MST Coordinator ensures that Veterans and potentially eligible individuals are aware of the MST Coordinator role and contact information; and are familiar with local services available.  

    (4)  Serving as a point of contact, source of information, and problem solver for MST-related issues at the facility and associated CBOCs.  

    (a)  The MST Coordinator establishes formal mechanisms for communication and problem-solving related to MST issues at the facility and associated CBOCs, with a particular emphasis on establishing relationships with the facility Business Office (or other offices dealing with enrollment, eligibility, and billing issues); Information Resource Management Service; Women Veterans Health Program Manager; clinical directors in Mental Health, Primary Care, and other relevant clinical areas; and facility leadership among others.  

    (b)  MST Coordinators serve as POC for Veterans and other individuals with questions about MST-related services at the facility and associated CBOCs.  Accordingly, the MST Coordinator ensures that staff at various points of entry into the system (e.g., telephone operators, information desk staff, Mental Health clerks, Business Office staff) know the MST Coordinator’s role and contact information.  

    (c)  MST Coordinators address systems issues that may create barriers to Veterans and eligible individuals entering care and act as an advocate for Veterans and eligible individuals in their interactions with relevant VHA clinics and offices.  For example, when fee basis care is warranted, the facility credentialing and privileging system must be notified prior to the initial visit with the fee basis provider; this notification alerts the credentialing and privileging system to obtain information needed to update the provider’s file and authorize prescription of medications.  

    (d)  MST Coordinators help ensure that systems are in place to prevent Veterans and eligible individuals from encountering difficulties in obtaining reimbursement, filling prescribed medications, or receiving appropriate care.

    (5)  Communicating with national, VISN, facility-level leadership, and other stakeholders.  The MST Coordinator communicates regularly with the VISN-level MST POC and other MST Coordinators in the VISN, as well as local mental health and national MST leadership in order to remain knowledgeable about policies and trends related to MST.  In addition, the MST Coordinator responds to requests for information about local MST programming from VA Central Office’s Office of Mental Health Services.  

5.  REFERENCES

    a.  Public Law 103-452, Veterans Health Care Extension Act, dated November 2, 1994.

    b.  Public Law 108-422, Veterans Health Program Improvement Act of 2004, dated November 30, 2004.

    c.  Title 38 U.SC. 1720D, Counseling and treatment for sexual trauma.

    d.  Office of General Counsel document, Military Sexual Trauma, dated June, 2006.

    e.  VHA Handbook 1160.01.  

6.  FOLLOW-UP RESPONSIBILITY:  Office of Mental Health Services (116) is responsible for the contents of this Directive.  Questions may be referred the Director, Family Services, Women’s Mental Health, and Military Sexual Trauma, at: 202-340-4192. 
 
7.  RECISSIONS:  VHA Directive 2005-015 is rescinded.  This VHA Directive expires 
July 31, 2015.

    Robert A. Petzel, M.D.
    Under Secretary for Health 

DISTRIBUTION:        E-mailed to the VHA Publications Distribution List 7/15/2010