This study used national VHA data to compare the proportions and characteristics of the 82% of veterans treated exclusively in traditional mental health outpatient clinics to the 18% of veterans treated in VHA’s four major specialized community-based programs. Veterans treated in all four types of community programs were distinguished most strikingly, by being diagnosed with 2-3 times more numerous multimorbid substance use disorders, were more likely to have HIV and hepatic disease, to be from urban areas, of black race and also, as expected, had 3-13 times more mental health outpatient visits, most of which were in community-based programs themselves. Veterans served in the specialized programs for SMI veterans (only 2% of the total) were much more likely than clinic patients to be diagnosed with psychotic disorders, to manifest psychiatric multimorbidity and personality disorders and had 13 times more total visits, receiving over three times as many prescriptions for psychotropic medications.
In the decades after the closure of public psychiatric hospitals in the 1950s-70s, public mental health systems faced the question of how to address the broad needs of: 1) SMI patients who formerly would have been institutionalized, as well as the needs of emerging populations of 2) homeless people with mental illnesses; 3) criminal justice involved adults with mental health disorders; 4) veterans seeking rehabilitation/employment along with 5) a much larger group of people newly seeking effective care for less severe problems. The intensive community programs included in this study all originated in a push by VHA to develop care beyond the clinic in the community, primarily to better address the clinical challenges of SMI. At their inception, these programs were at times organizationally integrated  or co-located  together and with primary care services. While there has been extensive documentation of the reduction in long term State and VHA psychiatric hospital beds [54,55,5], and many studies of the growth of outpatient mental health treatment generally [56-58]; we know of no previous system-wide studies of the place of community-based services in any public mental health system nor of characteristics of people who use these services as compared to people served by standard outpatient clinics.
On the one hand, available studies have examined mental health service delivery in the US as a whole and have shown that “the system” faces major challenges with respect to the treatment engagement of people with serious mentally illness . On the other, the National Comorbidity Survey (NCS) and NCS Replication show that between 1990 and 2003 basic treatment rates for people with mental illness increased significantly while the overall rates of mental illness did not change  although many remained underserved . Additionally, among people with SMI, rates of any mental health treatment increased from 24.3% to 40.5% . Furthermore, data from the Healthcare for Communities Survey showed an increase in mental health specialty treatment for people with SMI from 39% in 1997 to 51% in 2001 with an even larger increase (from 47% to 76%) for the subgroup who perceived a need for treatment . These studie, however, did not examine community-based services, specifically, and most studies have focused on people with mild to moderate mental illness. For example, studies of the National Ambulatory Medical Care Survey found that treatment for depression tripled between 1987 and 1997 , and that most antidepressants are prescribed by primary care providers [59,60].
Local studies based on Medicaid data do show that community programs continued to provide ACT and ACT-like services to the most seriously mentally ill and functionally impaired adults , though one recent survey suggested that less than 20% of non-VA community mental health facilities offer ACT  and even fewer offer other community services such as peer support, employment, and housing services . While most research has focused on either people who use less intensive services (i.e. from standard mental health outpatient clinics) or specific community-based treatments like ACT or supported housing, no study to our knowledge has addressed the broad array of clinic and intensive community-based services offered together in a national system or even in one community. The present study, based on VHA data showed intensive community-based service are provided to 18% of those receiving any specialty mental health services especially to those with multiple substance use disorders, severe mental illness, criminal justice involvement, and/or homelessness. A previous study of VHA care showed that considering all patients with psychiatric diagnoses, one-third receive no specialty mental health treatment at all and recieive care for mental disorders exclusively in primary or specialty care clinic setiings . That study and this one taken together, thus appear to be unique in mapping the major components of VHA mental health care, a comprehensive mental health system in which most patients receive care in standard outpatient mental health and primary care clinics but distinct subgroups receive intensive community-focused care largely shaped by social determinants and SUD-related multimorbidity.
In view of this perspective, it is notable that several recent reviews have emphasized the unique role of mental health services in addressing social determinants of health as well as individual biomedical conditions [65,26,27]. The portrait of community-based care in VHA presented here illustrates the way mental health systems have been shaped by such social determinants. Sheilds-Zeeman described two types of intervention which are referred to as “social risk–informed” care and “social risk-targeted care.” Social risk–informed care tailors clinical plans to reduce the effect of social or economic adversity, most often in conventional clinic settings, without necessarily targeting the social condition itself. Social risk-targeted care, in contrast, more directly helps patients to reduce social or economic adversity, and is more focused on community intervention. The community-based programs described here fall into both categories in that they seek to provide in vivo services at the individual level focusing on real world adaptation to challenging circumstances while also directly addressing patient-level problems such as housing, criminal justice involvement, impaired activites of daily living, limited employment opportunities, social isolation and a stigmatizing environment. The developing conceptualization of mental health care within a social determinants of health framework, thus provides an overarching context for understanding the unique role of community-focused programs.
Several methodological limitations of this study require comment. First, our ability to identify services delivered through community-based programs is limited to those identified by specific clinic codes in VHA administrative records. It is likely that other programs in VHA that would conform to our concept of community-based care that were implemented through local initiatives, which we could not identify. However, those examined here were developed through national initiatives, often supported by special funding and are probably the largest and best definied. Perhaps the issue most neglected by this study is poverty, addressed by VA disability compensation and pension programs for many veterans. These programs were less commonly used by veterans served by outreach to criminal justice involved and homeless veterans although their access to these benefits likely increases after a period of program participation . Crucial data are also not available on the income obtained from social security and local welfare programs.
Second, the definition of intensive community-based programs is not precise and while most programs addressed here involve frequent contact with veterans outside of health care facilities there is variability from program to program (e.g. criminal justice programs focus on linkage rather than intensive service delivery) and facility to facility in the extent of vivo as contrasted with office-based service delivery in these programs. Nevertheless, all of the programs are intended to address exceptionally serious clinical conditions and specific socially determined challenges to community adaptation.
Third, administrative diagnoses are not based on formal diagnostic instruments or criteria, but have the advantage of representing real-world clinical judgements.
Fourth, this study focuses on data from the VHA which offers the advantage of providing comprehensive national data from electronic health records. However VHA is federally funded and operated and serves only veterans, who are overwhelmingly male, and thus its generalizability to other populations and health systems is unknown. The extent to which veterans studied here received non-VA services is also unknown. This study offers a sketch of one system which, it is hoped, will stimulate similar studies of others.
Finally, the data used in this study are somewhat dated as they are now 8 years old. However, 2012 was closer than more contemporary data to the point in time when community-based services emerged in the VHA in response to emerging social needs of several subgroups of veterans. In addition, a recent study  found little change in the characteristics of homeless veterans treated by VHA from FY 2008 to FY 2015, a major segment of the population with social challenges that the VHA now serves through community-based programs..
This study could not describe each type of intensive community-based program offered by the VHA in detail but rather, summarized their primary service models and characterize the veterans they serve. We do provide data on the average number of contacts of each program with the veterans it serves.