[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
HONORING THE COMMITMENT: OVERCOMING
BARRIERS TO QUALITY MENTAL HEALTH CARE
FOR VETERANS
=======================================================================
HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
__________
WEDNESDAY, FEBRUARY 13, 2013
__________
Serial No. 113-3
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida CORRINE BROWN, Florida
DAVID P. ROE, Tennessee MARK TAKANO, California
BILL FLORES, Texas JULIA BROWNLEY, California
JEFF DENHAM, California DINA TITUS, Nevada
JON RUNYAN, New Jersey ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan RAUL RUIZ, California
TIM HUELSKAMP, Kansas GLORIA NEGRETE MCLEOD, California
MARK E. AMODEI, Nevada ANN M. KUSTER, New Hampshire
MIKE COFFMAN, Colorado BETO O'ROURKE, Texas
BRAD R. WENSTRUP, Ohio TIMOTHY J. WALZ, Minnesota
PAUL COOK, California
JACKIE WALORSKI, Indiana
Helen W. Tolar, Staff Director and Chief Counsel
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C O N T E N T S
__________
February 13, 2013
Page
Honoring The Commitment: Overcoming Barriers To Quality Mental
Health Care For Veterans....................................... 1
OPENING STATEMENTS
Hon. Jeff Miller, Chairman, Full Committee....................... 1
Prepared Statement of Chairman Miller........................ 35
Hon. Michael Michaud, Ranking Minority Member, Full Committee.... 3
Prepared Statement of Hon. Michaud........................... 36
Hon. Jackie Walorski, Prepared Statement only.................... 37
Hon. Raul Ruiz, Prepared Statement only.......................... 37
WITNESSES
M. David Rudd, Ph.D. ABPP, Dean, College of Social and Behavioral
Sciences, Co-Founder and Scientific Director, National Center
for Veteran Studies, University of Utah........................ 5
Prepared Statement of Dr. Rudd............................... 37
Linda Spoonster Schwartz, RN, Dr.PH, FAAN, Commissioner of
Veterans Affairs, State of Connecticut......................... 7
Prepared Statement of Dr. Schwartz........................... 39
Joy J. Ilem, Deputy National Legislative Director, Disabled
American Veterans.............................................. 9
Prepared Statement of Ms. Ilem............................... 45
Ralph Ibson, National Policy Director, Wounded Warrior Project... 11
Prepared Statement of Mr. Ibson.............................. 51
Robert A. Petzel, M.D., Under Secretary for Health, Veterans
Health Administration, U.S. Department of Veterans Affairs..... 22
Prepared Statement of Robert A. Petzel....................... 56
Accompanied by:
Dr. Mary Schohn, Director, Office of Mental Health
Operations, Office of Patient Care Services, Veterans
Health Administration, U.S. Department of Veterans
Affairs
Dr. Sonja Batten, Deputy Chief Consultant for Specialty
Mental Health, Office of Patient Care Services,
Veterans Health Administration, U.S. Department of
Veterans Affairs
Dr. Janet Kemp, Director, Suicide Prevention and Community
Engagement, National Mental Health Program, Office of
Patient Care Services, Veterans Health Administration,
U.S. Department of Veterans Affairs
STATEMENT FOR THE RECORD
The Department of Veterans Affairs Office of the Inspector
General........................................................ 65
The Government Accountability Office............................. 67
The American Counseling Association.............................. 71
The American Legion.............................................. 73
Iraq and Afghanistan Veterans of America......................... 79
National Guard Association of the United States, (NGAUS)......... 84
National Military Family Association............................. 88
Paralyzed Veterans of America.................................... 92
Vietnam Veterans of America...................................... 94
QUESTIONS FOR THE RECORD
Letter From: Hon. Jeff Miller, Chairman, To: Hon. Robert A.
Petzel, M.D., Under Secretary for Health, Department of
Veterans Affairs............................................... 97
Questions From: Hon. Jeff Miller, Chairman, Congressman Jeff
Denhan, and Congresswoman Jackie Walorski To: Department of
Veterans Affairs............................................... 98
Responses From: Department of Veterans Affairs, To: Hon. Jeff
Miller, Chairman, Congressman Jeff Denhan, and Congresswoamn
Jackie Walorski................................................ 100
Questions From: Hon. Michael Michaud, Ranking Minority Member,
To: Department of Veterans Affairs............................. 129
Questions From: Congresswoman Julia Brownley, Ranking Minority
Member, Subcommittee on Health, Veterans Affairs, and
Congressman Waxman, To: Veterans Affairs....................... 131
HONORING THE COMMITMENT: OVERCOMING BARRIERS TO QUALITY MENTAL HEALTH
CARE FOR VETERANS
Wednesday, February 13, 2013
U.S. House of Representatives,
Committee on Veterans' Affairs,
Washington, D.C.
The Committee met, pursuant to notice, at 10:04 a.m., in
Room 334, Cannon House Office Building, Hon. Jeff Miller
[Chairman of the Committee] presiding.
Present: Representatives Miller, Bilirakis, Flores, Denham,
Runyan, Benishek, Huelskamp, Amodei, Coffman, Michaud, Takano,
Brownley, Kirkpatrick, Ruiz, Negrete McLeod, Kuster, and Walz.
OPENING STATEMENT OF CHAIRMAN MILLER
The Chairman. The Committee will come to order. We are
awaiting some of our witnesses that were caught up in traffic
this morning, and also in security outside of the building.
They will be here momentarily. Before we begin our hearing this
morning, I would like to recognize Mr. Takano to talk about the
impact of recent events in California last night. Mr. Takano?
Mr. Takano. Thank you, Mr. Chairman. My district, the 41st
District, is based in Riverside County, and the largest city
within my district is the City of Riverside. And I would like
to offer a moment of silence for Officer Michael Crain of the
Riverside Police Department, who was shot and killed last
Thursday by former LAPD Officer Christopher Dorner; and for the
other, three other victims of Dorner's violence.
Prior to his service with the Riverside Police Department,
Officer Crain served in the United States Marine Corps, and was
deployed for two tours in Kuwait as a rifleman. He was awarded
multiple honors for his bravery. So I would ask the Committee
to take a moment of silence to honor the memory of Officer
Crain, and the three other victims, three others whose lives
were needlessly taken, and their families.
The Chairman. Without objection, the Committee will pause
for a moment of silence.
[Moment of silence]
The Chairman. Thank you, Mr. Takano. Our thoughts and
prayers are with you and your constituents, and their families.
Mr. Takano. Thank you, Mr. Chairman.
The Chairman. Thank you very much. Thank you, everybody,
for joining us this morning for the first Full Committee
hearing of the 113th Congress, Honoring the Commitment:
Overcoming Barriers to Quality Mental Health Care for Veterans.
It is only fitting that we would start with this hearing
today, as we begin our oversight by addressing what I think is
one of the most pressing and fundamental issues facing our
servicemembers, veterans, and their families. That is, the
ability to provide timely and effective mental health care to
veterans who need it, when they need it. This issue is not a
new one, but I think everybody will agree that it is a growing.
In the last six years there has been a 39 percent increase
in VA's mental health care budget, and a 41 percent increase in
VA's mental health care staff. Unfortunately these significant
increases have not resulted in equally significant performance
and outcomes. Less than a year ago the VA Inspector General
released a review of veterans mental health care access that
painted a disturbing picture, showing that the majority of
veterans who seek mental health care through VA wait 50 days on
average for an evaluation. That figure amounts to thousands of
veterans in need. Veterans who have recognized that they need
help, and who have taken the hard step of asking for that help,
being told by the Federal bureaucracy tasked with caring for
them that they must wait in line because VA cannot provide them
with the timely access to the care that they need to begin
their healing process. And it only gets worse.
Earlier this month, VA released its 2012 Suicide Data
Report. The report shows, among many alarming findings that the
suicide rate among our veterans has remained steady for the
past 12 years, with 18 to 22 veteran deaths per day since 1999.
As that report so clearly illustrates, when a veteran is in
need of care, the difference of a day or a week or a month can
be the difference between life and death.
This morning the department is going to testify that
progress is being made to increase access to mental health care
services and reduce veteran suicide. I think they are going to
proclaim that they have hired just over 3,200 additional mental
health care personnel. However, despite our request, VA has yet
to provide evidence to verify its efforts.
While I am and will remain supportive of the improvements
that the department is attempting to make, it has become
painfully clear to me that VA is focused more on its process
and not on its outcomes. The true measure of success with
respect to mental health care is not how many people have been
hired, but how many people have been helped.
Since 1999 their mental health care programs, their budget,
and staff have increased exponentially and the number of
veterans seeking care has grown. Yet the number of veterans
tragically taking their own lives is still the same. What is
more, the Suicide Data Report that I mentioned earlier shows
that the demographic characteristics of veterans who die by
suicide is similar among those veterans who access VA care and
those veterans who do not access VA care. Something somewhere
is clearly missing.
Now on our first panel this morning we will hear from
representatives from our veterans service organizations, an
established veterans mental health researcher, and a state
commissioner of veterans affairs. Three of them are veterans
themselves, and all of them will testify that the provisions of
mental health care services through VA is seriously challenged
and that what is needed to fix is decidedly not more of the
very same thing.
Last night the President announced that a year from now
34,000 of our servicemembers currently serving in Afghanistan
are going to be back home. The one-size-fits-all path that the
department is on, leaves our returning veterans with no
assurance that current issues will abate and fails to recognize
that adequately addressing the mental health needs of our
veterans is a task that VA cannot handle by themselves.
In order to be effective, VA must embrace an integrated
care delivery model that does not wait for veterans to come to
them, but instead meets them where they are. VA must stand
ready to treat our veterans where and how our veterans want to
be treated, not just where and how VA wants to treat them. I
can tell you this morning that our veterans are in towns and
cities and communities all across this great land, and the care
that they want is care that recognizes and respects their own
unique circumstances, their preferences, and their hopes. I
earnestly appreciate all of you being here today and I yield to
our Ranking Member Mr. Michaud for his opening statement.
[The prepared statement of Chairman Miller appears in the
Appendix]
OPENING STATEMENT OF HON. MICHAUD
Mr. Michaud. Thank you very much, Mr. Chairman, for
continuing to keep the issue of access, quality, and timely
mental health services provided to our veterans at the
forefront of this Committee. And thank you to all of our
witnesses today for coming and talking with us about the
critical issues of veterans mental health access. I would also
like to thank all of you in the audience who are here today for
your continued support for our veterans population.
We as a Nation have a responsibility, a sacred trust to
care for those whom we send into harm's way. When we send our
citizens into battle around the world, we must be leading the
charge here at home, within our government, to make them whole
again upon their return by ensuring that adequate resources and
proper programs are in place to address their needs.
Oversight of the VA's mental health programs have been a
focus of this Committee for some time now. Over the years we
have held numerous hearings, increased funding, and passed
legislation in an effort to address the challenges of our
veterans from all eras. VA spent $6.2 billion on mental health
programs in fiscal year 2012. I hope to see some positive
progress that this funding has been applied to the goals and
outcomes for which it was intended and the programs are really
working. We all know that mental health is a significant
problem that the Nation is facing now, not only in the VA, but
throughout our population. And the broader challenge is an
opportunity for the VA to look outside of their walls to solve
some of the challenges that they face rather than operate in a
vacuum as they sometimes have done in the past.
One of the most pressing mental health problems we face is
the issue of suicide and how to best prevent it. Fiscal year
2012 tragically saw an increase in military suicides for the
third time in four years. The number of suicides surpassed the
number of combat deaths. Couple that with the number of
suicides in the veteran population of 18 to 22 per day and the
picture becomes even more alarming.
I believe VA is heading in the right direction. I believe
that they have made a true effort to get a true picture of the
suicide issue that surrounds veterans. But I believe a lot more
can and must be done. I will be interested to hear from our
panelists about the national mental health picture and helping
this Committee put the veterans suicide rate in context, as
well as what is happening nationally in treating mental
illness.
Today's hearing will examine the progress VA has made in a
variety of areas concerning mental health and providing timely
access and quality care. I'm hopeful that this will be a good
discussion on ways to provide the care, such as more partnering
with the public and private sector, increasing the pool of
providers, and other creative ways to address mental health
issues.
And finally, I would be remiss if I did not acknowledge the
dedication of the VA employees for providing quality mental
health care to our veterans everyday. The directors, nurses,
doctors, hospital workers are a team. And I want to thank them
for all what they are doing. But we have to do a lot more. As
you heard the Chairman talk about the President's speech last
night, about our soldiers who are going to be coming back from
Afghanistan. I do not know how many of those soldiers are going
to be Guard and Reservists that will be going back to rural
areas. Access and quality and the timeliness of care that our
veterans will need to address these mental health issues should
be readily available. And we definitely do have to think
outside the box to make sure that they do get the help that
they need when they need it.
So with that, Mr. Chairman, once again I want to thank you
for your dedication, your commitment, and your willingness to
keep this issue before the Full Committee so we can make sure
that our veterans get the help when they need it. Thank you,
and I yield back.
[The prepared statement of Hon. Michaud appears in the
Appendix]
The Chairman. Thank you very much to the Ranking Member. If
I could invite the first panel to the witness table. And as you
are making your way forward, I would like to introduce the
witnesses to the Members of the Committee. First, Dr. David
Rudd, Dean of the College of Social and Behavioral Sciences,
and Co-Founder and Scientific Director of the National Center
for Veterans Studies at the University of Utah. We also have
Dr. Linda Schwartz, Commissioner of the Connecticut Department
of Veterans' Affairs. Dr. Schwartz is a Vietnam Veteran having
served on active duty as a Reservist for the United States Air
Force. Dr. Schwartz, thank you for your service. They are
joined by Joy Ilem, the Deputy Director of Legislative Affairs
for the Department of Disabled Veterans of America. Ralph
Ibson, the National Policy Director for the Wounded Warrior
Project. Ms. Ilem and Mr. Ibson are both veterans of the United
States Army. Thank you both for your service.
I want to again say thank you to all of our witnesses for
agreeing to appear this morning. This Committee is uniquely
interested in what is going on. I would say that there are
numerous members that are doubled up right now in an Armed
Services Committee hearing as well that deals with the
continuing resolution and sequestration. So their absence here
does not affect the fact that they are very interested in this
issue and they will be coming in and out as the hearing
progresses. So with that, Dr. Rudd, please proceed with your
testimony, sir.
STATEMENTS OF M. DAVID RUDD, PH.D. ABPP, DEAN, COLLEGE OF
SOCIAL AND BEHAVIORAL SCIENCES, CO-FOUNDER AND SCIENTIFIC
DIRECTOR, NATIONAL CENTER FOR VETERAN STUDIES, UNIVERSITY OF
UTAH; LINDA SPOONSTER SCHWARTZ, RN, DR.PH, FAAN, COMMISSIONER
OF VETERANS' AFFAIRS, STATE OF CONNECTICUT; JOY J. ILEM, DEPUTY
NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS; AND
RALPH IBSON, NATIONAL POLICY DIRECTOR, WOUNDED WARRIOR PROJECT
STATEMENT OF M. DAVID RUDD
Mr. Rudd. Mr. Chairman, Mr. Ranking Member, Members of the
Committee, I want to thank you for the opportunity to speak
with you here today. You have my written testimony. I'm not
going to read that testimony other than just comment and
emphasize a number of points that are embedded within the
testimony.
If we look at this problem over the course of the past
decade, I think it is critical that we put it in context, that
we understand it in context. And I think a starting point for
understanding the trajectory of this problem over the course of
the last ten to 11 years is to recognize that prior to Iraq and
Afghanistan, service in the military was a protective variable
to suicide. That the suicide rates for young men and women of
comparable ages were about half that of the general population.
So prior to these wars things were different. Things have
changed. There are many of us that would speculate about what
that is. I would tell you it probably is related to pre-
enlistment screening, how we handle screening. It's probably
related to issues of unit cohesion. That ten to 11 years of war
impact and affect unit cohesion in very profound ways. I have
talked with many soldiers and service people about that very
issue. The influence of purpose that ten to 11 years of war
affects your sense of purpose, and ultimately the sense of
warrior identity that we find in soldiers today which is
profound and I will talk with you a little bit more about
later.
As a starting point, also let me applaud the transparency
and the thoroughness of the VA Suicide Data Report. Dr. Kemp is
with us and I would tell you that the effort is genuinely
historic. This is something that we should have done decades
ago to fully understand, be able to track, and monitor the
problem. We have to have a system in place to genuinely
understand the problem. This is a first effort to genuinely
understand the nature of the problem, have accurate data that
can actually inform policy and inform decisions. I think it is
simply an exceptional move on the part of the VA and I am very
glad to see that.
Now when I say that, I think it is critical that we put
these rates in context. When you look over the course of the
last 12 years specifically, that if we look at the death rates
by suicide for veterans, if you look at those death rates of
VHA service users, those rates are triple the rates for the
general population. They are double for the male population.
And although that comparison is a little bit clouded given the
nature of the two populations, if you look at the age specific
data for the VA, I think it is important to understand that the
18 to 34 year age group, that the rates are double that of
comparable young males in the general population. That that
risk endures. And I would suggest that in very specific ways
that it is probably linked to active duty risk over the course
of the last ten to 11 years. And it is a significant problem
that we need to think about. Starting to conceptualize this as
a continuum from active duty risk, to transition to veteran
status and the endurance of that risk for the first decade to
decade and a half of veteran status is an important thing for
us to look at.
As a result of the persistence of risk over the course of
the last ten to 12 years, and the better the data we have, it
seems more clear that the risk endures, I would very much agree
with you, Mr. Chairman. It is time for us not to do the same
thing. That more of the same simply is not working. That when
these rates endure at the high levels that they are, that
funding more of the same is not the route to go.
A couple of other points I would like to make about the
report. I think it is a significant move in terms of
establishing, maintaining, and monitoring the crisis line. I
find that a wonderful addition. I would encourage you, though,
that we may not be reaching the right population. That the drop
from 40 percent to 30 percent of the callers in terms of
individuals that identify themselves as suicidal may mean we
are not reaching the right group. We have got to think about
different ways of reaching those individuals.
And finally, I want to share briefly with you a story that
I think is probably symptomatic of the problem. I have included
it in my testimony. I am not sure that this is a clinical
problem. I think it is a management, I think it is a systemic
problem in terms of how we handle individuals that are at risk.
And I have included in my testimony the tragic suicide of
Russell Shirley. I spoke with Russell's mother over the course
of the last month. I have spoken with one of his dear friends.
And I think Russell is probably typical of the problem, the
tragic problem which will occur over the coming years.
Russell was a son, a husband, a father. He was a soldier.
He served his country proudly and bravely in Afghanistan. He
survived combat. He came home struggling with PTSD and
Traumatic Brain Injury. With a marriage in crisis and
escalating symptoms he turned to alcohol. He received a DUI.
And after ten years of dedicated service he was discharged. And
part of the rationale for the discharge was the increasing
pressure to reduce the size of the force. I think we are going
to see more and more of that over the coming years. After the
loss of his family, the loss of his career, and the loss of his
identify, Russell shot himself in front of his mother.
Having spoken with Russell I would tell you, or having
spoken with Russell's mother, I would tell you that a part of
the tragedy is, we knew that Russell was at risk prior to his
death. We recognized, identified him as an at risk soldier
prior to his discharge. But yet there are not adequate
transitional services in place that allow a clean connection
from an individual to an individual. And I think those are the
sorts of things that we need to start talking about, we need to
start thinking about. How do we connect at risk soldiers, once
we identify them and they are being discharged, particularly if
they are being discharged against their wishes, into the VA
system? And how do we connect them with an individual and not
just a system? How do we help them connect in a relationship
that can potentially save a life?
I have included a picture of Russell with his two children
at the end of my testimony and the reason I've done that is, I
think it is important for all of us, when I read the Suicide
Data Report, the one thing that is missing in this Suicide Data
Report are the names of the individuals, the names of the
families, the names of the loved ones that are affected and
impacted by these tragic deaths. And I think it is important
for all of us to remember that.
Thank you very much.
[The prepared statement of M. David Rudd appears in the
Appendix]
The Chairman. Thank you. Dr. Schwartz?
STATEMENT OF LINDA SPOONSTER SCHWARTZ
Ms. Schwartz. Good morning, Mr. Chairman, and good morning,
Congressman Michaud. I'm Linda Schwartz. I'm the Commissioner
of Veterans' Affairs for the State of Connecticut. As the
Commissioner, I've been the Commissioner for ten years, I am
serving my third governor, I am responsible for 277,000
veterans in our state. I have a 75-bed substance abuse
treatment recovery program. I have a chronic disease hospital.
I have the second largest domicile in America which has today
380 veterans in resident. I have three cemeteries and five
district offices.
I am here to kind of echo what was said by Dr. Rudd.
Because let me just say this, when you talk about the suicide
let us be clear. Let us be clear that no death index is going
to have accurate information. In my experience, we were looking
at suicides because it was a very important thing. Because I
started, because I have three cemeteries, I look and see what
are the causes of death? And many of these deaths are not
declared suicide out of respect for the religions beliefs of
the individual, for the family, or because no one wants to make
that call.
The reason it is so shocking is because it is secret. And
many of the things that are going on with our Reserves and our
Guard are not talked about openly. So I applaud the VA for at
least making an attempt to quantify.
But I also would like to move to the State of Connecticut,
where for the past 25 years our Department of Mental Health and
Addiction Services has been asking, ``Have you ever served in
the military?'' They have been asking, ``Are you a veteran?''
Interestingly, we did not quantify this until the late
nineties. I was a public health nurse at the time so I was
checking off those boxes. We had 5,000 veterans on the rolls of
our State Department of Mental Health and Addiction Services.
And even though we have had the opening of community-based
outpatient clinics, and Vet Centers in the State of
Connecticut, those numbers have not changed significantly. We
still have about 5,000 veterans receiving their care from the
state. I have referred to the reasons why, most of it, in my
testimony. But the proximity, access to care is a lot more than
being eligible for your VA benefits. It means that if your
closest VA hospital is 65 miles away, and you are having a
crisis, you want somebody in your community. You want somebody
who is going to listen. Additionally, VA provides wonderful
services, but you do not have access to your care provider 24/7
like somebody in private practice.
My masters is in psychiatric nursing, so I have had the
experience of working with mental health patients. But I would
just like to say that I am just going to skip, the President's
message night, that we are going to have all of these people
coming down, he mentioned a very important part. Some of these
people joined, you have an all volunteer force who has joined.
They intended to make this their career and now you have a draw
down. And that is a loss of identity. As a disabled veteran, I
had to leave military service and I had a long time finding a
new identity.
But I want to go quickly to what Connecticut is doing today
because I believe it addresses some of the issues that others
will raise. In 2005 we set aside money in our budget and the
Legislature enacted legislation that we would set up a program
for veterans, mostly at that time Guard and Reservist, who
would not be covered by VA services. We trained medical
professionals who were living in the community. We used a model
that came out of 9/11 that Connecticut was tasked with a lot of
mental health needs, so doing some training with people that
are already in practice, already have their credentials,
already have their professional requirements. We gave them 16
hours of what we called Military 101. We have a 24/7 hotline.
Anybody in the State of Connecticut, whether they are the
military member, the spouse, the children, the parents, the
significant other, are eligible for this program. If you call
that number right now, and you say, ``I live in Pawtucket,
Connecticut and my husband is going sailing every morning with
Captain Morgan. What should I do?'' They will tell me who in my
geographic area has gone through this training and is part of
that network. And to part of that network the professional has
to agree that they will contact that individual who makes that
call, the client from the Military Support Program, they must
contact them within 48 hours.
This is open because many of the providers do not charge.
However, the State of Connecticut has authorized 15 sessions
within a calendar year for all of these family members. I did
cite in my testimony that in Maine they did a study where they
found out that many military members are more likely to go to
treatment with their family because it does reduce the stigma.
The military member can say, ``I'm doing this for my family.''
And everybody will say, ``That's a really great thing you are
doing.'' And we hope, and we know, that they are also receiving
their care and some help, too.
I realize my time is almost out, but I want to say
something very important to all of you. The states, each one of
your states has someone like me, a director, responsible to the
governor and the people of your state to take care of your
people. States collectively put $6 billion on the table every
year to take care of veterans. The VA is a vast system which
cannot really meet the demands of our, the way we are doing
more with our Reservists and our Guards today. So the most
important thing that we are looking for is a little help from
the Federal benefits and grants. Too much emphasis is put on
having people go for health care where you have eligibility
requirements. We have to look to the veterans benefits side of
this, for outreach, for training for those individuals who will
be the service officers that develop these claims. And although
the VHA has a very robust and very good grant system, you need
to look at having the Veterans Benefits Administration also be
able to provide grants to support this. Can you imagine, I give
high marks to Secretary Shinseki and Hickey, because they have
done a lot to electronically do the records. But when it gets
down to the real, where the rubber meets the road, it's the
person who is taking the claims, it is the person that's
pressing the button. I have ten service officers. Some of them
are Vietnam veterans and they still feel that if they have to
touch the computer they will become electrocuted. So this is a
knowledge gap that is very, very essential.
I thank you so much, really, for giving me a little extra
time. But if you don't remember anything else I said today, VA
cannot do this by themselves. You have many good people in each
one of your states that wants to do a good job for your
veterans, all veterans. It's time to really look about
formalizing the partnership between your states and the Federal
VA. Thank you so much.
[The prepared statement of Linda Spoonster Schwartz appears
in the Appendix]
The Chairman. Thank you very much, doctor. We appreciate
all of our states and our territories for doing what they do in
partnership for our veterans. We appreciate your testimony.
Next, Joy Ilem from the DAV. You are recognized. Thank you.
STATEMENT OF JOY J. ILEM
Ms. Ilem. Thank you, Chairman Miller, and Members of the
Committee. I am pleased to present the DAV's views on access to
VA mental health services. Like the Committee, DAV is committed
to fulfilling our promises to the men and women who served. And
one of those promises is to ensure that veterans receive an
opportunity to fully recover from physical and psychological
wounds that occur as a consequence of their military service.
Given the diligent oversight by this Committee and the
significant level of new resources that have been authorized to
address the existing deficits and to improve VA mental health
services, the current question posed by the Committee chair is
a valid one. Is VA's complex system of mental health care and
suicide prevention services improving the health and wellness
of our heroes in need? Over the past five years, VA's Office of
Mental Health Services has made significant progress and placed
special emphasis on suicide prevention efforts, launched an
aggressive anti-stigma outreach and advertising campaign,
increased peer to peer services, mental health consumer
councils, and family and couples counseling and therapy
services. Yet despite the noted progress, in our opinion there
are several core issues that are likely responsible for the
continued mental health access issues that are plaguing VA.
These issues have been the topic of numerous congressional
and government oversight reports and include problems with VA's
outdated patient scheduling system, reliability of waiting time
data, proper staffing levels, and a mental health staffing
model that accounts for shifting trends and demand for specific
types of services. Many of these issues were addressed at the
May, 2012 hearing you held and VA noted work was underway on
several fronts and specifically that a prototype staffing model
was being tested in three VA networks. Like the Committee, we
are anxious to learn whether VA can deploy this prototype
throughout its system, and whether it works well for mental
health in particular. Likewise, we are eager to learn about the
progress on the variety of other issues addressed in the
various reports.
Mr. Chairman, another topic you asked that we address was
effectively partnering with non-VA resources to address gaps
that create more patient-centered network of care focused on
wellness based outcomes. In this regard you addressed a VA
TRICARE outsourcing alliance to serve the mental health needs
of some newer veterans that VA is admittedly struggling to meet
today. We urge VA to work with the Committee to ensure that if
mental health care is expanded using the existing TRICARE
network or some other outside network, veterans receive direct
assistance by VA in coordinating such services and that the
care veterans receive will reflect the integrated and holistic
nature of VA care.
When a veteran acknowledges the need for mental health
services and agrees to engage in treatment, it is important for
VA to determine the kind of mental health services that are
needed and whether the most appropriate care should come from a
VA provider or a community-based source. This type of triage is
absolutely critical because high quality, effective mental
health treatment is dependent on a consistent continuous care
relationship developed between the veteran and the provider.
Once a trusting therapeutic relationship is established, that
connection should not be disrupted if possible.
Mr. Chairman, DAV previously testified that in our opinion
our newer veterans can particularly benefit from VA's expertise
in treating coexisting PTSD, substance use disorders, traumatic
brain injury, and other post-deployment transition issues. To
that end, it is essential that VHA address and resolve the
barriers that obstruct consistent timely access to care at VA
facilities nationwide. However, if a veteran is referred by VA
to a community resource, we urge that care be coordinated by
VA. A critical component of care coordination is health
information sharing. The absence of obtaining health
information poses a barrier to implement good patient care
strategies, such a chronic disease management, prevention, and
use of safe care protocols within VA.
These are some of the principal flaws we see in VA's
current approach in fee-basis and contract care. We believe the
policy changes made by VA's Office of Mental Health Services
over the past decade are positive and ultimately equate to
better patient care and improved mental health outcomes. But
significant challenges are clearly evident and need continued
attention. Unfortunately the root causes for these existing
barriers in VA's mental health delivery system are complex,
system based, and long standing, and cannot be resolved by any
single reform. Therefore, we urge the Committee's continued
oversight of VA's progress in correcting not only the internal
processes and resolving the existing barriers that prevent some
veterans from receiving the timely services they need to fully
readjust and integrate following military service.
I just wanted to say I really think what Dr. Rudd said
really is a poignant point. That we really need for veterans
that are at risk, they need to be put together with an
individual, a person, someone they connect to and not just a
system. So with that, I am willing to answer any questions the
Committee may have. Thank you.
[The prepared statement of Joy J. Ilem appears in the
Appendix]
The Chairman. Thank you very much. I'd ask the panelists'
indulgence for just a moment while we recess the hearing and
enter into a quick business meeting. And with that, I recognize
Mr. Michaud for a motion.
Mr. Michaud. Thank you very much, Mr. Chairman. I would
like to offer a resolution adding Timothy J. Walz of Minnesota
as a Democratic Member of the Subcommittee on Oversight and
Investigations.
The Chairman. Thank you for that motion. Since we do now
have a quorum, all in favor will say aye.
Opposed, no.
The motion carries. Welcome, Mr. Walz, to the O&I
Subcommittee. And thank you, Mr. Michaud, for your motion. Our
business meeting is now adjourned. And we will take up the
hearing again. Mr. Ibson, you are recognized.
STATEMENT OF RALPH IBSON
Mr. Ibson. Thank you, Mr. Chairman. Chairman Miller,
Ranking Member Michaud, Members of the Committee, let me also
congratulate Mr. Walz, for Wounded Warrior Project and those we
serve, the issues raised this morning, and the challenges it
poses, are profound. We greatly appreciate your scheduling this
hearing and greatly appreciate your powerful opening
statements.
My organization's mission is to honor and empower those
wounded since 9/11. And let me give you some context for the
concerns we have. In a large survey of our wounded warriors
last year, 69 percent of respondents screened positive for
PTSD, 69 percent. Sixty-two percent indicated they were
currently experiencing symptoms of major depression. More than
two-thirds of those surveyed indicated that emotional problems
had interfered with work or regular activities during the
previous four weeks. Some acknowledged getting help from VA
therapists, but more than one in three reported difficulties in
accessing effective mental health care. The feedback in essence
was that VA is overwhelmed.
I do want to acknowledge the hard work done by VA's central
office mental health leadership, as well as the step VA took
last year to increase mental health staffing. That step,
though, is not a comprehensive solution. There is no single
silver bullet out there in our view, because the system faces a
range of different problems. One of the leading researchers in
the field, Dr. Charles Hogue, has, I think captured the scope
of VA's challenge as follows. ``Veterans remain reluctant to
seek care, with half of those in need not utilizing mental
health services. Among veterans who begin PTSD treatment with
psychotherapy or medication, a high percentage drop out. With
only 50 percent of veterans seeking care, and a 40 percent
recovery rate, current strategies will effectively reach no
more than 20 percent of all veterans needing PTSD treatment.''
So the issue is not simply improving access. One has to
ask, for example, access to what? Mental health care also has
to be effective. At a minimum, that requires building a
trusting relationship between provider and patient. And that
trust can be quickly broken when a veteran, for example, who
needs one on one therapy is simply offered medication. Or when
that same veteran is put into group therapy prematurely, or is
only offered therapy that requires reliving the painful trauma
of war when he or she is not ready for that level of intensity.
Many of our warriors become frustrated and drop out of VA
treatment. But many VA clinicians as well are also frustrated.
Why? Because the VA system too often bars them from exercising
their best clinical judgment. Instead, VA performance
requirements dictate clinical practice. As one psychiatrist
told me recently, ``The number of required clinical reminders I
get keeps growing. I have a patient who is homeless and whose
wife has recently died. But I have to take time away from
treatment to administer a depression screening test, even
though I know the individual is depressed.'' Similarly, ``I
need to be able to spend enough time addressing the veteran's
wife's recent death rather than being required to urge him to
stop smoking.''
Sadly, a clinician who bucks the performance requirements
in the name of exercising good clinical judgment can incur
financial repercussions as a result. As one described it, ``The
reality is that the VA is a top down organization that wants
strict obedience.''
At best, these performance requirements measure processes,
as you indicated Mr. Chairman, rather than determining whether
the patient is getting better. And as prior hearings have
documented, these requirements are often circumvented or gamed.
VA has acknowledged a need to improve mental health care
deliver. But what seems to be missing in some instances is
transparency. We wonder, for example, why after conducting
mental health site visits at 150 VA medical centers last year,
VA has not provided this Committee a detailed report of those
findings. Last year to its credit, VA conducted a survey of its
mental health staff. Why have we not heard about the findings?
Let us be clear. There are things that are working well in
this system. The Vet Center program is one. Providing peer
outreach and peer support, as VA has begun to do, and is called
for in the President's Executive Order, would be another one if
it were launched in full and accomplished as intended. And
again, let me emphasize that there are many well intentioned,
highly dedicated mental health staff at VA centers and clinics
who are committed to providing good treatment.
But more must be done, in our view, to close gaps in the VA
system. Close gaps between its promise and its on the ground
reality. Between policy and practice. Congressional oversight
has been a critical catalyst in identifying the need for system
improvement.
I think there are also opportunities to break down what can
be an adversarial relationship between a Committee and a
department, for greater partnership, for greater dialogue. I
think as you suggested in your opening statements, there are
different directions to be taken. There are opportunities, as
Linda indicated, for greater partnerships between VA and
states, and between VA and communities. These are all steps
that ought to be pursued. Vigilant oversight, again, must
continue. And we stand ready to support in that effort. I would
be pleased to answer any questions you might have. Thank you.
[The prepared statement of Ralph Ibson appears in the
Appendix]
The Chairman. Thank you very much, Mr. Ibson. And thank you
for what the Wounded Warrior Project does as well. We
appreciate, again, the testimony of our panelists, and all of
your complete written statements will be entered into the
record without objection. I recognize myself for five minutes
for questions.
Dr. Rudd, I was struck by your comment that we need to
connect veterans in need not just with the system, but with
people within the system. I think everybody here has said
something very similar to that. I think it is important for us
from a clinical standpoint to understand the need to connect
personally and the personal efficacy and the importance of
choice within the mental health care field. So can you talk a
little bit about why it is so critical to connect on the
personal level?
Mr. Rudd. Oh, absolutely. If you look at, let us take for
example the recent active duty numbers for this past year. So
if we look at this, if we look at the recent active duty
numbers from this past year, half of those individuals who died
by suicide either were in treatment or had received care of
some sort, either inpatient or outpatient care. If you look at
the VA numbers from the report, you will see that 80 percent of
those individuals had had a nonfatal event. In other words,
made a suicide attempt. Were in treatment four weeks prior to
the event.
What I would tell you that both of those numbers reveal is
the nature of how they are connected to care. That the problem,
if we took the active duty numbers and took those, half of
those individuals that tragically died, they remained in care
and were effectively treated, the problem would no longer
exist. We would be back to numbers that we had seen prior to
Iraq. Those rates would have dropped dramatically. And so it is
the nature of those connections that really is the critical
thing.
If you look at the work that we do in terms of studying
effective treatment for suicidality, so we have got two
clinical trials currently underway at Fort Carson in Colorado,
it is the nature of the relationships that are established and
maintained. Do we have mechanisms in place to maintain those
relationships in an effective fashion? The question that I ask
when I look at that Suicide Data Report data on, they had a
contact a month prior, the question that I ask is how long was
it until the next appointment? So when they had that contact,
was the next appointment scheduled six weeks out? Was that the
problem? Or was the next appointment scheduled a week out, and
they did not keep the appointment?
My concern is that from the individuals that we talk with
that we treat, from the individuals that I know, the families,
surviving family members of those that have died, oftentimes it
is an issue of the system getting in the way of being able to
keep an appointment, get an appointment, or get to an
appointment. That those individuals that are connected need to
be connected to people. They need to be connected to the same
people. They need to be continued frequently in treatment. They
do not need to receive care every six weeks. They are going to
need more frequent care. It is those kinds of questions that I
think we need to be asking, is how do we connect? How do we
keep them there? Not necessarily are we getting them there. I
think we are doing a good job of getting people there. I think
the Army data, the military data reveals that. I think that the
VA data reveals that. But ultimately the question is, how do we
keep them engaged? How do we keep them involved? Have we made
the system accessible so that they can, they can continue to be
a part of the treatment cycle? That really is my core concern.
The Chairman. Anybody got anything they would like to add
to that? Doctor?
Ms. Schwartz. I would. I would say it would be very
interesting, and I did not read the report, it would be very
interesting to see how many of these people were, had done
multiple deployments and multiple tours. In my testimony, I
wrote of a situation which I hope everyone will take a look at.
The fact that people, veterans of the Guard and Reserve who
have come to our state, who are already rated service-connected
at 70 percent or 80 percent for mental health issues have been
told, and they do, sign a waiver to stop their disability
checks, and then sign up for another deployment. I have had
some very difficult times for these people who already are
rated, which is not an easy thing to do, and yet they sign away
their checks. Someone, and it is well known because there is
already a form for it. So they are deployed back to the combat
zones, thinking that when they return they are going to get
their disability checks are just going to smooth, and they will
have their disability rating. They do not realize what they
jeopardize. Nor do the people at the National Guard and Reserve
levels understand what this is all about.
But when you take someone who has been deployed multiple
times, and in our state it varies from services. I myself am an
Air Force veteran, so many deployments by the Air Force are not
a whole year long. But the issue is, they come home. They just
get reacquainted with their family or the community, and then
they are gone again. And there is really no time for a
decompression kind of experience where they can learn to be
back in the community again before they have to gear up. And I
do feel that some of this is they never gear down. They are
always, as if the adrenaline is as if they are in the combat
zones. And many families are at a loss. They think they are
going to welcome them home and they find that the individual is
not, that is now where it is at for them.
So these multiple deployments, using people that already
have disabilities to redeploy to the combat zones, that has to
stop. It's just incomprehensible to me. I mean, as a military
member when I had to leave my squadron it was probably the
saddest day of my life. That was me. I wanted to go back. And
somebody did offer me a chance to go back, and I could have
signed my life away and gone back. Gone back. But I knew that I
couldn't do the work. So you have a group of people right now
who will do, some of them will do anything to get back. Because
of the jobs, because of the feelings that this is a very
important job that they are doing. So this is, this is not a VA
thing. But we are left, all of us in the veteran community are
left to deal with these situations.
The Chairman. Thank you very much. Mr. Michaud?
Mr. Michaud. Thank you, Mr. Chairman. Dr. Schwartz, first
of all thank you for your continued service to our veterans and
their families. I really appreciate it. You stated in your
testimony that serving veterans is a shared responsibility with
state and the Federal government. And I agree with you, and I
also believe that the community needs to be involved as well.
Can you elaborate a little bit more on the barriers that
you have encountered while seeking to partner with the
Department of Veterans Affairs? As well as, have you sought out
other Federal agencies? And if you had, how has that
relationship been?
Ms. Schwartz. I think the VA has been operating on the
notion that they have to do it all. And with the new
hostilities and the heavy use of our Guard and Reserves, the
real true citizen soldiers. So they have developed programs
which, their counterparts in the states, or did not even know
about. There is very little dialogue about, for example, I will
just give you, you know, they create a program where they are
working with the homeless. Well I have 380 homeless people. I
have the most homeless people in the State of Connecticut.
Second only in the Nation to California. But the issue is, the
kind of dialogue we have, especially over some of the programs,
the kind of dialogue, if they are going to start a new program
to assist veterans, I do believe that VA has to at least talk
to the state. If they are building a facility for assisted
living in the State of Connecticut, and they really have not,
the Commissioner and Mental Health and Addiction Services and I
had no idea. It is being built on the premises of Newington VA.
We had no idea that this was going on. However, it does affect
that state. And I think that is one way.
But the other thing, and let me be very clear, there are
some really good models of how it works. For example, my
substance abuse treatment program has 75 beds. The VA at
Newington has a 21-day program. So all of my initial people in
the program go to the 21-day program at Newington. They stay in
a residential mode with us. And after they, because we think
maybe you need a little more than 21 days, especially with some
of our veterans, then they work with my clinical staff. And
they can stay up to six months because what we do is as we work
with them on their sobriety, we also work with them in getting
back into the community. I am very proud to say that yes, we
have a lot of people. But last year over 150 veterans left my
facility with a job and a place to live. So some of them, and I
would also say we have over 500 veterans of Iraq and
Afghanistan have gone to this program in my time. That is ten
years.
But the issue here is there is so much more that needs to
be done besides calling or giving, you need to have that
interaction. Perfect hand-off. I talked about the military
support program. It, we have expanded that program in the State
of Connecticut to all veterans and all veteran families because
of our concern about suicide. So that if somebody can call even
in the middle of the night and get a friendly voice, we also
have veteran workers standing by as crisis intervention. And I
am not, we are not the only state. Massachusetts and other
states are doing wonderful work along these lines. But it is a
beginning. It is not, just as was mentioned, you want somebody
there that they can trust and talk to. The therapeutic alliance
does not necessarily happen with the VA because in the middle
of the night you cannot call your VA clinician. You cannot talk
to them. Families sometimes cannot even talk to them because of
the HIPAA laws. So if any of our clinicians in the community
find that this is a little over their head, they will make the
referral to the appropriate place. And many of them are. Many
of the veterans are referred to the VA. But at least, it is
almost like a triage at the local level. And the hand-off that
they get is a little personalized because it is not like you
are calling an 800 number.
And I would also add that some of the suicides that we have
seen, do not think it is just men. I think some of the saddest
things for me is that women are killing themselves, too. Women
with children. And that really brought it to the forefront in
our state. So the VA has to, in my testimony I do say that
Secretary Shinseki has acknowledged this. The problem is, the
problem is, as was noted in other testimony, that has not, that
mind set has not filtered down to the people at the
administrative local levels. I have a wonderful relation with
my homeless outreach people at the VA level because we touch
people. We are not shuffling papers. I know, I had to learn how
to do that, too. But the point is, the people that touch people
are deeply, deeply ingrained in making it happen. So as a, we
have a new challenge here. And we have to challenge the status
quo and begin to create new models. Because we are not going
backwards. This is the way America is going to do war in the
future. And these are, the Guard and the Reserve are going to
be your clients, my clients.
Mr. Bilirakis. [Presiding] Thank you very much. And I will
recognize myself for five minutes. The first question is for
Mr. Rudd. You mention in your testimony that in order to reduce
wait times and increase access to mental health care, the VA
may need to explore partnerships with private community
providers. What do you believe is the biggest obstacle
preventing the VA from doing this?
Mr. Rudd. You know, I am really not sure what the biggest
obstacle is outside of the simple fact that it has not been
done, that it is a non-traditional approach. That the way that
we have done this, I think, over the years, particular since
the start of these wars, is that we have made the VA larger. I
think the evidence would suggest that the VA does not need to
continue to get larger. That I was not overly encouraged when I
read the response that they have hired 1,000 individuals and
some of these numbers. I do not see that as a solution. I think
the solution is that we look at partnerships like TRICARE
partnering, which is a wonderful partner approach. Primarily
because those providers are already in those small communities.
Those providers are available, accessible in those small
communities. But what that means is shifting funding, shifting
money to a non-traditional model. And I think that is
personally the way to go. I think that is how you connect
people to people at a local level so that individuals do not
have to travel great distances.
Mr. Bilirakis. Very good. Anyone else wish to comment on
this subject matter?
Ms. Ilem. I would just comment, I think from DAV's
perspective we have a little bit of a different thought on
that. We are definitely invested in wanting to make sure that
the VA receives the proper funding and what they need to do
their job. I mean, they are the primary source of government
response to this issue, you know, to when veterans are coming
home and need assistance. They are going to be there for the
long term. And I think VA's long term relationships with its
patients are extremely important in providing really high
quality care. And not to say that VA does not have to partner
with the community, and in these cases we have certainly found,
you know, there has just been continued issues with access. And
but at the same time, I think we really want to see VA resolve
some of the issues that we know have been identified by the
GAO, by the Office of the Inspector General, and VA itself. So
what is the problem? Where is the logjam that they cannot
overcome those obstacles within the system to be more efficient
and spend the money which has been provided and authorized by
this Committee, and by Congress, in significant amounts to
really care for these people with the specialized treatment and
services that they have, you know, really, they are second to
none. And especially with these coexisting disorders. But they
do, I think, need to look outside the box given the issues that
we're, you know, they continue to experience with access. So
but I would like to see VA really step up to the plate. I know
that there are a lot of people that are trying hard. But you
know, the time has come where it is just absolutely critical
given all of these reports with, you know, the suicide and
various issues we continue to hear about.
Mr. Bilirakis. Thank you very much. Dr. Schwartz, in your
testimony you make a valuable point that the Federal, State,
and local initiatives should be coordinated. I agree with you,
and I am a proponent of the one stop shop models. How do you
believe that this integration can be best facilitated?
Ms. Schwartz. I think there are models in the Federal
government. And I know I did not respond to the question
adequately. You know, with the public health, HHS gives grants.
They have local level coordination across states of certain
programs that are funded. I see that VA will always be, in
reference to Joy Ilem's statement, VA will always be the crown
jewel. But the needs of the veterans today are much different.
For example, when I was in the military, and I am going to
age myself, I was not allowed to be married. Then they allowed
us to be married, and when you had a child, you had to leave
the military. Now, almost 83 percent of the people on active
duty have families, and 58 percent of the Guard and Reserve all
of them, the family, especially with this generation, and was
referred to the camaraderie, the sense of camaraderie, the need
to be with each other. But the family, the family unit is more
important now than it is ever. And VA is not authorized, across
the board, to help these families. So that is why other
programs have evolved.
So the most important thing with these models is I would
say, I am not telling you to just be dropping money everywhere,
but that we would have grants to do the outreach to connect
people. VA has a large grant per diem program for state homes.
I have one. There is quality assurance that is built into that
program, that could be built into the mental health program.
But you are not going--as long as we rely on the Guard and
Reserve, it is too long for someone to drive. And we did a
survey of our veterans that they had to drive more than 30
minutes to a source for anything, it was too far. I would have
to drive. It is 65 miles from my home to the VA hospital. And
if you had to take public transportation in the State of
Connecticut, it would take you two days on public
transportation.
So accessibility is much more than eligibility.
Accessibility is having someone, someone, a private clinician
that, that is not the model of the VA, but that is a model that
can be built using clinicians. This worked very well for the
State of Connecticut after 9/11. I did not mention this, but we
have had over 3,500--since this program had, we have had over
3,500 clients, I would say a third of them have been referred
to VA for care. But most of them are in treatment in the homes
and the towns where they live, and the reimbursement if it's
not coming from the--any other third party reimbursement, the
State of Connecticut pays these therapists.
Many of them do, actually I have to say do this pro bono
because they want to help. But this is an excellent example of
how it can go to where it needs to be. Thank you.
Mr. Brownley. Thank you very much. I yield back, Mr.
Chairman.
Mr. Chairman. Thank you very much, Ms. Brownley.
Ms. Brownley. Thank you, Mr. Chair, I appreciate this. I
had a question actually for Dr. Rudd. And in your testimony you
mentioned, you mentioned about access to service, but also
transition services for people transitioning out of the
military. And I recently, when I was assigned to the Committee,
I decided to visit all of the veteran facilities in my
district. And I visited the transition center at Naval Base
Ventura County. And I was actually very, very impressed by what
they are doing there, and their focused attention, and program
that is very comprehensive that goes on for a pretty long
period of time to prepare them for this kind of transition.
And so I am really wondering, you know, how we can capture
these best practices when we see a good facility like this
doing good work, how we can create new models and best
practices to replicate better than we are doing throughout the
country.
Mr. Rudd. Well, I agree with you. I think there's some very
nice models out there. I think a part of the problem is that
you can--you see one side or the other doing a nice effort, but
not both simultaneously. So if you look at the death of Russell
Shirley as an example. He was, because of the DUI, he was
referred for treatment, substance abuse treatment on the active
Army side, which when his discharge was processing, was
discontinued, is a part of the--as a part of the discharge
process.
It is those little things that make the big difference. It
is whether or not somebody actually gets into the service, gets
connected with a provider in these critical moments. And so
often times, those are non-clinical kinds of issues. Those are
issues with commanders, those are issues with administrators,
not with the clinical staff. And when I referenced, and I do
not believe this is a clinical problem, I really do not believe
this a clinical problem, I believe it is how we shepherd people
through the system, they are at high risk with non-clinical
procedures.
Ms. Brownley. Uh-huh.
Mr. Rudd. I think it is how we end up connecting them and
then maintaining them there that is the problem. So I think
part of the difficulty in Russell Shirley's death was the fact
that the company commander disconnected him from treatment, did
not connect him to transition services. Those are the kind of
things that we need to find policies and implement, that can be
maintained and monitored so we can effectively manage these
people, as we move them through the system. I think more
attention has to be focused there, not at the transition
center. But how do you get somebody in the door? And then how
do you monitor and make sure that they stay there, and they
stay all the way through? And if they disengage, what are the
procedures for re-engaging them if they disengage? Those are
the kind of things that I think ultimately will save lives.
Ms. Brownley. And are we doing anything vis-a-vis
accountability to look at these transition centers and others
to see--identifying people who are in trouble after transition,
and looking specifically at the transition, the transitioning
that they have or have not received.
Mr. Rudd. Well, I think that we started the process. I
mean, I think one of the tragedies of this, is that it has
taken 10, 11 years of war, many deaths, and many tragic
suicides for this to happen, that we are now putting systems in
place to be able to look at this effectively. And I think the
work that Dr. Kemp does genuinely is historic, but it should
have happened decades ago. We should have had a system in place
so we can monitor, manage and understand how many people are
dying by suicide, and we can accurately the number of events.
And we're still only at 21 states that have accurate data with
the two largest states without accurate data at this point.
And so I think we are just building the system. That's a
wonderful contribution, but it really is just a foundation. So
I think that when we get the foundation set, a part of what we
have to layer in is some general patients with the idea that we
do not have the infrastructure in place to do the very things
you are asking. And I think that we need to ask that question
repeatedly to get the infrastructure in place. We have got some
of that on the suicide front, but it has to happen in so many
different layers. And that is very much a non-clinical problem.
I mean that very much is a management problem.
And that is where I think making the VA bigger creates
bigger challenges, because the management of big systems is
tough. And so I think that is where we need to think a little
bit creatively about how to do this.
Ms. Brownley. Thank you, sir.
The Chairman. Thank you. Dr. Benishek?
Mr. Benishek. Thank you, Mr. Chairman. Dr. Schwartz, you
said a couple of things earlier that sort of intrigued me. I
want to ask you about them a little bit more.
You said that, you know, there was a need for the private
sector mental health care, because calling the VA, there is no
access to people at the VA at night.
Ms. Schwartz. Right.
Mr. Benishek. So the Veteran Affairs Mental Health does not
have any on-call person to take a call?
Ms. Schwartz. Well, they do have an on-call person, but in
the sense of mental health care, it is very essential that they
find somebody that is responsive, not just somebody in the
emergency room.
Mr. Benishek. Right, right, right.
Ms. Schwartz. And in large states, they may not even know
this person. So the accessibility of trying to contact your
mental health provider in the evening is not standard. We have
had via the populations of veterans that I have also use VA,
trying to get ahold of the person that is their primary treater
for mental health, we do not have access to the primary care
provider.
Mr. Benishek. But you are saying in the private sector----
Ms. Schwartz. We do.
Mr. Benishek. --you do.
Ms. Schwartz. I mean, I--just for example, I--my masters is
in psychiatric nursing, and so a lot of clinical nurse
specialists are in private practice, and they, when they are
not available, any psychiatrist, they always have someone or
psychologist, always have coverage. They--you have-- you can
call into your provider, get ahold of them if it is a crisis,
and if they are on vacation, you will get somebody that they
have told you will be covering for them.
Mr. Benishek. Right, right, right. Well, yeah.
Ms. Schwartz. So it is there. It is there. It is somebody
that you can really talk to.
Mr. Benishek. Well, I am just sort of amazed by the fact
that the VA does not have that same sort of a system. And I'm
disappointed to hear that frankly.
Ms. Schwartz. It is a large, large system, and was very
well described, the larger the system gets, there is another
thing, and I bring this in my testimony, the soldiers of today
expect their treaters to be competent, to understand them, to
respect them, and they expect the same kind of care they would
if they were going to a private provider.
Which means, if I am having trouble right now, if I want to
call my psychiatrist, I want to call the office.
Mr. Benishek. Right.
Ms. Schwartz. And I want to talk to them, or maybe I need
to go somewhere. This is not available----
Mr. Benishek. Right.
Ms. Schwartz. --on an individual basis. The large system
may respond, but if I have somebody in crisis, and I get
somebody at the VA that does not know this patient----
Mr. Benishek. Right.
Ms. Schwartz. --they're not going to be as helpful as----
Mr. Benishek. Right, right. No, I completely understand.
Mr. Ibson?
Mr. Ibson. I think it--you know, I think the concept of
partnership was discussed earlier, and I think we have to
recognize that there is a national shortage of mental health
providers. What I think--you know, what I think Linda had
indicated earlier, and I hope VA is moving away from, is the
sense that we own this issue alone. I think the opportunity is
there for community and VA to work closely together. And I hope
that is a direction we will see.
Mr. Benishek. Right, right. Dr. Schwartz, you said one
other thing, and that is, people waive their mental health
disability to return to deployment.
Ms. Schwartz. Yes.
Mr. Benishek. How often does that happen?
Ms. Schwartz. In a very small state, but I know at least
five cases of this happening, because what happens is when they
come back, they expect those checks to just keep rolling, and
then they come to me because I have service officers, and we
have to tell them the sad truth that you just signed away--when
you signed--when you said you are good to go, you signed--
stopped your check, it says I am fit for duty.
Mr. Benishek. Right, right, right.
Ms. Schwartz. So if they are deployed, and they come back
and they think they are going to get that, they have not been
really--they were not well informed that they are signing away
something that is very important. But at the same time, it is
incomprehensible to me, I served 16 years in the United States
Air Force, it is incomprehensible to me that they would ask
someone who is already compromised----
Mr. Benishek. Right, right.
Ms. Schwartz. --to--at any rate, unless it was like
somebody really, really unique, but these people are choosing
to go back into the military because it is a job, and they feel
as if they belong there. So you put that knowledge into the
fact that we are going to have a drawn down of tens of
thousands of people who feel that is where they belong.
Mr. Benishek. Well, no, it just worries me that we are
taking people that have, you know----
Ms. Schwartz. Yes, it worries me too. They can----
Mr. Benishek. --relating to mental illness to deployment
are there----
Ms. Schwartz. --get themselves into a lot of trouble.
Mr. Benishek. I do not even know that we should be allowing
that to occur.
Ms. Schwartz. I would hope that this Committee would really
look at that, and work with people to stop that.
Mr. Benishek. Thank you for your comments, a lot of time.
The Chairman. Thank you, Doctor. Ms. Negrete McLeod? Mr.
Runyan? Mr. Coffman?
Mr. Coffman. No questions.
The Chairman. Mr. Michaud, have you got anymore questions?
Okay. Thank you very much for being here. We do have some
additional questions we would like to present to you for the
record. Thank you so much for what you do. I look forward to a
continued relationship with each of you on this very important
issue and you are now excused.
I'd like to invite our second panel to the witness table.
Joining us from the Department is the Honorable Dr. Robert
Petzel. Dr. Petzel, thank you for making your way through
traffic and all kinds of security issues to be here. Dr. Petzel
is the Under Secretary for Health for the Department of
Veterans Affairs. He's accompanied today by Mary Schohn,
Director of the Office of Mental Health Operations, Dr. Sonja
Batten, Deputy Chief Consultant for Specialty Mental Health,
and Dr. Janet Kemp, Director of Suicide Prevention and
Community Engagement for the National Mental Health Program. We
thank you all for joining us today, and Dr. Petzel, you are
recognized to proceed with your testimony.
STATEMENT OF HONORABLE DR. ROBERT A. PETZEL, M.D., UNDER
SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY: DR. MARY
SCHOHN, DIRECTOR, OFFICE OF MENTAL HEALTH OPERATIONS, OFFICE OF
PATIENT CARE SERVICES, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; DR. SONJA BATTEN, DEPUTY CHIEF
CONSULTANT FOR SPECIALTY MENTAL HEALTH, OFFICE OF PATIENT CARE
SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS; AND DR. JANET KEMP, DIRECTOR, SUICIDE
PREVENTION AND COMMUNITY ENGAGEMENT, NATIONAL MENTAL HEALTH
PROGRAM, OFFICE OF PATIENT CARE SERVICES, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF ROBERT A. PETZEL, M.D.
Mr. Petzel. Good morning, Chairman Miller, Ranking Member
Michaud, and the Committee Members. I appreciate the
opportunity to come here to discuss VA's comprehensive mental
health care and services for our Nation's veterans. I am
accompanied today as the Chairman indicated by Dr. Mary Schohn,
Dr. Sonja Batten, and Dr. Janet Kemp.
Since early 2009, VA has been transforming and expanding
its mental health care delivery system. We have improved our
services for veterans, but we know that there is much more work
to be done. My written testimony has more detailed information,
and I would submit that for the record.
Mr. Chairman. Without objection.
Mr. Petzel. This morning, I will summarize these remarks,
and update you on our major accomplishments. As the President
stated last night, we will keep faith with our veterans
investing in world class care, including mental health care for
our wounded warriors, supporting our military families, and
giving our veterans the benefits, education, and job
opportunities that they have earned.
We are progressively increasing veterans' access to mental
health care by working closely with our Federal partners to
implement the President's Executive Order, to improve access to
mental health services for veterans, servicemembers and
military families, as well as implementing the 2013 National
Defense Authorization Act.
We know these changes require investment. Last year VA
announced an ambitious goal to hire 1,600 new mental health
care clinical providers, and 300 administrative support staff.
As of January 29, 2013, VA has hired 1,058 clinical providers,
and 223 of the administrative staff. We are on track to meet
the requirements of the Executive Order, and have these
positions filled by June 30th of 2013.
VA has many entry points for care, including 152 medical
centers, 821 community-based out-patient clinics, 300 vet
centers, 70 vet center vans, and the VA's crisis line, to name
but a few.
We have also expanded access to care by leveraging
technology, Telehealth, phone calls, secure messaging, online
tools, mobile applications, and outreach efforts, mental health
integration into primary care, community partnerships and
academic affiliations.
Out-patient visits have increased by over--to over 17
million in 2012. The number of veterans receiving specialized
mental health treatment rose to 1.3 million in 2012 from
927,000 to 2006.
In part, this is because our primary care physicians
proactively screen veterans for depression, PTSD, problem
drinking, and military sexual trauma to help these veterans
actually receive the treatment that they need.
We are also refining how we measure access to ensure we
accurately reflect the timeliness of the care we provide. VA is
updating scheduling practices, strengthening its performance
measures, and changing timeliness measures to best track new
and existing patient access times.
We will continue to measure performance, and hold employees
and leadership accountable to ensure that the resources are
devoted where they are needed for the benefit of America's
veterans.
VA has been working with partners to address access and
care delivery gaps. In response to the Executive Order, VA is
collaborating with health and human services to establish 15
pilots using community-based health clinics and mental health
clinics.
VA is also partnering with DoD to advance a coordinated
public health model to improve access, quality, and
effectiveness of our mental health services through an
integrated mental health strategy.
VA is committed to ensuring the safety of our veterans,
even one, even one veteran suicide is one too many. July 25th,
2012 marked five years since the establishment of the veteran
crisis hotline. This offers 24/7 emergency assistance. Last
year this crisis hotline received more than 193,000 calls
resulting in over 6,400 rescues, people rescued from harming
themselves or someone else.
Earlier this month, VA released a suicide report, developed
collaboratively with the states. This report includes data on
prevalence and characteristics of suicide amongst veterans,
including those veterans that are not treated within the VA.
The report provides us with valuable information as we
eluded to earlier, to identify populations that need targeted
inventions, such as women and Vietnam veterans. Moreover, it
identifies opportunities to train providers who care for
veterans in non-mental health settings.
The report makes clear that although there is more work to
be done, we are making a difference. There is a decrease in
suicide attempts by veterans getting care within the VA, calls
to the crisis hotline are becoming less acute, also
demonstrating that the VA's early intervention appears to be
working.
Mr. Chairman, we know our work to improve the delivery of
mental health services to veterans will never be done, and
there is much more, much more to do. We appreciate your
support, and encouragement in identifying and resolving
challenges as we find new ways to care for this Nation's
veterans.
My colleagues and I are prepared to respond to any
questions you may have.
[The prepared statement of Robert A. Petzel appears in the
Appendix]
The Chairman. Thank you very much. At the end, and I did
not have a chance to run back to your statement, but--one of
your last comments was that the number of calls coming in to
the crisis line were decreasing.
Mr. Petzel. No, actually, sir, not the number of calls were
decreasing, the intensity of the calls. The patients that are
calling now are less acute than they were when we first
entered, first developed the crisis line indicating----
The Chairman. Well, and again, so you say that's a success?
Mr. Petzel. I'm saying that that's an indication of the
fact that we are having some impact.
The Chairman. Could they be going somewhere else other than
your crisis line?
Mr. Petzel. We do not think so. The calls are, if anything,
increasing. We are seeing the volume, we are not seeing the
acuity.
The Chairman. Because we had testimony from the Connecticut
State Director about having 5,000 veterans on their rolls,
could they be going to their mental health providers or
somewhere else?
Mr. Petzel. Let me ask Jan Kemp who runs that hotline to
comment, Dr. Kemp.
Ms. Kemp. Yeah, we looked extensively at the number of
people who are calling the crisis line, and what they look
like, and where they are coming from. Our volumes continue to
increase. We think our messaging is out there, we are reaching
people. We are making an increased number of referrals, so when
those people call the crisis line, we are able to refer them
primarily to VA mental health providers through their suicide
prevention coordinators, but we do also have partnerships with
other organizations for those veterans who do not want to go to
the VA, such as Wounded Warriors, and given our--and Vets for
Vets, so we have lots of options to give veterans referrals to,
and we are proud of those.
What is going down, however, is the number of rescues that
we are having to call. So people hopefully, and we believe are
calling earlier in their sort of crisis trajectory process,
that we are able to get them help sooner before it comes to the
point where they have already taken pills, or they are holding
a gun to their head.
That was our intent. That was one of the reasons why we
sort of changed our messaging campaign halfway through the
stream. We changed the name of it. We want to get people
sooner. We think we are doing that.
Mr. Chairman. Dr. Petzel, you said in your opening
statement and I agree with this, that ``our ultimate desired
outcome is a healthy veteran.'' The problem is after you said
that, the focus, I think of the majority of your testimony was
processes, number of people hired, numbers, numbers, numbers,
and I think the most important number is how many veterans are
getting healthy or healthier or helped.
And so I think this Committee would like to know how you
quantify whether or not a veteran is getting better--it is easy
to quantify the number of people hired, but how do you quantify
whether a veteran is being helped or is getting healthy.
Mr. Petzel. Well, Mr. Chairman, we would agree with you,
that the important data is how have we helped veterans. And we
mentioned in the opening statement, and we will elaborate on
that several instances. Number one is the crisis line data. No
question about the fact that that indicates that there is some
impact on veterans with mental health problems of the programs
that we are involved in.
Number two is the suicide data. The suicide data is going
to become an important part of us evaluating how well we are
doing. And there is an indication in that suicide data that
indeed we are having an impact that people are being treated in
the VA.
The third thing is----
Mr. Chairman. And--there is a difference, though, and I
apologize, but being treated is one thing. How many of them are
becoming healthy again?
Mr. Petzel. Well, if the suicide rate is declining, if
there are fewer suicide attempts, if there is a decreased need
to rescue, that tells me that those people are getting better.
Mr. Chairman. But not every person who has a mental health
issue is--subject to a suicide attempt, or an actual suicide.
They may continue with mental health and depression issues for
a long time, so basing everything off of the crisis line, and
the suicide numbers supposedly remaining stable--again, how do
you quantify that a veteran suffering from depression or PTSD
is getting better?
Mr. Petzel. Let us take an example, Mr. Chairman, of PTSD.
We can evaluate the symptoms in a patient when they initially
present with PTSD, and they may go through cognitive behavior
and therapy or another evidence based therapy. And subsequently
they are evaluated for the presence of the symptoms related to
PTSD. And we have good evidence in the literature that people
that go through that program do indeed have less symptomatology
associated with their PTSD, and are better adjusted to living
in society.
There are many instances of the treatment protocols that we
have, where we can demonstrate the direct impact on those
individuals that have been through that therapy.
Mr. Chairman. Is there a disincentive for a veteran who has
been rated for PTSD to show improvement?
Mr. Petzel. I do not believe that there is. I believe that
people that are suffering from PTSD do want to have that PTSD
treated, and do want to go through therapy, and do want to make
a better adjustment to their living circumstances, no.
Mr. Chairman. Okay. Thank you. Mr. Michaud.
Mr. Michaud. Thank you, Mr. Chairman. Thank you, Under
Secretary for being here today.
Mr. Ibson mentioned in his testimony about central office
doing a survey of clinicians as far as the best clinical
judgment. Is that survey completed, and could you share with
the Committee? And my other question is, you mentioned the
President's Executive Order, and that it is going to establish
15 pilot sites. We heard earlier testimony today that when you
look at the huge influx of soldiers that are going to be coming
back, and 40 percent are in rural areas, how were the locations
of those pilot sites determined, and did you take into
consideration the problems we are facing in rural areas?
Mr. Petzel. Thank you, Congressman Michaud. I am going to
have to talk with Ralph Ibson about the survey that he referred
to. I am not quite sure which one he meant. I know that more
than a year ago, what really touched off the eventual feeling
that we had to hire additional mental health workers, was a
survey of our mental health providers, as to whether or not
there was adequate staffing. And they may be what he is
referring to, but I will talk with him after we finish----
Mr. Michaud. Okay.
Mr. Petzel. --with the hearing, and then we will then get
back to you.
In terms of the pilots, the--15 sites were selected, they
were selected based upon the desire of the local network, our
hospital to participate, and a need is identified often by how
rural the areas were. There is one urban center where we are
doing this in Atlanta, to get a feeling for what that might be
like, because there are many, many community mental health
clinics in the Atlanta area.
I want to mention just tangentially to the pilots, that we
have been participating with community and mental health
centers in certain parts of the country prior to the pilots. In
Montana, there is a network of community mental health centers
that are providing care to veterans in that phenomenally remote
state where we are not able to provide mental health providers
in each one of the communities.
We think that this is a--this is going to be a viable
alternative in the future to us cooperating in the community
with providing care in these again remote rural areas.
Mr. Michaud. Okay. On the suicides, I understand the VA now
has a memorandum of understanding with all 50 states to report
the suicide data. We heard earlier this morning that the two
largest states, I think it is Texas and California have not
submitted that information. Are there any other states that
have not submitted that information?
Because my concern is when you look at the increase in
suicide rates, it went from 18 to 22, and that is--to me that
is the low number, because there is a lot more suicides, I
believe out there that are not being reported. So are there any
other states out there that have not reported?
Mr. Petzel. I would ask Dr. Kemp who runs the suicide
program to comment on that. I do not know the answer.
Ms. Kemp. We now have agreements with all states that they
will. We have gotten data from both Texas and California since
the report came out. There is a couple of states that we are
still working with over privacy issues and how we are going to
share the data, and I am confident that we will get those soon.
Mr. Michaud. Thank you. Earlier today we also heard, I
think it was actually Mr. Ibson I believe, talked about the
clinicians within the VA, that they have to meet certain
performance requirements set out by central office.
Last year, I think it was last year, we also heard from the
former VA employee who worked in the facility, I believe it was
New Hampshire, pretty much said the same thing, that they have
a certain performance criteria they have to deal with, that
they do not feel that they can provide the services to our
veterans the way they should be providing it, because it is
trying to just get them through the system, and that is a
concern that I have. Can you talk about other performance
requirements for the clinicians?
Mr. Michaud. Thank you, Congressman Michaud. Yes, there
are, and there is attention and a balance between having the
time available and the need to provide direct clinical care,
and on the other hand, the need to document what has been done.
And the need to provide information in terms of performance
measures, sometimes for us to be able to answer the Chairman's
question about are we having an impact on patients. And often
times, the performance measures, particularly outside of mental
health in the medical health system are a very important part
of our being able to say yes, we have had an impact. We have
helped this patient to avoid cardiac disease or whatever.
So it is important to have performance measures, and I
think it is incumbent on us as the leaders to make sure that
there is the proper balance between time available to do
clinical care, and the necessity of meeting performance
measures.
And just an example, one of them would be, a reminder will
pop up, you need to immunize this patient for influenza, and
that is a reminder that has got to be satisfied, and there are
a number of other kinds of reminders that need to be satisfied
to do those things.
Mr. Michaud. Would you provide the Committee with those
performance standards that they have to meet?
Mr. Petzel. Yes, we can. It is a--okay, we can. Yes, sir.
Mr. Michaud. I take it by your delay, that it is probably a
lengthy----
Mr. Petzel. Congressman, it is not so much it is lengthy,
it varies from the kind of clinical setting that one is in, but
we can do this, yes.
The Chairman. How does reminding a provider that somebody
needs an immunization help them get better mentally? I mean
that is what we are focused on at this point, providing mental
health to the veteran. Clinically, I guess I understand if he
or she needs a flu shot, but that is not what they are there
for.
Mr. Petzel. I'm sorry, Mr. Chairman. I was trying to give
an example to the Congressman of the things that we hear
clinicians complaining about in terms of performance measures
and clinical reminders. There are clinical reminders that are
related to mental health, such as----
Mr. Chairman. No, I understand that. Just a question. I
apologize. Mr. Runyan.
Mr. Runyan. Thank you, Chairman. Some of my questions I am
not even sure you can answer, because as Chairman Miller said,
there is not a lot of data on what is happening day-to-day. My
one question, Dr. Petzel, I do have, there seems a lot of
things we do specifically in the mental health field,
especially in the VA, and I think nationally, too, because I do
not know if we are there yet as a medical field.
The balance of being reactive to being proactive a lot of
times is way out of balance. And have you had any movement on
trying to figure out how we can get in? Obviously, a lot of the
PTSD that a lot of our veterans have is triggered at some
point. It is there, maybe we could have proactively got in
front of that. Is there anything you've been discussing or have
on the horizon that we can say that we are going to move in
that direction, so we do not have to wait till the last minute,
till there is a crisis?
Mr. Petzel. That is an excellent question, Congressman
Runyan, and I want to harken back to what Dr. Rudd said in
terms of transition.
Identifying--all the patients that we see come out of the
Department of Defense, they are soldiers, sailors, Air Force
members, airmen, Marines, and we need the opportunity to
interact with these people before they leave the service. The
new mandated transition assistance program I think is going to
give us that opportunity to both present and interview the
individuals before they leave the service to identify those
people who are at risk, who might have a previous problem, who
might have a problem in transition, so that we can do, what was
referred to earlier as a hot transfer. A warm transfer between
the Department of Defense, the Army, whatever it might be, and
our VA health care system, so that these people do not fall
through the cracks, so that we do get them into our system.
We can do, we can do a very good job, once we can get
people into the system, and I think a major issue is providing
for the right kind of transition. And that involves our being
able to get at these individuals in this mandated transition
assistance program.
The second thing that I would like to talk about in
relationship to your question is another issue that came up,
and that is establishing the kind of relationship with a
patient, so that they will tell you their story.
I mean, there are certain--in our age population, 50 and
over, particularly, there are certain things that are
associated with suicide, antecedent so to speak. Substance
misuse, pain, depression, maybe PTSD, life stressors, we need
to have a relationship with that patient such that they will
tell us about those. They will tell us their story if you will,
as opposed to the usual, is anything bothering you; no, nothing
is bothering me. I think you have heard the interactions many,
many times where it tends to be superficial and you don't
really get the story.
So getting at patients early through transition, and
developing the relationships where they will tell us where
there are things that may be antecedents to suicide that are
bothering them, that we can act on again before there is a
crisis.
Mr. Runyan. Well, I think, and this is more of a statement
than anything else. I think the bigger question is, it is human
nature to be secluded and not do that. But how statistically
can we deal with DoD data, kind of figure out people that are
in the same unit, or that have been exposed to things like
that, how can we proactively prod them, if you will, do you
know, give us that information?
Mr. Petzel. Well, certainly if we have access to the
medical record with this integrated health record that is being
developed, we will be able to see those people that have had
difficulty meeting their mortgages, that have a difficulty with
substance misuse, that have had behavioral problems, et cetera.
Those things are all triggers that would indicate to us this
person needs to be evaluated, this person needs to be looked at
closely.
It is getting the information, and the contact with the
individual before they have the difficulty as you have pointed
out is the problem.
Mr. Runyan. Thank you, Chairman. I yield back.
Mr. Chairman. Dr. Petzel, you may not be able to answer
this today, but going back to testimony that was received two
years ago, about a study published in the Journal of Traumatic
Stress on the treatment utilization rates of veterans of Iraq
and Afghanistan which found that less than ten percent of those
newly diagnosed with PTSD received the recommended number and
intensity of VA evidence based treatment sessions within the
first year of their diagnosis.
Can you comment on that? Has that gotten better?
Mr. Petzel. I think you are right, Mr. Chairman. We are
going to have to get back to the Committee. I am not familiar
with the study, and I am not able to cite any specific evidence
if that situation is different than what is in the study. So if
we could, we would appreciate the opportunity to come back to
you.
Mr. Chairman. It was Dr. Karen Seal who testified, in mid-
June of 2011, but we will get you the information. I would like
to measure this year against last year.
Mr. Petzel. I would also. Thank you.
Mr. Chairman. Okay. Yes, sir. Ms. Brownley.
Ms. Brownley. Thank you, Mr. Chair. Before I ask a
question, I would like to ask you, I mentioned earlier that I
recently visited some VA facilities or most of the VA
facilities in my district, the Oxnard, CBOC, the Ventura Vet
Center, and West Los Angeles Medical Center, which serves both
Ventura vets as well as Los Angeles County vets. And as you
know, it is the VA, the West LA Medical Center is the largest
medical center in the country.
And I would just like to ask consent to include some
written questions into the record for--as a result, I have
questions from those visits that I had in Ventura County, as
well as the West LA Medical Center, if I could submit those to
the record on behalf of myself and Congressman Waxman, who also
represents specifically the West LA Medical Center?
Mr. Chairman. Without objection, and let the record show it
is at the request of all Members of this Committee.
Ms. Brownley. Thank you, Mr. Chair. And I just wanted to go
back to, I think, you know, listening to the testimony of the
first panel, I think my sort of biggest take away from that
testimony is looking at our models of delivery, noting that
personalization, trust, are essential components. Some of the
testimony talked about looking, comparing our delivery of vet
services to private practice, meaning having contact with one
individual, with one therapist who you can call, you know, 24/7
if needed.
And so--and I know that they are--and your testimony that
you talked about a lot of different programs which I believe
are beneficial and are improving services, but it still is a
concern to me if the personalization and trust is still built
in to all of those programs. If you have to move from one
program to the next program to the next program, I mean, that
is one thing when you are having heart trouble, and you are
going to get an X-ray and moving from one situation to the
next. But for mental health care services, vets I believe, are
different.
So in the spirit, I guess, of--in any operation, in the
spirit of sort of continuous improvement, are we looking down
the road to sort of other models of delivery that would improve
and enhance and bring our delivery of services perhaps closer
to a private practice model?
Mr. Petzel. The answer short is yes, Congresswoman
Brownley. But I mean, in a moment, I am going to ask the other
witnesses to comment on the remarks that Dr. Schwartz made,
which are not the case. I cannot speak specifically what is
going on in Connecticut, but our providers give their cell
phone numbers, develop safety plans, et cetera to individual
patients, and they are available 24/7, in addition to the
emergency room services that we have available in all of our
medical centers, and some of our larger clinics. That is just
the way the system works.
But as I said earlier, this developing of a relationship
and such that people will talk to you about what is going on, I
think is a very important fundamental part. And we have a newly
organized task force that Dr. Kemp is chairing, that is going
to look at how we can develop a different paradigm, if you
will, for the way we deliver care to people that have chronic
pain, sleep disorders, depression, et cetera. The thing that
have the greatest impact on suicide.
The other care model that is growing rapidly in our system
is the embedding of mental health providers into the primary
care clinic, or the PACT team. We now have, I believe 593
places where that is actually happening, both in our medical
centers, in our primary care clinics.
And there you would have a nurse practitioner in mental
health, perhaps a psychologist, or a psychiatric social worker
who works with that primary care team, and has a relationship
back to the primary mental health group, a psychiatrist, et
cetera. And that individual is able to manage the mental health
issues in that panel of primary care patients. Therefore, that
individual with mental health difficulties does not have to
leave that clinic. All those services are available in that
same arena.
I think that is going to become a rapidly developing
phenomena. The VA is a pioneer in that, but I think this is
something you are going to see in other integrated delivery
systems in the private sector.
And then the last thing is telemental health, which is
growing very rapidly, and is the way that we are reaching, one
of the ways that we are reaching into the rural parts of this
country to provide the specialized mental health services.
Ms. Brownley. And following up, there was also a comment
about--part of the testimony saying that the larger the VA
becomes, there is the possibility, I guess I should say of the
quality and effectiveness of programs going down. And the
notion of combining--partnering VA services with state services
and I think community services to, again, I think to attract
the right models of personalization and consistency and
effectiveness, so.
And what you were just suggesting and looking ahead to, are
you also looking at greater community partnerships for our
veterans?
Mr. Petzel. Yes, we are, Congressman. That is what the 15
pilots are all about. That is what the network that we already
have established in Montana is all about. And I think that
there is going to be fruitful work to be done, particularly
with the community mental health systems, which is another
federally funded system around the country.
You know, the difficulty in the private sector is, they
have got the same problems with shortages as everybody else
does. When you look at a map of this country, there are 33
states where more than 25 percent of the population is under
served in terms of mental health, going all the way down the
inter-mountain country, there are 18 states in that area that
have a shortage of mental health providers. There is not a lot
out there for us to contact within these community mental
health clinics, are one of the resources that we know, you
know, is there. And we intend to exploit that.
Ms. Brownley. And what about pipeline issues? I read, I
think, in your testimony or in another report that for example,
psychiatrists, there is a shortage of psychiatrists, and I hear
your concern about the limited amount of talent that is out
there, that we need to secure. And so are we looking towards
that sort of pipeline issue to make sure that we do, that we do
indeed--am I over my time, Mr. Chair?
The Chairman. Yes. There is a clock right in front of you.
Ms. Brownley. Oh, I was looking at my clock here, and it
says three minutes. I apologize.
The Chairman. Yes, the little red light, the little red
light, three minutes means you are three minutes over time.
Ms. Brownley. Oh, I apologize.
Mr. Petzel. May I take a moment, Mr. Chairman, to respond?
Mr. Chairman. Please.
Mr. Petzel. In terms of the pipeline, very important
question. VA is the largest health--trainer of health care
professionals in the country. We devote 6,400 trainee
physicians a year to mental health programs. 1,900 psychology
training positions, mostly internships, the finishing year for
a psychologist, 3,400 psychiatry residency physicians, again
the largest trainer of psychiatrists in the country; and then
1,100 psychiatric social worker positions.
We added last year 220 positions to that, all of them in
these new concept team care organizations, training physicians
in the PACT mental health embedded program, et cetera.
So we are a big trainer. Seventy percent of the people we
recruited in psychiatry and psychology trained within the VA.
It is a very important recruitment tool for us. But I think the
Committee must recognize the fact there is a shortage of
psychiatrists in this country. There are not enough training
positions for psychiatric residencies.
The Chairman. Thank you very much. Mr. Coffman?
Mr. Coffman. Thank you, Mr. Chairman. Dr. Petzel, in your
testimony you state that as of March 2012, the VA was said to
have 18,587 mental health providers, and by using an approved
accounting methodology, the VA currently has 19,743, but on
April 19th, 2012, the VA indicated it was adding 1,900 staff,
``to an existing workforce of 20,590.'' Now, I'm not a
mathematician, but the numbers show that VA is losing mental
health professionals. So in what kind of fuzzy math is your
current level of 19,743 a ``net increase'' over the past level
of 20,590?
Mr. Petzel. Well, Congressman Coffman, it is not fuzzy
math. We had a process for assessing how many people we had on
board in March that I would describe as incomplete. We took one
database, and applied it across the country, and came up with a
number that approximated 20,500 if I remember correctly.
Over the summer, we have refined the way we count our on
board strength, and what we have discovered is that there were
people not doing clinical work, that were included in that
20,500. They were hired to do clinical work and research, and
we were counting them a hundred percent clinical. They were
hired to do clinical work and education, and we were counting
them as a hundred percent clinical work.
When we went back and used two separate databases and
refined these educational and research components and
administrative components out of that, we came back with an on
board strength in March of 18,587. Using that same methodology
in November, we came on--we came to an on board strength of
19,743. Thus, an increase of 1,156. Very clear, it is not
fuzzy, it is not playing with the numbers, that is the fact.
Mr. Coffman. I think that--it is odd that you--that VA
would not know exactly how many people when asked are providing
work to help our veterans. And so the--Dr. Petzel, has VA done
anything to find out what your own mental health providers are
saying about the work being done?
Mr. Petzel. Yes. That is an excellent question. When we,
this spring have got implemented our performance criteria for
timeliness, the intention is to go out and do three things.
One, look at the measures. Two, survey veterans as to whether
or not they were--had timely access as well as other
satisfaction related questions. And three, to survey the staff.
Are they able to provide timely access for their patients, are
they adequately staffed, do they have enough people to do the
work that they are being required.
So, yes, we are going to do it. And we will be doing that
on a regular basis. That is part of evaluating whether or not
we are accomplishing what we said we would accomplish in terms
of access.
Mr. Coffman. Great. Could you please provide a copy of the
unadulterated results to the Committee by the end of the day?
Mr. Petzel. Well, this is something we are going to be
doing this spring, Congressman.
Mr. Coffman. But there was a recent survey done, was there
not? Could you provide to the Committee any recent surveys done
in the last 12 month period on your providers, in terms of what
we just talked about?
Mr. Petzel. Yes, we will.
Mr. Coffman. Thank you very much. Mr. Chairman, I yield
back.
The Chairman. Thank you very much. Mr. Michaud, anymore
questions?
Dr. Petzel, thank you and the folks that have joined you
for what you do. We all want to work together to resolve this
issue. My last question I guess to you is, what recommendations
do you have for this Committee that we can do to aid you in
your quest to provide quality and timely mental health services
to our veterans?
Mr. Petzel. That is an excellent question, thank you. One
is facilitating our interactions with the community health
centers. I cannot be specific, but I think that is an important
part of the future.
Two, is helping us work with the private sector, provide a
community where it is available to provide services in areas
where we are not able to do that.
And then three, I would add as I mentioned earlier, I do
not know how this Committee can influence it, but there is a
real shortage of psychiatrists in this country, and mental
health training positions. And whatever can be done to help
improve that, I think would benefit the veteran community.
The Chairman. I do find it quite interesting that you have
mentioned the shortage of providers several times in your
testimony, yet you are almost exceeding your goals for hiring.
What do you do that the private sector cannot do that helps you
fill those slots so quickly?
Mr. Petzel. Thank you, that is also a very good question.
Number one, our salaries are very competitive for nurses, for
psychologists, and for social workers. Number two, is a good
place to have a career. It is a large organization, and can
work in many different parts of the country, and you do many
different kinds of jobs.
We do have, however, difficulty in the psychiatry. I mean,
I do not want to brush over that. Of all of the professionals
in mental health, the most difficult problem we are having is
recruiting psychiatrists, and we have barely been able to
recruit half of the new ones that we said we wanted to do, and
that it is in spite of raising the salary quite substantially,
providing incentives for recruitment bonuses, et cetera.
The Chairman. Okay. Thank you very much. I would ask
unanimous consent that all Members would have five legislative
days to revise and extend their remarks, or add any extraneous
material for the record. Without objection, so ordered.
Thank you everybody for being here today. Thank you to both
panels. This hearing is adjourned.
[Whereupon, at 12:02 p.m., the Committee was adjourned.]
A P P E N D I X
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Prepared Statement of Hon. Jeff Miller, Chairman
The Committee will come to order.
Good morning, and welcome to today's Full Committee hearing,
``Honoring The Commitment: Overcoming Barriers To Quality Mental Health
Care for veterans.''
Today's hearing is our first Full Committee hearing of the 113th
Congress and it is only fitting that we begin our oversight by
addressing one of the most pressing and fundamental issues facing our
servicemembers, veterans, and their families--our ability to provide
timely and effective mental health care to veterans in need.
This issue is not a new one, but it is a growing one.
In the last six years, there has been a thirty-nine percent
increase in VA's mental health care budget and a forty-one percent
increase in VA's mental health care staff.
Unfortunately, those significant increases have not resulted in
equally significant performance and outcomes.
Less than a year ago, the VA Inspector General released a review of
veterans mental health care access that painted a disturbing picture,
showing that the majority of veterans who seek mental health care
through VA wait fifty days, on average, for an evaluation.
That figure amounts to thousands of veterans in need--veterans who
have recognized they need help and who have taken the hard step of
asking for it--being told by the Federal bureaucracy tasked with caring
for them that they have to wait in line because VA cannot provide them
with the timely access to care they need to begin healing.
And it gets worse.
Earlier this month, VA released its 2012 Suicide Data Report.
That report shows, among many alarming findings, that the suicide
rate among our veterans has remained steady for the past twelve years,
with eighteen to twenty-two veteran suicide deaths per day since 1999.
As that report so clearly illustrates, when a veteran is in need of
care, the difference of a day or a week or a month can be the
difference between life and death.
This morning, the department is going to testify that progress is
being made to increase access to mental health care services and reduce
veteran suicide.
They will proclaim that they have hired just over thirty-two
hundred additional mental health care personnel.
However, despite our requests, VA has not provided evidence to
verify its efforts.
And while I am and will remain supportive of the improvements the
department is attempting to undertake internally, it has become
painfully clear to me that VA is focused more on its process and not
its outcomes.
The true measure of success with respect to mental health care is
not how many people are hired, it is how many people are helped.
Since 1999, VA's mental health care programs, budget, and staff
have increased exponentially and the number of veterans seeking care
has grown, yet the number of veterans tragically taking their own lives
has remained the same.
What's more, the Suicide Data Report I mentioned earlier, shows
that the demographic characteristics of veterans who die by suicide is
similar among those veterans who access VA and those veterans who
don't.
Something is clearly missing.
On our first panel this morning we will hear from representatives
from our veterans service organizations, an established veterans mental
health researcher, and a state commissioner of veterans affairs.
Three of them are veterans themselves, and all of them will testify
that the provision of mental health care services through VA is
seriously challenged and that what is needed to fix it is decidedly not
more of the same.
Last night, the President announced that a year from now thirty
four thousand of our servicemembers currently serving in Afghanistan
will be home.
The one size fits all path the department is on leaves our
returning veterans with no assurance that current issues will abate and
fails to recognize that adequately addressing the mental health needs
of our veterans is a task that VA cannot handle alone.
In order to be effective, VA must embrace an integrated care
delivery model that does not wait for veterans to come to them, but
instead meets them where they are.
VA must stand ready to treat our veterans where and how our
veterans want, not just where and how VA wants.
I can tell you this morning that our veterans are in towns and
cities and communities all across this country, and the care they want
is care that recognizes and respects their own unique circumstances,
preferences, and hopes.
Thank you all for being here today.
Prepared Statement of Hon. Michael Michaud
Thank you, Mr. Chairman, for continuing to keep the issue of
access, quality, and timely mental health services provided to our
veterans at the forefront of this Committee.
Thank you to all of our witnesses today for coming and talking with
us about the critical issue of veteran mental health access. I would
also like to thank all of you in the audience who are here today in
support of veterans.
We, as a Nation, have a responsibility - a sacred trust - to care
for those whom we send into harm's way. When we send our citizens into
battle around the world, we must be leading the charge here at home,
within our government, to make them whole again upon their return by
ensuring that adequate resources and proper programs are in place to
address their needs.
Oversight of VA's mental health programs has been a focus of this
Committee for some time now. Over the years we have held numerous
hearings, increased funding and passed legislation in an effort to
address the challenges veterans from all eras face.
VA spent $6.2 billion dollars on mental health programs in Fiscal
Year 2012. I hope to see some positive progress that this funding has
been applied to the goals and outcomes for which it was intended, and
the programs are working.
We all know that mental health is a significant problem that the
Nation is facing, not just veterans or the VA. In this broader
challenge is an opportunity for the VA to look outside their own walls
to solve some of the challenges they face, rather than operate in a
vacuum as they sometimes have done in the past.
One of the most pressing mental health problems we face is the
issue of suicide and how best to prevent it.
Fiscal Year 2012 tragically saw an increase in military suicides
and for the third time in four years, the number of suicides surpassed
the number of combat deaths. Couple that with the number of suicides in
the veteran population of 18 to 22 per day and the picture becomes even
more alarming.
I believe VA is headed in the right direction. I believe that they
have made a true effort to get a good picture of the suicide issues
that surround veterans. I believe more can and must be done.
I will be interested to hear from our panelists about the national
mental health picture and helping this Committee put the veteran
suicide rates in context, as well as what is happening nationally in
treating mental illness.
Today's hearing will examine the progress VA has made in a variety
of areas concerning mental health and providing timely access and
quality care.
I am hopeful that this will be a good discussion on ways to provide
that care such as more partnering with the public and private sector,
increasing the pool of providers, and other creative ways to address
mental health.
Finally, I would be remiss if I did not acknowledge the dedication
of the VA employees who provide quality mental health care to our
veterans every day. The directors, doctors, nurses and hospital workers
are a team that when it comes together in a collaborative and
synergistic way delivers on the Nation's responsibility and sacred
trust to care for those who have sacrificed.
With that Mr. Chairman, I yield back.
Prepared Statement of Hon. Jackie Walorski
Mr. Chairman, it's an honor to serve on this Committee.
I thank you for holding this hearing on such an important issue
facing our Nation's veterans.
I must first express my sincere gratitude to the 50,000 veterans
and their families back in Indiana's Second Congressional District. \1\
I am indebted to these men and women for their sacrifice in protecting
this great Nation.
---------------------------------------------------------------------------
\1\ There are an estimated 53,318 veterans in IN-02. This data was
compiled on 09/30/2012, based on the district lines from the 112th
Congress. http://www.va.gov/vetdata/Veteran--Population.asp
---------------------------------------------------------------------------
While I am proud of these veterans, I am appalled and saddened by
the progress that has been made in providing them with timely and
appropriate mental health care. It is obvious that we must work to
significantly improve the procedures and systems used in providing
mental health care to current veterans as well as those servicemembers
soon transitioning to civilian life.
I look forward to working with my colleagues and our panelists to
ensure our veterans are provided with the best access to mental health
care.
Thank you.
Prepared Statement of Hon. Raul Ruiz
Thank you Mr. Chairman for holding today's hearing on mental health
care services for our veterans. Oversight of VA's mental health
programs has long been a focus of this Committee. And while much has
been accomplished, we still have a long way to go in providing our
veterans with quality, efficient mental health care.
I am always discouraged when I hear stories of struggling veterans
facing delay and denial of much needed care here at home when they
sacrificed so much abroad. Our health care system is not only dated,
but also strained to capacity. We need to begin modernizing and
streamlining the process so veterans who need care can get care
quickly.
In this spirit, I am encouraged by a recent announcement last April
of the addition of 1,600 mental health clinicians and 300 support staff
to the VA's existing workforce. While this is a start, the VA needs to
continue to focus on the many other cracks in the system including its
inaccurate reporting of timely patient care.
These issues are extremely important to veterans in my district
considering the location of VA's Palm Desert clinic which provides
primary care services for veterans in the Coachella Valley, including
mental health care services.
Thank you, Mr. Chairman, and I yield back my time.
Prepared Statement of M. David Rudd
Mr. Chairman and members of the committee, I appreciate the
opportunity to speak on the issue of barriers to quality mental health
care for Veterans. As revealed in the Department of Veterans Affairs
2012 Suicide Data Report, Veterans continue to die by suicide at
tragically high rates, with an estimate of 22 deaths per day. However,
the true scope of the problem is only realized by coupling VA and
active-duty data. As has been widely reported, there were 349 suicides
among active-duty service members in 2012, with that total exceeding
combat deaths (and the rate doubling since 2004). Prior to Iraq and
Afghanistan, military service was actually protective, with military
suicide rates noticeably lower than general population rates likely
secondary to pre-enlistment screening, unit cohesion, the influence of
a remarkable sense of purpose, and a warrior identity. A decade of war
has changed many things. It is important to recognize that Veteran
suicides may actually be underreported, with reliable data only
available in 21 states and data from two of our largest states (Texas
and California) not included in the report. I have serious concerns
that these numbers will continue to grow in the coming months and
years, primarily a function of converging forces that can both be
anticipated and managed more effectively.
Although I applaud the transparency and thoroughness of the VA
Suicide Data Report and progress made to date, I believe it critical
for the committee to put the data into context. It is correct that
suicide rates among Veterans (VHA users) have been relatively stable
over the course of the past 12 years, with an overall rate of 35.9/
100,000 in 2009 (and a male suicide rate of 38.3). It is critical to
recognize, though, that the rate is three times the national rate of
12.0 in 2009 and double the male suicide rate (19.2) for the general
population. It is also reported that although the suicide rate among
Veterans rose 22 percent over the past decade the general population
rate rose 31 percent. Please understand, though, that the Veteran
suicide rate is already so high that the rate of growth should
naturally slow. Similarly, the drop in the percentage of our nation's
suicides accounted for by Veterans is important (from 25 percent to 21
percent), but that means that one in five suicide deaths in the general
population is by a Veteran despite the lowest military service rates in
U.S. history. Perhaps most worrisome among findings is that younger
Veterans appear to be dying by suicide at disproportionate rates (when
compared to the percent of Veterans in the contributing states), with
rates more comparable in older age groups. This data might reflect a
persistence of problems from activity-duty to Veteran status for Iraq
and Afghanistan Veterans in particular. My concern is that the data
need to be accepted for what they represent, a very serious and
significant health problem among Veterans. Contrast and comparisons to
the general population, although limited, help us recognize the
magnitude and persistence of the problem. These data should challenge
us to do better not reassure us the problem is under control. These
data should challenge us to think about doing things differently, not
simply funding ``more of the same''. These data can be added to almost
a decade worth of findings that indicate what we have been doing has
not been particularly effective.
As indicated in the report, since 2009 approximately 30 percent of
callers to the national crisis line have endorsed thoughts of suicide,
down from 40 percent. Although the drop could suggest progress, it is
more likely that the crisis line is not actually attracting the highest
risk callers. Are we reaching those at greatest risk for suicide? The
persistence of high suicide rates would suggest the VA might need to
explore other options for identifying and reaching those at greatest
risk. The fact that 80 percent of those with non-fatal events were seen
4 weeks prior to the event suggests the need to target the continuity
and intensity of care, along with raising the question of whether or
not heightened risk is readily recognized by clinicians. If it is, we
need to improve access, the frequency, and continuity of care. We know
the VA provides high quality care. Access to predictable, frequent
follow-up care is an issue to target. Similarly, the fact that 90
percent were seen in an outpatient setting suggests the need to target
primary care and outpatient mental health as the focal points. The fact
that the greatest risk is among Veterans over age 50 speaks to the
chronicity of many of these mental health problems and the importance
of not just crisis care, but ongoing long-term treatment. In order to
reduce wait times and provide accessible, predictable, long-term care
the VA will need to explore partnerships with private community
providers. Continued centralization within VA healthcare needs to be
challenged.
I am convinced that the bulk of the problem is not a clinical one.
We have to do a better job of managing those at risk, providing easy
and frequent access to care, and convincing Veterans to stay in care.
The more difficult we make it to get or stay in care, the more Veterans
will die by suicide. I believe that among the most significant barriers
to care for Veterans is the lack of meaningful transitional services
for those evidencing heightened risk while on active duty, only to be
discharged and left alone to navigate the maze of government services.
The tragic suicide of Russell Shirley demonstrates the problem. I
recently spoke with Russell's mother and one of his close friends. His
mother consented to me sharing his story. Russell was a son, a husband,
a father and a soldier. He served his country proudly and bravely in
Afghanistan. Although he survived combat, he came home struggling with
post-trauma symptoms and traumatic brain injury. With a marriage in
crisis and escalating symptoms, Russell turned to alcohol, with the net
outcome a DUI and eventual discharge. Russell lost his family, his
career, his identity, and eventually put a gun to his temple and pulled
the trigger in the presence of his mother. His mother now struggles
with her own brand of PTSD. Russell's high risk status was easily
recognized. In order to help struggling soldiers like Russell, we need
to connect them not just the VA system, but people in the system. The
DoD and the VA need to work hand in hand to improve transitional
services for high-risk service members being discharged or voluntarily
separating. With significant budget cuts likely, these numbers will
only grow. The VA needs to experiment with partnerships in local
communities that allow Veterans to receive accessible and long-term
care near home rather than having to travel great distances. Instead of
building an even bigger and less flexible and responsive healthcare
bureaucracy, now is the time to experiment with new and creative
alternatives.
For the first time in history, we have conducted clinical trials
with active-duty service members struggling with PTSD, depression and
suicidality. Early results are promising. Can we find a way to provide
treatment prior to designating a Veteran as ``disabled'', as we know
that once someone is identified as disabled it is unlikely that status
will ever change? This also speaks to the chronic nature of the
problems revealed in the VA report, i.e. the highest suicide rates
among those over age fifty. As the drawdown in Afghanistan continues
and the DoD grapples with smaller budgets and force reductions there
will be more tragedies like that experienced by the family of Russell
Shirley unless we find ways to ease the transition from activity duty
to VA services, improve access, retain Veterans in treatment, and
experiment with alternatives to permanent disability status.
It is important to recognize that behind every statistic quoted
above there is a large collection of friends and loved ones. I have
included a photo of Russell with his children at the end of this
document so you and I can remember the Americans touched by this
problem.
M. David Rudd, Dean, College of Social & Behavioral Science,
University of Utah
Co-Founder and Scientific Director, National Center for Veterans
Studies
Prepared Statement of Linda Spoonster Schwartz
Good morning Mr. Chairman and Members of the Committee, my name is
Linda Schwartz and I have the honor to be Commissioner of Veterans'
Affairs for the State of Connecticut. I am medically retired from the
United States Air Force Nurse Corps and hold a Doctorate in Public
Health from the Yale School of Medicine. I also serve as North East
Vice-President and Chairman of Health Care for the National Association
of State Directors of Veteran Affairs. I want to thank you for holding
this hearing and for being concerned about overcoming barriers to
quality mental health care for veterans.
I served 16 years in the United States Air Force both on Active
Duty and as a Reservist (1967-1986), since that time, a great deal has
changed in the composition and needs of America's military and the
Nation's expectations for the quality of life and support for the men
and women of our Armed Forces. Now women comprise approximately 20 % of
the military force, a stark contrast to the fact that before the advent
of the all volunteer force, women were limited by law to only 2% of the
Active Duty force. Another striking feature of our military force today
is the heavily reliance on the ``citizen soldiers'' of our Reserve and
National Guard and the increasing number of military men and women on
Active Duty who are married with children. The Department of Defense
reports that 93% of career military are married and the number of
married military personnel not considered career is more than 58%
today. Because military families of our Reserve and National Guard
units are no longer housed on military instillations, they do not have
the support systems and sense of community enjoyed by previous
generations of military members.
As America has continued to task Reserve and National Guard units
with greater responsibilities in combat areas the realities of multiple
deployments, loosely configured support systems and traditional
military chain of command mentalities are challenging mental health
delivery systems. Transitioning in and out of family life is not only
difficult for the military member, the family, spouse, children,
mother, father, sister, brothers and/or significant others are also
traumatized as well. This is not happening on a remote site or military
base, this time we read about our neighbor next door, the young woman
who teaches kindergarten, our friend from school or church.
As Connecticut's Commissioner of Veteran Affairs since 2003, I have
a unique position and responsibility to be sure that we do not repeat
the mistakes of the past. As a veteran of the Vietnam War and a nurse
who has dedicated over 20 years to advocacy for veterans, I am acutely
aware of the fact that the veterans returning home now are very
different than the veterans of my generation or my fathers World War II
generation. While they are not encumbered with validating the
legitimacy of Post Traumatic Stress, they have brought the issues of
blast concussions, Traumatic Brain Injuries, suicides and the
importance of families to mission readiness to the forefront. Perhaps
it is because they may have trained with a unit for years and
experienced the intensity of living in the danger of a war zone with
their unit, that they feel isolated in their own homes. During
deployments, they longed for family and friends with visions of a
celebrated homecoming only to find upon their return home that crowds
and daily responsibilities are both overwhelming and frightening. After
living on the edge of danger for the prolonged deployment periods, life
in America seem boring and mundane. Although they care deeply about
their families, they are ``different'' and ill at ease in their
everyday existence and can't seem to find their way ``HOME Along with
the ``Send Off'' ceremonies and the ``Welcome Homes'', observers began
to realize that families left behind experienced difficulties and
stress every day of the deployment. Along with readjusting to the
absence of the military member and the great unknown of what they would
be encountering during their tour of duty, those of us tasked with
working with these families came to the realization that there were
serious gaps in the system. In addition to the day to day concerns of
home repairs, young spouses managing additional duties in the home,
environment and financial constraints, families were having
difficulties that indicated a need for professional counseling and
treatment to cope with the demands and strains they encountered.
State of Connecticut Mental Health Services and Programs for
Veterans For more than 25 years, the State of Connecticut Department of
Mental Health and Addiction Services (DMHAS) has documented the veteran
status of their clients. As a Public Health Nurse working with
psychiatric patients in the community, I was impressed that the
question was included in the application for services. However it was
not until the late 1990's that someone thought to quantify this
population and found that over 5,000 Connecticut Veterans were
receiving their Mental Health Service from the State. Over time that
number has fluctuated but remains steady at the 5,000 mark. In that
time VA has increased their outreach to veterans across our small State
and established six Community Based Outpatient Clinics (CBOCS) in
addition to 5 Vet Centers. I believe our experience with these services
and the veterans in our State illustrate some of the ``barriers'' you
are discussing today.
As the wars in Iraq and Afghanistan have continued, the needs of
veterans of those hostilities as well as veterans from previous periods
of service, who need mental health services, have challenged the VA
systems of care on several fronts. The deployment of Connecticut's
largest National Guard Unit to Iraq brought to light the question of
how this utilization of the true ``citizen soldiers'' would be assessed
and addressed and what did we need to do to assure they received the
help they earned when they came home. With over 1,000 members each town
and city in our town had someone deployed to an active combat zone. As
the State agency tasked by Statute with providing services and assuring
the quality of services for those who ``are and have served in the
Armed Forces of the United States''. I realized that our State needed
to decisively address the issues of this new generation of soldiers and
begin to plan for their return and programs that would be effective,
timely and appropriate.
Thus, Connecticut embarked on three major efforts: a) Survey of
Recently Returned Veterans conducted in conjunction with the Center for
Policy Research at Central Connecticut University; b) Summit for
Recently Returned Veterans; c) Military Support Program spearheaded by
the Department of Mental Health and Addiction Services. All of these
efforts were implemented in 2007. I will refer to these programs and
will be happy to provide details on how we accomplished and implemented
the Summit and Survey. Most important and a strength of what we have
learned is that these findings came from our veterans and have been
preserved in their own words. I use them to illustrate my points but
wish to stress that Connecticut Governors, Congressional and State
Legislators, Commissioners and Directors of State Departments of Mental
Health, Public Health, Labor, and Education were and have remained
deeply committed and engaged in this effort.
Survey of Recently Returned Veterans
With the reality that troops being deployed to Iraq, Afghanistan
represented a striking departure from the mobilization of American
troops in previous wars, the pro forma conventional methods and
remedies relied on in the past seemed inadequate for addressing the
emerging needs of military and veterans in the 21st Century. Thus, we
embarked on a survey of returning veterans to ``take the pulse'' of
their thinking, needs and expectations. To assess the growing
population of returning ``Warriors'' and ``Heroes'' and specific
problems they were encountering, as well as their expectations for
services and the goals, we embarked on a series of surveys (2005 and
2010) in collaboration with Central Connecticut State University's
O'Neil Center for Public Policy. More than 650 veterans, a mix of
Active Duty, Reserve and National Guard, with the majority being
veterans of Iraq and Afghanistan and married (63%) who identified their
major concerns as problems with spouses (41%), trouble connecting
emotionally with others (24%), connecting emotionally with family (11%)
and looking for help with these problems (10%). Using the ``Post
Traumatic Stress Checklist - Military scale developed by VA National
Center for PTSD which indicated that the responses of more than a
quarter of the respondents reported symptoms which exceeded the
diagnostic threshold for Post-Traumatic Stress Disorder.
Common Barriers we have observed are:
1. Proximity to VA - Most veterans today do not want to travel
distances for care. We tend to think of access to care as being a
question of eligibility for VA care. However we need to broaden the
context of access to include transportation, hours of operation,
qualifications of the provider, consistency in health care provider and
availability to contact the primary care provider. Most mental health
providers are available at the local level, have coverage after hours
and are available to talk with their patients at any time of the day or
night. This access to primary mental health providers is not standard
operating procedures for most VA mental health providers. Additionally
it is a common practice, that many providers in the VA System are not
Board Certified or professionally credentialed. However these
expectations are not unreasonable given the requirements for providers
in the private sector. It is important to remember that veterans in
today's society are very informed and often have acquired an
expectation of competency, understanding and support that a health care
provider especially a mental health provider should have. It is not
uncommon for veterans to drop out of treatment because they are
disappointed with the wait times for appointments. Many veterans are
unwilling to devote and entire day to coming to the VA for care.
Additionally they expect and deserve clinicians that have an
understanding and respect for them. Clinicians, who do not meet the
veteran where they are both with the symptoms they are experiencing and
understanding and appreciation for the military service, will fail to
engender a sense of trust that is essential to a therapeutic
relationship.
2. Treatment of Family Members - As mentioned earlier families,
more than any other time, in the history of the Armed Forces are an
essential consideration when considering the well being and mission
readiness of our military today. While VA publications actually
acknowledge that with the return of the veterans from deployments, the
entire family will go through a period of transition. Along with many
suggested activities, there is specific reference for a need for
opportunities to reacquaint families with one another. Part of the
transition is expected to be a process or restoring trust, support and
integrity to the family circle. While there is an expectation that
``Things have changed'' there is also the daunting task of beginning
the difficult work of transition from soldier to citizen and
reestablishing their identity in the family, work environment and
community. Although the publication does a fine job of identifying the
circumstances and the perils, the directions are not for family but how
family can assist the veterans. Because services are focused on the
military member and/or veteran the options for family members is
limited. VA advises ``Families may receive treatment for war related
problems from a number of qualified sources: chaplain services, mental
or behavioral health assistance programs.'' In other words, as a rule,
most VA Mental Health Programs do not treat family members or include
them in the treatment of veterans or military members. While some VA
facilities and individual programs have loosened the restrictions for
providing services to family members either on an individual, couples
or family therapy, serious consideration must be given to include these
vital members of the veterans' support system. Vet Centers have been
providing this care on a regular basis for decades, this is a model of
how a system can adapt to the needs of veterans without compromising
quality of care and managing existing resources. An example from our
Summit for Recently Returned veterans illustrates the disparity this
creates. A young Veteran recounted that he felt that treatment at the
VA was preventing him from getting on with his life which he implied
really meant VA was doing the exact opposite of what it should be doing
for veterans and their loved ones. He said that for him, not attending
the VA meetings ``was not about stigma, it's just that the VA is
unhelpful.'' When he did go to the VA for help, his wife went with him,
and they (VA) expressed surprise that she and her husband had come in
as a couple. The wife was told to stay out of it, that it was ``his
problem'' and not hers. She felt cut off. This spurred a more
generalized discussion about how families have no idea how to interact
with their veterans and feel lost. The conclusion was ``What little the
VA does for veterans, it does even less for their families''.
Domestic Violence
When addressing the issue of mental health treatment for families,
I would be remiss if I did not reference the increase body of evidence
which links combat veterans, Post Traumatic Stress with violent and
abusive traumatic events in the home. Domestic Violence has always been
a factor in military life. It is not new. What is new is the fact that
victims are no longer silent and someone is listening. The American
public is not as tolerant as it was decades ago to the litany of brutal
deaths suffered in military communities or at the hands of a military
member of veteran. While the Pentagon has made efforts to address these
issues and offer support and education to military families, the
present hostilities heavy reliance on citizen soldiers of the Reserve
and National Guard Components accentuate the stressors on everyone
involved and bring these volatile scenarios to every town and city in
our Country.
Additionally over 1 million children in America have had one of
both of their parents deployed since 9/11. The long separations and
multiple deployments which have become the standard for todays'
military can create a sense of isolation, confusion, anxiety which can
create higher levels of stress and more difficulties within the family.
The total impact this environment has for members of these families has
far reaching effects we have yet to know. The high rates of divorce
within the military community verify that these dynamics are
disruptions in family life which creates erosions of trust, instability
that deeply wounds and destroys families.
3. Women Veterans - The rising number of women serving in the
military is a well known fact. They are pushing the envelope, serving
as never before in the combat areas and rising to new leadership roles.
As a woman veteran, I want to say that along with these achievements
and advancements, women have come to expect equal respect for their
contributions to the military mission and defense of this Nation. In
fairness, we must acknowledge that VA has come a long way with their
programs for women veterans with programs that have evolved to options
we only dreamed of in the past.. However when we look at cause and
effect, we see that reports of Military Sexual Trauma perpetrated on
women in the military by other military members is both astonishing and
unacceptable.
In our States, we see women reluctant to seek treatment because of
the experiences and victimizations they have had in the military. When
the Department of Defense acknowledges that 23% of the women in combat
areas report being victims of sexual assaults . . . not to mention the
harassment which is not reported, there has not been an adequate
response to deter these violent acts from reoccurring. Congress and the
Department of Defense must take more stringent steps to ending the
decades of this injustice for the women who wear our Nations uniform.
What would happen if there was a report that 23% of the women working
at IBM had been assaulted by their coworkers? Where is the demand for a
``Congressional Investigation''? Why do these reports go unanswered?
Why would a woman veteran victimized by their own Government look of
help at the VA? Until Congress, deems this an unacceptable statistic,
it will continue and these veterans and military members will continue
to be second class citizens.
4. Concerns About Confidentiality - With the perfusion of social
and electronic technology and breaches of confidentiality, there is a
great deal of concern on the part of military members, private
providers and veterans about preserving the confidentiality of their
health care, especially mental health care. Veterans, of deployments
who are still in the military services as Reservists and National
Guardsmen have a great deal of anxiety about seeking treatment at the
VA and how that will affect their military careers and promotion
potential. Additionally how those records are handled when they are
transported or used to substantiate a Service Connected Disability are
deeply troubling and do influence where these veterans receive their
care. VA is a large system and there is a lack of clarity about what
access DOD has to these records and where the information will travel.
The issue of stigma associated with individuals who receive
professional treatment for mental health problems is a big deterrent
for veterans in need of this care. In our two surveys of Connecticut
Veterans the most frequent reason cited for not seeking treatment was
stigma. Veterans indicated their reluctance because:
``I would be seen as weak''; ``Commanders would not trust me'';
``My Unit would have less confidence in me''; ``Leaders would blame me
for problems''; and ``It would harm my career''. Interestingly
respondents to the surveys with the most symptoms suggestive of Post-
Traumatic Stress were also the participants who most often reported
that ``stigma'' was the greatest barrier to treatment.
5. Understanding the Military/Veteran Culture - Failure of the
treatment providers to understand key aspects of the military/veteran
culture can influence both the willingness to seek treatment and
continue in treatment. Effective communications is key to any encounter
but more so when we are dealing with populations that have the shared
experiences and values of serving in the Armed Forces. In the current
veteran population, the sense of community that comes from training and
being deployed in Units strengthens the sense of solidarity, friendship
and acceptance. Increased emphasis to orienting VA providers that care
for veterans is essential for success in treatment and trust to stay in
treatment. It is important that VA acknowledge and support educational
experiences with include an introduction to the military and veterans
culture. We realized the importance of this from the surveys we did and
``Focus Groups'' we convened.
Most interesting we learned:
a) Being in combat in Iraq of Afghanistan is profoundly life-
altering
b) Importance of camaraderie with fellow military or veterans
c) A sense of isolation from the community and not being understood
d) Communication difficulties with everyone except fellow military
e) The experiences of women were not the same as men
6. Multiple Deployments - It is no secret that a common strategy
during the wars in Iraq and Afghanistan has been the multiple
deployments of Active Duty, Reserve and National Guard Units. The
cycles of these deployments is another consideration which needs to be
addressed when discussing the quality of mental health services.
America is yet to know the real consequences of this process. However
there is a particularly disturbing aspect of this process which bears
heavily on the individual military member, the quality of their mental
health services and the defense of our Nation. We have become aware
that Iraq and Afghan veterans who have received VA Service Connected
Disability Ratings, some as great as 80-100% are being redeployed. Some
of these veterans have been rated for mental health disabilities but
have signed paperwork to stop their disability compensation so that
they can qualify for mobilizations and redeployments. You cannot
imagine what kind of difficulties they face after multiple tours, many
of them expect that their VA checks and Disability Ratings will be
reinstated upon their return home. Not only are the realities of the
system a shock, when they learn this does not happen, many face the
disability rating process all over again. It is incomprehensible to me
that this practice is permitted and known by the military.
7. Coordination of Services and Resources - Although Congress, DOD
and the VA may identify a problem, and derive solutions to these needs,
the process of enacting legislation and implementing programs is years
in the making. In the age of text messaging, the response time is
considered by many to be out of touch and negligent compared to what
returning ``Wounded Warriors'' or ``Heroes'', their families and most
importantly the Public have come to expect in exchange for their
service to the Country. Because our National Guard, comes under the
authority of Governor's and State Legislatures, there is much more
demand for accountability at the State and Local Levels that has not
been experienced by DOD or VA in the past. Active Duty and Reservists,
who return to their homes as individuals are also of concern because
their immediate problems and needs arise where they live far from
Federal Systems. This group is especially vulnerable because, for the
most part they have retained or received little or no information about
what is available to them or where to go for help. Many of these
veterans have undiagnosed injuries or disabling conditions and
cognitive difficulties which further complicates their ability to
articulate their needs for help. Currently there exist within large
public services agencies, including VA, many layers and silos of the
administration and delivery of services but little emphasis on
oversight activities and accountability directly effecting veterans at
the grassroots levels.
A Shared Responsibility
The task of serving veterans is a shared responsibility with States
and the Federal Government. There is a need to move away from the idea
that all services and programs must and should be provided by the
Federal Government. Collectively State Governments spend more than $6
Billion a year to support their veterans. In order to develop the best
seamless transition, maximize existing resources and improve the
accountability for these services t dedicated to the care and support
of veterans and their families, we must challenge the status quo. Just
as our military has changed, we must accept the realities that vast
system changes in support of the military and their families are in
order. Too often VA on the National and State level do not coordinate
or even communicate with the State Departments and agencies tasked with
caring and providing services for our veterans. State based programs
are augmented by thousands of private-sector, community volunteers and
faith based initiatives that attempt to help disabled and injured
service members and their families meet housing, transportation,
childcare, employment, mental health and short-term financial aid. We
are not lacking in people wanting to help, we are lacing in a
coordinated effort, accountability and creative approaches to solving
problems in the local communities Just as all politics are local, the
care and welfare of each military member, veterans and their families
is not only a priority for State Governments, there are local programs,
services and resources that have been developed to meet the needs of
veterans where they live and work. State Legislators are as vitally
engaged in the needs of veterans and also creating new programs and
services as are Members of Congress.
A true partnership of Federal and State resources can only improve
the opportunities for our veterans, especially the troops returning
today, and their families. My Governor and the citizens of Connecticut
expect the best for our veterans and know that holding VA accountable
is often an exercise in futility. While I am heartened that Secretary
Shinseki has acknowledged States as partners in providing for our
Nations veterans and has brought this relationship to new prominence,
it is disappointing that individual administrators and staffs do no
share his opinion or vision. This is not the continuum of service and
care that veterans have earned and deserve.
Several times, Congress has considered legislation which would
authorize funding to States agencies to support service programs of
outreach to veterans. Challenge grants, matching funds and program
grant opportunities are vehicles which must be considered to meet the
unique needs of veterans and further the work of VA. Consider how much
time and money has been expended on addressing the backlog for
processing disability claims and compensation. While the ``Big VA'' has
made many efforts to streamline the process, consider the possibilities
of improving the quality of the claim at the start of that process.
Grants to support, educate and initiate quality assurance at the State
Veteran Service Officer level from the initial intake, development of
the claim and final submission has the potential to create fully
developed claims from the beginning which will facilitate the entire
rating process.
Connecticut's Military Support Program
In 2004 the Connecticut General Assembly enacted legislation
authorizing the Department of Mental Health and Addiction Services
(DMHAS) to provide ``behavioral health services, on a transitional
basis, for the dependents and any member of any reserve component of
the armed forces of the United States who has been called to active
service in the armed forces of this state or the United States for
Operation Enduring Freedom or Operation Iraqi Freedom. Such
transitional services are to be provided when no Department of Defense
coverage for such services was available or such member was not
eligible for such services through the Department of Defense or until
an approved application is received from the federal Department of
Veterans' Affairs and coverage is available to such member and such
member's dependents.'' (CGS 27-103).
From the beginning, this initative was a collaborative effort
between Connecticut's Departments of Mental Health and Addiction
Services (DMHAS), Veteran Affairs (CTVA), National Guard (CTNG)
Department of Families and Children (DCF) and the Family Readiness
Group. Building on the experience DMHAS had gained in assisting
families in the aftermath of 9/11, the concept of working with mental
health professionals in the community was ideally suited for the broad
context of the legislation and the geographical distribution of
potential clients.
Also taking from previous ``lessons learned'', the scope of the
program was created not only to include military members, their spouses
and children but immediate family members (parents, siblings) and
significant others were also eligible for care. With the assistance of
the Connecticut and Federal Departments of Veteran Affairs and the
Adjutant General, sixteen hours of training in Military 101, dynamics
of deployments and post traumatic stress including panel discussions by
OIF/OEF veterans and their families was provided to 400 volunteer
mental health professionals licensed in Connecticut. Only clinicians,
completing the training were eligible to participate in the program.
The Military Support Program (MSP) was designed to streamline the
process of access to care with an emphasis on confidential services
throughout the state. The goal of delivering quality, appropriate,
timely and convenient services was further enhanced by a 24/7 manned
toll free center, veteran outreach workers and State reimbursement for
clinical services when there was no other funding available.
Typically, anyone eligible for the program can call the 24/7
number. In this day and age, it is important that a real person answers
the call. If the nature of the call does not involve a mental health
issue, the caller is directed to an individual at the appropriate
agency. Should the nature of the call be a request for help with a
problem best handled by a mental health professional, the caller is
given the names of clinicians in their immediate geographical area, who
have completed the training and are registered with DMHAS.
Another very attractive aspect of this approach is the fact that
families including the military member can have the opportunity to work
out their issues together. Due to the limitations of VA Health Care,
families are often excluded from the therapeutic process which can be
counterproductive in the long run. Family therapy is less threatening
to a military member who may not seek treatment because of the stigma
associated with mental health problems. A 2005 study of Iraq Veterans
assigned to the Maine National Guard indicated that 30% of those in the
study expressed a likelihood of participating in ``confidential
services in the community''. Responses to the question of who they
would be most likely to participate in support groups included ``with
other veterans (32%), couples' communication skills training (28%) and
couples/marital counseling (26%). (Wheeler, 2005) lends credence to the
concepts we have implemented.
Suicides
Although there is no exact method to determine the actual numbers
of suicides, even matches with the Death Index would be under reported
because of concern for the family, religious beliefs or unanswered
questions. Even the press has no idea of the true numbers of suicides
in the military or veteran communities because the ``secret'' is also
part of the shock. However the increased awareness and concern for the
number of these events and the great hope that these could be prevented
with better systems, Connecticut Governor Malloy, in consultation with
the Departments of Mental Health and Veteran Affairs, authorized the
expansion of the Military Support Program in 2012 for all military,
veterans and their families.
Since the Connecticut Military Support Program (MSP) has been in
operation, they have responded to over 3,500 calls. A particularly
important aspect of this program is the fact that there is an immediate
response to a caller with an offer to help. Part of the responsibility
of a Clinician in the network is to respond within 48hrs of being
contacted by the MSP client. Many veterans and their families can be
treated in the communities where they live. While some may require more
intense care or services offered by the US Department of Veteran
Affairs the immediate need, assessment, crisis intervention and if need
be referral to VA provides appropriate, timely and professional
responses that the situations require.
Connecticut has been caring for veterans since 1863. From that time
to this, each generation of Americans, who have shouldered the
responsibility of serving in our Armed Forces, has influenced the
development of the collective service systems provided by Federal,
State and Local governments. Just as the business of conducting war and
defending the Nation has changed dramatically, America and this
Committee need to rethink the delivery system and the care we extend to
those who have borne the battle. The old adage that ``if the military
wanted you to have a spouse they would have issued you one'' has been
outstripped by the number of married military members we rely on to
protect our freedoms. In this day and age, the expectation of caring
for our military must include tending to the health of their families.
Mr. Chairman this concludes by testimony, I will be happy to answer
any questions you may have.
Prepared Statement of Joy J. Ilem
Chairman Miller, Ranking Member Michaud and Members of the
Committee:
On behalf of Disabled American Veterans (DAV) and our 1.2 million
members, all of whom are wartime wounded, injured or ill veterans,
along with 200,000 Auxiliary members, I am pleased to present our views
on addressing the barriers veterans face when trying to gain access to
mental health services from the Department of Veterans Affairs Veterans
(VA). DAV is committed to fulfilling our promises to the men and women
who served, and one of those promises is to ensure that veterans
receive a full and lasting opportunity to recover from physical,
emotional and psychological wounds that occur as a consequence of their
military service experience.
We appreciate your determination, Mr. Chairman and Members of this
Committee, for continued concentration on this important and pressing
issue, as well as the opportunity to offer DAV's views on the
challenges confronting the Veterans Health Administration (VHA) in
meeting the critical mental health needs of our nation's veterans.
DAV's statement focuses on the Committee's concerns about the status of
VA's progress on growing mental health professional staffing levels;
mandates outlined in the President's recent Executive Order to improve
access to mental health services for veterans, service members and
their families; addressing the recommendations in the 2012 Office of
Inspector General (OIG) report on waiting times for mental health
services; improving data collection related to access measures;
scheduling processes and procedures; and partnering with non-VA mental
health providers to address gaps in VA care.
Since the wars in Iraq and Afghanistan began over a decade ago,
more than 2.4 million individuals were deployed to overseas combat
theaters; many have deployed several times. Of this group of brave men
and women, 1.5 million have been honorably discharged and are now
eligible for VA health care. VA's most recent cumulative data shows
that 834,467 of them have obtained VA health care and that 53 percent,
or 444,551 veterans, have been diagnosed with a mental disorder.
Additionally, there were a record 349 military suicides in 2012,
exceeding the 310 combat deaths reported during that period.
More than eleven years of war have clearly taken a toll on the
mental and physical health of American military forces and the veterans
among them who have returned to civilian life. Research shows that post
deployment mental health readjustment challenges and post-traumatic
stress disorder (PTSD) are prevalent in many returning service members
and veterans. We believe that everyone returning from contingency
operations overseas should be empowered to achieve maximal opportunity
to recover and successfully readjust to civilian life. But to do so, as
warranted by their circumstances, they must be able to gain ``user-
friendly'' and easy access to Department of Defense (DoD) and VA mental
health services--services that have been validated by research evidence
to ensure their best opportunities for full recovery and reintegration
with their families, jobs and private life.
Over the past five years, the post-deployment health status of our
servicemen and women and veterans, suicide prevention, and timely
access to appropriate mental health services, have been topics of
numerous Congressional hearings, government reports and regular media
scrutiny. Collectively, the hearing findings, reports and coverage cast
a negative impression related to appropriate and timely access to
services, often highlighting barriers to care and systemic flaws in an
overly ``medicalized,'' bureaucratic health care system. Given the
diligent oversight by the Veterans' Committees in both Chambers, and
the significant level of new resources that were authorized to address
the existing deficits and to improve VA mental health services and
other care for veterans, the current question posed by the Committee
Chair is a valid one: ``Is the VA's complex system of mental health
[care] and suicide prevention services improving the health and
wellness of our heroes in need?''
Mr. Chairman, although flaws unquestionably can be found in the
system, and must be addressed, DAV would be remiss in failing to
recognize and applaud VA's efforts to date to improve these programs.
Tens of thousands of dedicated mental health practitioners and
Readjustment Counseling Service Vet Center counselors work day-in and
day-out, to help veterans who are struggling in their post-deployment
readjustments.
Over the past five years, VA's Office of Mental Health Services
(OMHS) has developed and disseminated a comprehensive array of mental
health services throughout the VA health care system, while
accommodating a 35 percent increase in the number of veterans receiving
mental health services and managing a 41 percent increase in mental
health staff. At DAV, despite all the problems reported, we believe
this is remarkable progress. In 2011 (most recent data), VA provided
specialty, recovery focused mental health services to 1.3 million
veterans, at very high levels of satisfaction. These services were both
patient-centered and integrated into the basic care of the patients
using VA services. Today, mental health is a prominent component of VA
primary care - a long sought goal of DAV, other veterans' advocates and
the mental health research community.
VA offers veterans a wide range of mental health services, from
treatment of the milder forms of depression and anxiety in primary care
settings themselves, to intensive case management of veterans with
serious, chronic mental challenges such as schizophrenia, schizo-
affective disorder, and bi-polar disorder. VA also offers specialized
programs and treatments for veterans struggling with substance-use
disorders and post-deployment readjustment difficulties, including
providing evidence-based treatments for PTSD for combat veterans and
for those who endured and survived military sexual trauma.
For at least the past five years, while under intense external
pressure, VA has placed special emphasis on suicide prevention efforts,
launched an aggressive anti-stigma, outreach and advertising campaign,
and provided services for veterans involved in the criminal justice
system, including direct VA participation in the veterans treatment
courts initiative, to support both pre-release and jail-diversion
programs in a rising number of states and cities. Peer-to-peer
services, mental health consumer councils, and family and couples
counseling and therapy services have also been evolving and spreading
throughout the VA health care system. We at DAV are encouraged by these
developments, we believe they are humane approaches, and are saving
lives.
Yet despite noted progress, the Institute of Medicine (IOM)
released a report, entitled Treatment for Posttraumatic Stress Disorder
in Military and Veteran Populations, in July 2012, that addresses some
of the Chairman's concerns--specifically, whether the readjustment
services available to veterans improving the health and wellness of our
nation's transitioning service members. In the report, after a
comprehensive review of government programs for the treatment of PTSD,
the IOM found a lack of coordination, assessment and monitoring by both
DoD and VA. The IOM concluded treatment is not reaching everyone who
may need it, and that the Departments are not tracking which treatments
are being used, or evaluating whether and how well they work over the
long term.
DAV concurs with recommendations made by the IOM that VA and DoD
should invest in targeted research to fully evaluate the effectiveness
and health outcomes of existing PTSD treatment and rehabilitation
programs and services. Likewise, VA and DoD should support research
that investigates new and emerging technologies and web-based
approaches to overcome barriers to accessing mental health care, and
adhering as well to more comprehensive and long-term evidence-based
treatments. The report noted that the IOM committee's analysis of
innovative or complementary and alternative medicine treatments such as
yoga, acupuncture and animal-assisted therapy was limited since these
types of treatments lacked empirical evidence of their effectiveness.
Given that these alternative treatments have become more popular and
requested by many veterans, DAV urges that both DoD and VA carefully
study and evaluate these treatments to judge their efficacy versus
other approaches.
OFFICE OF INSPECTOR GENERAL 2012 RECOMMENDATIONS, AND PRIOR EXTERNAL
REVIEWS
Based on a request from both Committees on Veterans Affairs, in
April 2012, the VA OIG reported on the level of accuracy the Veterans
Health Administration (VHA) documents in waiting times for mental
health services for new and established patients, and whether the data
VA collects is a true depiction of veterans' ability to gain and keep
access to needed services. The OIG found that VHA's mental health
performance data is inaccurate and unreliable and that VHA's data
reporting of first-time access to full mental health evaluation was not
a meaningful measure of waiting.
Since the OIG had found a similar practice in previous audits
nearly seven years earlier, and given that VHA had not addressed the
longstanding problem, OIG urged VHA to reassess its training,
competency and oversight methods, and to develop appropriate controls
to collect more reliable and accurate appointment data for mental
health patients. The OIG concluded that the VHA `` . . . patient
scheduling system is broken, the appointment data is inaccurate and
schedulers implement inconsistent practices capturing appointment
information.'' These deficiencies in VHA's patient-appointment
scheduling system have been documented in numerous reports.
STAFFING ISSUES
The OIG also recommended in the 2012 report that VHA conduct a
comprehensive analysis of staffing to determine if mental health
provider vacancies were systemic and impeding VA's ability to meet its
published mental health timeliness standards.
The DAV shares the Committee's concerns about how VA plans to
resolve its mental health staffing deficits to meet rising demand for
critical mental health services. In April 2012, the Secretary announced
VA would add approximately 1,600 mental health clinicians and 300
support staff to VA's existing mental health staff of 20,590, in an
effort to help VA facilities meet burgeoning demand. In his testimony
before this Committee on May 8, 2012, Secretary Shinseki testified that
he estimated six months would be required for VA to hire most of these
new mental health personnel. DAV awaits VA's report on the number of
new providers who have been hired, and are now providing care to
veterans. As we have noted in prior testimony, the bureaucratic and
cumbersome human resources process in VA, especially in credentialing
new VA professional providers, continues to hamper VA's ability to
quickly put newly-hired individuals on the front lines caring for
patients. For more insight on these challenges, please review our
discussion of VA human resources concerns in the Fiscal Year 2014
Independent Budget, at www.independentbudget.org.
VHA's timely access goal is simply to treat a veteran patient in
clinic within 14 days from the desired date of care. One method VA uses
to monitor access to health care including mental health services is to
calculate a patient's waiting time by measuring the number of days
between the desired date of care to the date of the treatment
appointment. Appointment schedulers at VA facilities must enter the
correct desired date(s) of care in the automated scheduling system to
ensure the accuracy of this measurement.
Data generated to measure a veteran patient's timely access to care
continues to remain unreliable. There continues to be weaknesses in
VA's policy and implementation of scheduling medical appointments based
on several reports spanning more than a decade from VA's OIG and the
U.S. Government Accountability Office. \1\ The weaknesses reported
include VA's definition of the ``desired date'' of the medical
appointment contained in policy, \2\ and VHA's training and oversight
program to address the problems in measuring waiting times. We urge VA
OIG to report on the status of those recommendations from its 2007
review, which indicated that five out of eight recommendations were
either not implemented or were only partially implemented.
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\1\ HEHS-00-90, VA Needs Better Data on Extent and Causes of
Waiting Times, May 31, 2000; GAO-01-953, More National Action Needed to
Reduce Waiting Times, but Some Clinics Have Made Progress, Aug 31,
2001; GAO-12-12, Number of Veterans Receiving Care, Barriers Faced, and
Efforts to Increase Access, Oct 14, 2011; VA OIG Report No. 02-02129-
95, Audit of Veterans Health Administration's Reported Medical Care
Waiting Lists, May 14, 2003; VA OIG Report No. 04-02887-169, Audit of
the Veterans Health Administration's Outpatient Scheduling Procedures,
July 8, 2005; VA OIG Report No. 07-00616-199, Audit of the Veterans
Health Administration's Outpatient Waiting Times, September 10, 2007,
and; VA OIG Report No. 12-00900-168, Veterans Health Administration
Review of Veterans' Access to Mental Health Care, April 23, 2012.
\2\ VHA Directive 2010-027
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Without reliable data, VA will remain challenged in conducting
meaningful analysis and decision-making that directly impact the
quality, patient-centeredness and timely delivery of needed care,
including mental health care.
After more than a decade of effort, VA's Office of Information and
Technology has remarkably still not completed development of a
replacement for VHA's antiquated, 25-plus year-old scheduling system,
and one that can effectively manage the scheduling process, provide
accurate workload data capture and reporting technology, and be
responsive to the needs of VA's mental health patients and providers.
As noted in OIG's most recent report on veterans' access to mental
health care, VA's ``scheduling software is 25 years old and the
software interface is not ``user-friendly.'' This automated scheduling
application has been an essential component of the Veterans Health
Information Systems and Technology Architecture (VistA) electronic
health record, and performs multiple, interrelated functions. VistA
captures and assembles utilization data, which is intended to enable VA
to measure, manage and improve access, quality and efficiency of care,
and evaluate the operating and capital resources used.
GAO reported in 2010 on VA management deficiencies, principally
VA's second effort at developing a replacement scheduling system for
the aging VistA. \3\ Since that time, VA has abandoned this project,
and on December 21, 2012, VA issued a request for information in
Federal Business Opportunities to update and rebuild the application,
with responses due from industry by January 31, 2013. VA plans the new
scheduling system to be standards-based, extensible and scalable and
interoperable with the version of VistA held by the Open Source
Electronic Health Record Agent (OSEHRA). According to VA, the new
health scheduling system will rely on web- and mobile-device
capabilities for quick and secure communications with veterans, and
support for resource allocation decisions based on truer data, with
more opportunity to adjust capacity dynamically to meet changing needs.
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\3\ GAO-10-579, Management Improvements Are Essential to VA's
Second Effort to Replace Its Outpatient Scheduling System, May 27 2010.
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Because of current weaknesses in measuring veteran patients' access
to care, it is unclear to DAV at this time if VA's new direction will
correct lengthy VA waiting times, yield accurate access measures, or
result in less cumbersome scheduling processes and procedures. DAV
recommends the Committee conduct further oversight on VA's plans and
intentions with respect to the replacement of VistA. This challenge has
become much more acute based on VA's and DoD's joint announcement last
week of their decision to abandon their long sought joint electronic
health record project that would have served both the veteran and
military populations, to proceed in separate directions, but to rely on
a Janis GUI interface technique to translate data from one system to
the other. In this case, VA scheduling software and its ongoing
problems are a major weakness that must be addressed. Most importantly,
the OIG report noted that meaningful analysis and decision making
required reliable data, not only related to veterans' access to care,
but also on shifting trends in demand for services, the range of
treatment availability and mix of staffing, provider productivity and
treatment capacity of the facilities. From this study, the OIG made
four major recommendations to VHA. Similar to previous external
reviews, the VA Under Secretary for Health concurred with all
recommendations and replied that a number of responsive actions were
underway. Again, in this instance we are anxious to determine from VHA
the progress made thus far on the above-referenced recommendations.
In August of 2012, the President issued an Executive Order (EO) to
improve access to mental health services for veterans, service members,
and military families. It was noted that based on the wars in Iraq and
Afghanistan, the need for mental health services will only increase in
the coming years as the nation deals with the effects of more than a
decade of conflict. We concur and agree that coordination between the
DoD and VA during service members' transitions to civilian life is
essential to achieving the goal of timely access to the provision of
high quality mental health treatment for those who need it.
The EO focused on six areas including: suicide prevention; enhanced
partnerships between VA and community mental health providers; expanded
VA mental health services staffing; improved mental health research,
and appointment of a military and veterans mental health interagency
task force. Specific mandates in the EO included: expanding the 1-800-
273-TALK ``Veterans Crisis Line'' capacity by 50 percent; developing
and implementing a joint VA-DoD national suicide prevention campaign;
establishing no fewer than 15 pilot programs and formal agreements with
community-based mental health providers; hiring and training at least
800 new VA peer counselors by December 31, 2013; hiring 1,600 VA new
mental health professionals by June 30, 2013; establishing a ``National
Research Action Plan'' within eight months of the EO; developing in the
DoD and Department of Health and Human Services (HHS) a comprehensive
longitudinal mental health study with an emphasis on PTSD and TBI,
including enrollment of at least 100,000 service members by December
31, 2012; and, development of an Interagency Task Force of VA, DoD and
HHS to identify reforms and take actions that facilitate implementation
of the strategies outlined in the EO.
This is clearly an ambitious plan, and we look forward to VA's
report of progress on the outlined initiatives to improve access to
mental health services for veterans, service members, and military
families.
PARTNERING WITH NON-VA RESOURCES TO EXTEND ACCESS FOR VETERANS WITH
MENTAL HEALTH CHALLENGES
Mr. Chairman, you recently endorsed a VA-TRICARE outsourcing
alliance to serve the mental health needs of newer veterans that VA is,
admittedly, struggling to meet today. Having offered little to bolster
the confidence of DAV's members and millions of other veterans and
their families that mental health services are, in fact, being
effectively provided by VA where and when a newer veteran might need
such care, we urge VA to work with the Committee to ensure that, if
mental health care is expanded using the existing TRICARE network or
some other outside network, veterans must receive direct assistance by
VA in coordinating such services, and the care veterans receive must
reflect the integrated and holistic nature of VA mental health care.
In working with Congress on this issue, the primary question is
whether VA should partner with community mental health resources to
provide this care when local waiting times exceed VA's own policies.
When a veteran acknowledges the need for mental health services and
agrees to engage in treatment, it is important for VA to determine the
kind of mental health services needed and whether the most appropriate
care would come from a VA provider or a community-based source. This
type of triage is critical, because effective mental health treatment
is dependent upon a consistent, continuous-care relationship with a
provider. Once a trusting therapeutic relationship is established
between a veteran and a provider, that connection should not be
disrupted because of a lack of VA resources, a local parochial
decision, or for the convenience of the government.
Moreover, it is imperative that if a veteran is referred by VA to a
community resource we would insist the care be coordinated with VA.
According to the IOM study cited earlier, care coordination is at the
center of integration, and has been identified as a key component of
high-quality health care. We agree. A critical component of care
coordination is health information sharing between VA and non-VA
providers. Information flow increases the availability of patient
utilization and quality of care data, and improves communication among
providers inside and outside of VA. The absence of obtaining this kind
of health information poses a barrier to implement patient care
strategies such as care coordination, disease management, prevention,
and use of care protocols. These are some of the principal flaws of
VA's current approach in fee-basis and contract care.
Today, as an evidence-based, data-driven and integrated health care
system, VA has little meaningful information about how the care the
Department currently purchases from outside communities affects
clinical outcomes and health status of the veteran patient population
receiving those services.
DAV's desire is to avoid this situation for veterans who may be
referred by VA to receive mental health care from community sources,
whether in TRICARE networks or community mental health centers. VA
commissioned the RAND Corporation and the Altarum Institute to conduct
an independent evaluation of the quality of the VA's mental health care
system; they released a technical report in October 2011 titled,
Veterans Health Administration Mental Health Program Evaluation. This
report found a high degree to which veterans diagnosed with at least
one of five mental health conditions also have difficulties with
physical functioning and general health. That is, these veterans, while
representing only 15 percent of the VHA patient population in 2007,
accounted for one-third of all VHA health care costs because of their
high levels of medical care consumption.
Because of the likelihood these veterans will need more than only
mental health services, VA must be able to coordinate outside care with
the services it is able to directly provide, and do so in an integrated
manner. Integrated health care means the delivery of comprehensive
services that are well-coordinated, with effective communication and
health information sharing among providers, whether they are inside or
outside of VA. Patients become informed and involved in their
treatment, and when properly integrated, the care is high-quality and
cost effective.
DAV believes VA's current authority to purchase by contract health
care in the community ensures a continuum of medical care; however,
this authority to date has been specifically intended by Congress to be
a supportive (and restrictive) tool, to strengthen the VA health care
system and improve the quality of health care provided to veterans,
while ensuring no diminution of services that VA provides directly to
veterans.
Mr. Chairman, in accordance with DAV Resolution No. 212, adopted by
our members at our most recent National Convention in 2012, we urge VA
to establish a purchased-care coordination program that complements the
capabilities and capacities of each VA medical facility. Furthermore,
we urge Congress and the Administration to conduct strong oversight of
VA's purchased-care program to ensure service-connected disabled
veterans are not encumbered in receiving non-VA care at VA's expense.
DAV RECOMMENDATIONS
DAV has recommended that VA develop a proper triage, and a better
mental health staffing model, to help VA clinicians manage their
patient workloads to address the unique treatment needs of each
veteran, and to tailor treatment approaches to those needs. At your May
2012 hearing, VA also noted work was underway on a prototype staffing
model that was being tested in three Veterans Integrated Service
Networks (VISN). We are anxious to learn of the progress of the
determination on whether VA can deploy this prototype throughout its
nationwide system, and whether it works well for mental health in
particular.
We have urged VA to be flexible and creative in its approach to
solving this pressing issue of mental health and readjustment needs of
younger veterans, including the use of treatment options ranging from
non-traditional alternative and complementary care, peer- and non-
medical counseling, to traditional evidence-based therapies, depending
on the needs of individuals. We look forward to hearing about VA's
progress in making these adjustments.
CLOSING
Despite obvious improvements, it is clear to us that much progress
still needs to be accomplished by VHA to fulfill the nation's
obligations to veterans who are challenged by serious and, in some
cases, chronic mental illness, and particularly for younger veterans
who are impacted by post-deployment mental health, repatriation, and
transition challenges. Currently, we see the pressing need for more
timely mental health services for many of our returning wartime
wounded, injured and ill veterans, particularly in early intervention
services for veterans with substance-use disorders, and for evidence-
based treatments for those with PTSD, suicidal ideation, depression and
other consequences of combat exposure. If these symptoms are not
readily addressed at onset, they can easily compound and become chronic
and lifelong. The costs mount in personal, family, emotional, medical,
financial and social damage to those who have honorably served their
nation, and to society in general. Delays or failures in addressing
these problems can result in self-destructive acts, job and family
disintegration, incarceration, homelessness, and even suicide.
Mr. Chairman, DAV has previously testified, that in our considered
opinion, sending these veterans out of the system en masse is not the
answer--this group particularly can benefit from VA's expertise in
treating post-traumatic stress, PTSD, substance-use disorders, TBI and
other post-deployment transition challenges. To that end, it is
essential that VHA address and resolve the barriers that obstruct
mental health and substance abuse care and prevent consistent, timely
access to care at VA facilities nationwide.
Unfortunately, the problems in VA's mental health programs are
complex, and cannot be resolved by any single reform. The root causes
for existing barriers to care are multiple, systems-based,
longstanding, and complex. DAV urges VA to address these deficits by
addressing the root causes, not solely managing symptoms of the
problem.
We believe the policy changes made by VA's Office of Mental Health
Services over the past decade are positive and will ultimately equate
to better patient care and improved mental health outcomes--but
significant challenges are evident and need continued attention,
intensity, resources and oversight--and the development of sound and
workable solutions to ease the pressure while meeting veterans' needs.
In our opinion, VHA must develop a number of short- and long-range
goals to resolve existing problems identified by the OIG, GAO, Congress
and the veterans' service organization (VSO) community. VHA must
develop reliable data systems; fix the flaws in its appointment and
scheduling system with effective policies and IT systems that fill the
current gaps and are responsive to mental health needs; develop an
accurate mental health staffing model that accounts for both primary
and a multitude of complex specialty mental health capacity demands;
revolutionize its hiring practices and eliminate the barriers that
obstruct timely hiring of mental health providers and support staff;
adjust its practices to address the complexities of co-occurring
general health, mental health and psychosocial problems of veterans, in
a truly patient-centered manner, and re-establish trust with the
veterans that VA is charged to serve.
The DAV appreciates the efforts made by VA to improve the safety,
consistency, and effectiveness of mental health care programs for all
veterans. We also appreciate that Congress is continuing to provide
increased funding in pursuit of a comprehensive set of services to meet
the mental health needs of veterans, in particular veterans with
wartime service who present post-deployment readjustment needs. We urge
the Committee's continued oversight of VA's progress in fully
implementing its Mental Health Strategic Plan and resolving the
existing barriers that prevent some veterans from receiving the
services they need to fully readjust and reintegrate following military
service.
Chairman Miller and Members of the Committee, this concludes my
prepared statement. DAV appreciates the opportunity to provide this
testimony for the record of this important hearing.
Prepared Statement of Ralph Ibson
Chairman Miller, Ranking Member Michaud and members of the
Committee:
We are grateful to you for conducting this hearing and for your
continued oversight on the important issue of Veterans' Mental Health
Care. Thank you for inviting Wounded Warrior Project (WWP) to offer our
perspective.
With WWP's mission to honor and empower wounded warriors, our
vision is to foster the most successful, well-adjusted generation of
veterans in our nation's history. The mental health of our returning
warriors is clearly a critical element. As has been well documented,
PTSD and other invisible wounds can affect a warrior's readjustment in
many ways - impairing health and well-being, compounding the challenges
of obtaining employment, and limiting earning capacity. VA does provide
benefits and services that are helping some of our warriors overcome
such problems, but there is much more to do.
With the drawdown of forces in Afghanistan, more and more
servicemembers will be transitioning to veteran status and the issues
of engaging veterans and providing effective mental health care will
continue to grow. We applaud the oversight and focus your Committee has
provided, particularly regarding access to timely treatment, and we
welcome such initial steps as VA hiring additional mental health
providers. But increased staffing alone will not close all the gaps we
see in VA's mental health system.
Engagement in Treatment as a First Step
The scope of the problem is not limited to timely access. We see
evidence suggesting that veterans at many VA facilities may not be
getting the kind of mental health care they need or the appropriate
intensity of care. In a recent survey of over 13,000 WWP alumni, over a
third of respondents reported difficulties in accessing effective
mental health care. The identified reasons for not getting needed care
were inconsistent treatment (eg. canceled appointments, having to
switch providers, lapses in between sessions, etc.) and not being
comfortable with existing resources at the VA. \1\ Some report that the
VA is quick to provide medications, \2\ and others identify the limited
types of treatment available as potential barriers. VA is pressing
clinicians to employ exposure-based therapies that - without adequate
support--are too intense for some veterans, with the result that many
drop out of treatment altogether. VA is also not reaching large numbers
of returning veterans. As described by one of the leading mental health
researchers on the mental health toll of the conflict in Afghanistan
and Iraq, Dr. Charles W. Hoge,
\1\ Franklin, et al, 2012 Wounded Warrior Project Survey Report, ii
(June 2012). WWP surveyed more than 13,300 warriors, and received
responses from more than 5,600. (Hereinafter ``WWP Survey'').
\2\ Id. at 105. Studies document widespread off-label VA use of
antipsychotic drugs to treat symptoms of PTSD, and the finding that one
such medication is no more effective than a placebo in reducing PTSD
symptoms. D. Leslie, S. Mohamed, and R. Rosenheck, ``Off-Label Use of
Antipsychotic Medications in the Department of Veterans' Affairs Health
Care System'' 60(9) Psychiatric Services, 1175-1181 (2009); John
Krystal, et al., ``Adjunctive Risperidone Treatment for Antidepressant-
Resistant Symptoms of Chronic Military Service-Related PTSD: A
Randomized Trial,'' 306(5) JAMA 493-502 (2011).
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`` . . . veterans remain reluctant to seek care, with half of those
in need not utilizing mental health services. Among veterans who begin
PTSD treatment with psychotherapy or medication, a high percentage drop
out...With only 50% of veterans seeking care and a 40% recovery rate,
current strategies will effectively reach no more than 20% of all
veterans needing PTSD treatment. \3\
\3\ Charles W. Hoge, MD, ``Interventions for War-Related
Posttraumatic Stress Disorder: Meeting Veterans Where They Are,'' JAMA,
306(5): (August 3, 2011) 548.
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Without access or adequate care, one apparent consequence of only 1
out of 5 warriors getting sufficient treatment is a disturbing rise in
the number of suicides. Recent data have only begun to describe the
issue. Past research has shown that veterans were at an increased risk
of suicide during the 5 years after leaving active duty. \4\ There is
an urgent need for intervention and an ongoing issue of identifying and
tracking the scope of the problem. While access to care is the first
step in preventing suicide, identifying the factors that lead warriors
to drop out of therapy is a critical factor in reversing this troubling
trend.
---------------------------------------------------------------------------
\4\ http://articles.washingtonpost.com/2013-02-01/national/
36669331--1--afghanistan-war-veterans-suicide-rate-suicide-risk
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Another area of needed engagement is on mental health treatment for
victims of military sexual trauma (MST). Victims' reluctance to report
these traumatic incidents is well documented, but many also delay
seeking treatment for conditions relating to that experience. \5\ The
VA reports that some 1 in 5 women and 1 in 100 men seen in its medical
system responded ``yes'' when screened for MST. \6\ While researchers
cite the importance of screening for MST and associated referral for
mental health care, many victims do not currently seek VA care. Indeed,
researchers have noted frequent lack of knowledge on the part of women
veterans regarding eligibility for and access to VA care, with many
mistakenly believing eligibility is linked to establishing service-
connection for a condition. \7\ In-service sexual assaults have long-
term health implications, including PTSD, increased suicide risk, major
depression and alcohol or drug abuse and without outreach to engage
victims of MST on needed care, the long-term impact may be intensified.
\8\
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\5\ Rachel Kimerling, et al., ``Military-Related Sexual Trauma
Among Veterans Health Administration Patients Returning From
Afghanistan and Iraq,'' 100(8) Am. J. Public Health, 1409-1412 (2010).
\6\ U.S. Dept. of Veterans' Affairs and the National Center for
PTSD Fact Sheet, ``Military Sexual Trauma,'' available at http://
www.ptsd.va.gov/public/pages/military-sexual-trauma-general.asp.
\7\ See Donna Washington, et al., ``Women Veterans' Perceptions and
Decision-Making about Veterans Affairs Health Care,'' 172(8) Military
Medicine 812-817 (2007).
\8\ M. Murdoch, et al., ``Women and War: What Physicians Should
Know,'' 21(S3) J. of Gen. Internal Medicine S5-S10 (2006).
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With projections of only 1 in 5 veterans receiving adequate
treatment, the importance of early intervention and consequences of
delaying mental health care, and the rising rates of suicide and MST,
we must heed growing evidence that a majority of soldiers deployed to
Afghanistan or Iraq are not seeking needed mental health care. \9\
While stigma and organizational barriers to care are cited as
explanations for why only a small proportion of soldiers with
psychological problems seek professional help, soldiers' negative
perceptions about the utility of mental health care may be even
stronger deterrents. \10\ To reach these warriors, we see merit in a
strategy of expanding the reach of treatment, to include greater
engagement, understanding the reasons for negative perceptions of
mental health care, and ``meeting veterans where they are.'' \11\
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\9\ Paul Kim, et al. ``Stigma, Negative Attitudes about Treatment,
and Utilization of Mental Health Care Among Soldiers,'' 23 Military
Psychology 66 (2011).
\10\ Id. at 78.
\11\ Hoge, supra note 14.
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Importantly, current law requires VA medical facilities to employ
and train warriors to conduct outreach to engage peers in behavioral
health care. \12\ Underscoring the benefit of warriors reaching out to
other warriors, our recent survey found that nearly 30 percent
identified talking with another Operation Enduring Freedom (OEF)/
Operation Iraqi Freedom (OIF) veteran as the most effective resource in
coping with stress. \13\ Many of our warriors benefit greatly from the
counseling and peer-support provided at Vet Centers, but VA leaders are
failing other warriors when they resist implementing a nearly two-year-
old law that requires VA to provide peer-support to OEF/OIF veterans at
VA medical facilities as well. \14\
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\12\ National Defense Authorization Act for Fiscal Year 2013,
Public Law 112-239, Sec. 730, (Jan. 2, 2013). Additionally, the
President issued an Executive Order in August 2012 which included among
new steps to improve warriors' access to mental health services, a
commitment that VA would employ 800 peer-specialists to support the
provision of mental health care. Exec. Order No. 13625 ``Improving
Access to Mental Health for Veterans, Service Members, and Military
Families'' (Aug. 31, 2012)
\13\ WWP Survey, at 54.
\14\ Sec. 304, Public Law 111-163.
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While high percentages of OEF/OIF veterans are not engaging or
dropping out of mental health programs, peer support has been
identified as a critical element in reversing that trend. Last August's
Executive Order on Improving Access to Mental Health Services for
Veterans, Servicemembers, and Military Families was clear on improving
care for the mental health needs of those who served in Iraq and
Afghanistan. We applaud its directive that VA hire and train 800 peer
counselors by the end of this calendar year. We are concerned, however,
that VA's approach to the peer-support initiative in the Order is not
focused or targeted to OEF/OIF veterans.
In addition to peer outreach, enlisting family members in mental
health care helps foster recovery and facilitates warrior engagement.
VA has lagged in addressing family issues and involving caregivers in
mental health treatment. \15\ Given the impact of family support and
strain on warriors' resilience and recovery, more must be done to
implement provisions of law to provide needed mental health care to
veterans' family members.
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\15\ Khaylis, A., et al. ``Posttraumatic Stress, Family Adjustment,
and Treatment Preferences Among National Guard Soldiers Deployed to
OEF/OIF,''176 Military Medicine 126-131(2011).
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The VA has certainly taken significant steps over the years to
improve veterans' access to mental health care. But for all the
positive action taken, too many warriors still have not received
timely, effective treatment. In short, and as WWP has testified, \16\
wide gaps remain between well-intentioned policies and on-the-ground
practices.
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\16\ VA Mental Health Care Staffing: Ensuring Quality and Quantity:
Hearing Before the Subcomm. on Health of the H. Comm. on Veterans'
Affairs, 112th Cong. (May 8, 2012) (Testimony of Ralph Ibson, National
Policy Director, Wounded Warrior Project).
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Need for Outcome Measurements
Against the backdrop of a series of congressional hearings
highlighting long delays in scheduling veterans for mental health
treatment, the VA last April released plans to hire an additional 1900
mental health staff. \17\ While appreciative of VA's course-reversal,
WWP has urged that other related critical problems also be remedied. It
is not clear that VA medical facilities are sufficiently flexible in
accommodating warriors. Access remains a problem, particularly for
those living at a distance from VA facilities and for those whose work
or school requirements make it difficult to meet current clinic
schedules. Mental health care must also be effective, of course. As one
provider explained,
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\17\ Dept. of Veterans' Affairs Press Release, ``VA to Increase
Mental Health Staff by 1,900,'' (Apr. 19, 2012), available at: http://
www.va.gov/opa/pressrel/pressrelease.cfm?id=2302.
``Getting someone in quickly for an initial appointment is
worthless if there is no treatment available following that
appointment.'' \18\
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\18\ Id.
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Providing effective care requires building a relationship of trust
between provider and patient - a bond that is not necessarily instantly
established. \19\ Accordingly, congressional testimony highlighting
that many VA medical centers routinely place patients in group-therapy
settings rather than provide needed individual therapy merits further
scrutiny. \20\ We have also urged more focus on the soundness and
effectiveness of the VA's mental health performance measures; these
track adherence to process requirements, but fail to assess whether
veterans are actually improving. \21\
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\19\ VA Mental Health Care Staffing: Ensuring Quality and Quantity:
Hearing Before the Subcomm, on Health of the H. Comm. on Veterans'
Affairs, 112th Cong. (May 8, 2012) (Testimony of Nicole Sawyer, PsyD,
Licensed Clinical Psychologist).
\20\ VA Mental Health Care: Evaluating Access and Assessing Care:
Hearing Before the S. Comm. on Veterans' Affairs, 112th Cong. (Apr. 25,
2012) (Testimony of Nicholas Tolentino, OIF Veteran and former VA
medical center administrative officer).
\21\ VA Mental Health Care Staffing: Ensuring Quality and Quantity:
Hearing Before the Subcommittee on Health of the H. Comm. on Veterans'
Affairs, 112th Cong. (2012) (Testimony of Ralph Ibson), supra note 21.
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Unfortunately, the imperative of meeting performance requirements
can create perverse incentives, at odds with good clinical care. As one
provider explained, ``Veterans face many obstacles to care that are
designed to meet `measures' rather than good clinical care, i.e. having
to wait hours to be seen in walk-in clinic as the only point of access,
being forced to attend groups, etc.'' \22\ Prior hearings also
documented instances of such measures being ``gamed.'' \23\
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\22\ WWP Survey of VA Mental Health Staff (2011).
\23\ As one WWP-survey respondent explained in describing practices
at a VA facility, ``Unreasonable barriers have been created to limit
access into Mental Health treatment, especially therapy. Vets must go
to walk-in clinic so they are never given a scheduled initial
appointment. Walk-in only provided medication management, but Vets who
just want therapy must still go to walk-in. After initial intake, Vets
are required to attend a group session, typically a month out. After
completing the group session, Vets can be scheduled for individual
therapy, typically another month out. Performance measures are gamed.
When a consult is received, the Veteran is called and told to go to
walk-in. The telephone call is not documented directly (that would
activate a performance measure) . . . Then the consult is completed
without any services being provided to the Veteran. Vets often slip
through the cracks since there is no follow-up to see if they actually
went to walk-in. Focus of the Mental Health [sic] is to make it appear
as if access is meeting measures. There is no measure for follow-up, so
even if Vets get into the system in a reasonable time, the actual
treatment is significantly delayed. Trauma work is almost impossible to
do since appointments tend to be 6-8 weeks apart.''
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WWP has been encouraged by the VA's willingness to dedicate
research resources and additional mental health providers to addressing
gaps in veterans' mental health care. But it's not necessarily just
about reaching particular funding or staffing levels. It's about
outcomes--ultimately honoring and empowering warriors, and, in our
view, about making this the most successful generation of veterans.
It's not enough for VA administrators to set performance metrics for
timeliness or other process-measures (especially when those metrics may
not adequately reflect the true situation), they must establish
performance measures that recognize and reward successful treatment
outcomes.
Recent reports from VA Inspector General and Government
Accountability Offices have highlighted the need for more effective
measures to aid oversight. \24\ \25\ WWP shares concerns about
scheduling and wait times and urges VA to implement a reliable,
accurate way to measure how long veterans are waiting for appointments
in order to resolve problems effectively. Waiting too long during a
time of intense need undermines a veteran's trust in the system.
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\24\ U.S. General Accountability Office, ``Reliability and Reported
Outpatient Medical Appointment Wait Times and Scheduling Oversight Need
Improvement,'' GAO-13-130 (Dec 2012).
\25\ VA Office of Inspector General, ``Review of Veterans' Access
to Mental Health Care''' (Apr 2012).
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The reports underscore concerns that VA is unable to measure a
range of pertinent mental health matters, including timely access,
patient outcomes, staffing needs, numbers needing or provided
treatment, provider productivity, and treatment capacity. Greater VA
transparency and continued oversight into VA's mental health care
operations are starting points for closing those gaps.
Need for Continued Congressional Oversight
WWP welcomes the Department's acknowledgment of a ``need [for]
improvement'' in its mental health system. \26\ While there has been
movement in response to recent critical congressional oversight, the
VA's actions have often lacked needed transparency. To illustrate, the
VA testified to having conducted a ``comprehensive first-hand
assessment of the mental health program at every VA medical center,''
\27\ but it would not afford advocates the opportunity to participate
in such visits (despite a request to do so) and has not disclosed its
site-visit findings, the expectations for each such facility, or
facility remediation plans. The VA also cited its adoption, on a pilot
basis, of a prototype mental health staffing model, without meaningful
explanation of the foundation or reliability of its model. VA Central
Office recently also surveyed mental health field staff; but while its
survey effort could represent a healthy step, officials have neither
disclosed the survey findings nor indicated how the data might be used,
if at all.
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\26\ VA Mental Health Care Staffing: Ensuring Quality and Quantity:
Hearing Before the Subcomm. on Health of the H. Comm. on Veterans'
Affairs, 112th Cong. (May 8, 2012) (Testimony of Eric Shinseki,
Secretary of the Dept. of Veterans' Affairs).
\27\ Id.
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It bears emphasizing that PTSD and other war-related mental health
conditions can be successfully treated - and in many cases, VA
clinicians and Vet Center counselors are helping veterans recover and
thrive. But these problems have their origin in service, and more can
and must be done both to prevent and to treat behavioral health
problems at the earliest point - during, rather than after, service.
That will require not only overcoming negative perceptions among
servicemembers about mental health care, but affording them assurance
of confidentiality. \28\ Vet Centers - long a source of confidential,
trusted care--can and should be a greater resource. Provisions of the
National Defense Authorization Act for 2013 (NDAA) direct both DoD and
the VA, respectively, to close critical gaps in their mental health
systems, targeting particularly the importance of suicide prevention in
the armed forces and the VA's need to provide wounded warriors timely,
effective mental health care. \29\ Among its provisions, the NDAA
requires the VA - in consultation with an expert study committee under
the auspices of the National Academy of Sciences (NAS)- to establish
and implement both mental health staffing guidelines and comprehensive
measures to assess the timeliness and effectiveness of its mental
health care. \30\ WWP urges VA to give high priority to entering into a
contract with NAS as soon as possible - and bring some ``sunshine'' and
outside expertise into what should be an important step toward
improving VA behavioral health care.
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\28\ See Lt. Col. Paul Dean and Lt. Col. Jeffrey McNeil, ``Breaking
the Stigma of Behavioral Healthcare,'' U.S. Army John F. Kennedy
Special Warfare Center and School, 25(2) Special Warfare (2012),
available at: http://www.soc.mil/swcS/SWmag/archive/SW2502/
SW2502BreakingTheStigmaOfBehavioralHealthcare.html.
\29\ National Defense Authorization Act for Fiscal Year 2013, supra
note 18, at Sec. Sec. 580-583 and 723-730.
\30\ Id. at Sec. 726.
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Finally, as we suggested in testimony before the Health
Subcommittee last May, it is important to consider the ``culture''
within which VA mental health care is provided. As one clinician
described it succinctly in responding to a WWP survey,
``The reality is that the VA is a top-down organization that wants
strict obedience and does not want to hear about problems.''
Mental health staff at some VA facilities have described a
leadership climate that employs a command and control model that
imposes administrative requirements which too often compromise
providers' exercise of their own clinical judgment, and thus frustrate
effective treatment.
Without answers to what Central Office has learned through its site
visits or surveys about the extent to which clinicians have needed
latitude to exercise their best clinical judgment, we are left to
question whether morale or other problems compromise effective mental
health care and whether remedial steps are being taken. We cannot
answer such questions without greater VA transparency.
In the recent past, congressional oversight has been a critical
catalyst in identifying the need for major system improvements in the
provision of mental health care for wounded warriors and in effecting
necessary reforms. Such vigilant oversight must continue in order to
close remaining gaps in VA's mental health system. Among these, we urge
that congressional oversight include focusing on the following:
I Given new statutory requirements to work with the NAS to
establish new staffing guidelines and measures to assess timeliness and
effectiveness of mental health care, the VA must give high priority to
expeditiously contract with NAS to conduct the necessary assessments
and establish the framework for reforms required by law;
I DoD and the VA must work collaboratively, not simply to improve
access to mental health care, but to identify and further research the
reasons for--and solutions to - warriors' resistance to seeking such
care;
I As provided for in law and Executive Order, the VA in 2013 must
carry out large-scale training and employment of at least 800 returning
warriors (who have themselves experienced combat stress) to provide
peer-outreach and peer-support services as part of VA's provision of
mental health care to wounded warriors, and DoD must support that
initiative by referring servicemembers to be considered for such
employment;
I The VA should partner with and assist community entities or
collaborative community programs in providing needed mental health
services to wounded warriors, to include providing training to
clinicians on military culture and the combat experience;
I The VA must implement provisions of law that require it to
provide needed mental health services to immediate family members of
veterans whose own war-related mental health issues may diminish their
capacity to support those warriors;
I The VA should improve coordination between its medical
facilities and Vet Centers, and increase both Vet Center staffing and
the number of Vet Center sites, with emphasis on locating new ones near
military facilities; and
I The VA should provide for Vet Center staff to participate in
VSO-operated recreational programs that are designed to encourage
veterans' readjustment, as provided for by law.
Thank you for consideration of WWP's views on this most important
subject.
Prepared Statement of Robert A. Petzel
Good morning, Chairman Miller, Ranking Member Michaud and Members
of the Committee. Thank you for the opportunity to discuss VA's
delivery of comprehensive mental health care and services to the
Nation's Veterans and their families. I am accompanied today by Dr.
Mary Schohn, Director, Office of Mental Health Operations; Dr. Sonja
Batten, Deputy Chief Consultant for Specialty Mental Health; and Dr.
Janet Kemp, National Mental Health Program Director, Suicide Prevention
and Community Engagement, all from the Veterans Health Administration
(VHA)'s Office of Patient Care Services, Mental Health Services.
Since September 11, 2001, more than two million Servicemembers have
deployed to Iraq or Afghanistan with unprecedented duration and
frequency. Long deployments and intense combat conditions require
optimal support for the emotional and mental health needs of our
Veterans and their families. VA continues to develop and expand its
mental health delivery system. Since 2009, VA has learned a great deal
about both the strengths of our mental health care system, as well as
areas that need improvement. VA constantly strives to enhance the
services provided to our Veterans and will use any data and assessments
to achieve that goal.
VA is working closely with our Federal partners to implement
President Barack Obama's Executive Order 13625, ``Improve Access to
Mental Health Services for Veterans, Service Members, and Military
Families,'' signed on August 31, 2012. The executive order reaffirmed
the President's commitment to preventing suicide, increasing access to
mental health services, and supporting innovative research on relevant
mental health conditions. The executive order strengthens suicide
prevention efforts by increasing capacity at the Veterans/Military
Crisis Line and through supporting the implementation of a national
suicide prevention campaign. The executive order supports recovery-
oriented mental health services for Veterans by directing the hiring of
800 peer specialists, to bring this expertise to our mental health
teams. It also supports VA in using a variety of recruitment strategies
to hire 1,600 new mental health clinicians and 300 administrative
personnel in support of the mental health programs. Furthermore, it
strengthens building partnerships between VA and community providers by
directing VA to work with the Department of Health and Human Services
(HHS), to establish 15 pilot agreements with HHS-funded community
clinics to improve access to mental health services in pilot
communities, and to develop partnerships in hiring providers in rural
areas. Finally, it promotes mental health research and development of
more effective treatment methodologies in collaboration between VA,
Department of Defense (DOD), HHS, and Department of Education.
VHA has begun work on implementation of Fiscal Year 2013 National
Defense Authorization Act (P.L. 112-239) (NDAA), signed on January 2,
2013, including developing measures to assess mental health care
timeliness, patient satisfaction, capacity and availability of
evidence-based therapies, as well as developing staffing guidelines for
specialty and general mental health. In addition, VA is formulating a
contract with the National Academy of Sciences to consult on the
development and implementation of measures and guidelines, and to
assess the quality of mental health care. VA is also expanding efforts
to recruit mental health providers without compensation to support
delivery of mental health services.
My written statement will describe how VA delivers quality mental
health care and engages in ongoing research in such specialty areas as
post-traumatic stress disorder (PTSD), military sexual trauma, and
suicide prevention. It will then cover how we are refining mental
health access, and finally examine VA's recent enhancement of mental
health staffing.
I. Mental Health Care
VA operates one of the highest-quality care systems. VA is a
pioneer in mental health research, discovering and utilizing effective,
high-quality, evidence-based treatments. It has made deployment of
evidence-based therapies a critical element of its approach to mental
health care. State-of-the-art treatment, including both psychotherapies
and biomedical treatments, are available for the full range of mental
health problems, such as PTSD, consequences of military sexual trauma,
substance use disorders, and suicidality. While VA is primarily focused
on evidence-based treatments, we are also monitoring and assessing
those complementary and alternative treatment methodologies that need
further research, such as meditation in the care of PTSD. Our ultimate
desired outcome is a healthy Veteran.
VHA provides a continuum of recovery-oriented, patient-centered
services across outpatient, residential, and inpatient settings. VA has
trained over 4,700 VA mental health professionals to provide two of the
most effective evidence-based psychotherapies for PTSD: Cognitive
Processing Therapy and Prolonged Exposure Therapy. The Institute of
Medicine (IOM) report and the VA/DOD Clinical Practice Guideline have
consistently affirmed the efficacy of these treatment approaches.
Furthermore, VA operates the National Center for PTSD, which guides a
national PTSD Mentoring program, working with every specialty PTSD
program across the country to improve care. The Center has also begun
to operate a PTSD Consultation Program open to any VA practitioner
(including primary care practitioners and Homeless Program
coordinators) who requests expert consultation regarding a Veteran in
treatment with PTSD. So far, 500 VA practitioners have utilized this
service. The Center further supports clinicians by sending subscribers
updates on the latest clinically relevant trauma and PTSD research,
including the Clinician's Trauma Update Online, PTSD Research
Quarterly, and the PTSD Monthly Update. As IOM observed in its recent
report, ``Spurred by the return of large numbers of veterans from
[Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn
(OEF/OIF/OND)], the VA has substantially increased the number of
services for veterans who have PTSD and worked to improve the
consistency of access to such services. Every medical center and at
least the largest community-based outpatient clinics are expected to
have specialized PTSD services available onsite. Mental health staff
members devoted to the treatment of OIF and OEF veterans have also been
deployed throughout the system.'' \1\
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\1\ Institute of Medicine of the National Academies. Treatment for
Posttraumatic Stress Disorder in Military and Veteran Populations
Initial Assessment. July 13, 2012.
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Specialized care is available for Veterans who experienced military
sexual trauma (MST) while serving on active duty or active duty for
training. All sexual trauma-related care and counseling is provided
free of charge to all Veterans, even if they are not eligible for other
VA care. In FY 2012, every VHA facility provided MST related outpatient
care to both women and men and over 725,000 outpatient MST-related
mental health clinical visits were provided to 64,161 Veterans with a
positive MST screen. This is a 13.3 percent increase from the previous
year (FY 2011). Additionally, in FY 2012, of those who received care in
a VA medical center or clinic, over 500,000 Veterans with a Substance
Use Disorder (SUD) diagnosis received treatment for this problem. VA
developed and disseminated clinical guidance to newly hired SUD-PTSD
specialists who are promoting integrated care for these co-occurring
conditions, and provided direct services to over 18,000 of these
Veterans in FY 2012.
Use of complementary and alternative medicine (CAM) for treating
mental health problems is widespread in VA. A 2011 survey of all VA
facilities by VA's Healthcare Information and Analysis Group found that
89 percent of VA facilities offered CAM. VA's Office of Research and
Development (ORD) recently undertook a dedicated effort to evaluate CAM
in the treatment of PTSD with the solicitation of research applications
examining the efficacy of meditative approaches to PTSD treatment. The
result was three new clinical trials; all are currently underway,
recruiting participants with PTSD. VA has also begun pilot testing a
mechanism for conducting multi-site clinical CAM demonstration projects
within mental health that will provide a roadmap for identifying
innovative treatment methods, measuring their efficacy and
effectiveness, and generating recommendations for system-wide
implementation as warranted by the data. Nine medical facilities with
meditation programs were selected for participation in the clinical
demonstration projects. A team of subject matter experts in mind-body
medicine from the University of Rochester has been asked to provide an
objective, external evaluation. The majority of the clinical
demonstration projects are expected to be completed by March 2013, and
the aggregate final report by the outside evaluation team is due later
in 2013.
Veteran Suicide
Even one Veteran suicide is too many. VA is absolutely committed to
ensuring the safety of our Veterans, especially when they are in
crisis. Our suicide prevention program is based on the principle that
in order to decrease rates of suicide, we must provide enhanced access
to high quality mental health care and develop programs specifically
designed to help prevent suicide. In partnership with the Substance
Abuse and Mental Health Services Administration's National Suicide
Prevention Lifeline, the Veterans Crisis Line (VCL) connects Veterans
in crisis and their families and friends with qualified, caring
Department of Veterans Affairs responders through a confidential toll-
free hotline that offers 24/7 emergency assistance. VCL has recently
expanded to include a chat option and texting option for contacting the
Crisis Line. Since its establishment five years ago, the VCL has made
approximately 26,000 rescues of actively suicidal Veterans. The program
continues to save lives and link Veterans with effective ongoing mental
health services on a daily basis. In FY 2012, VCL received 193,507
calls, resulting in 6,462 rescues, any one of which may have been life-
saving. In accordance with the President's August 31, 2012, Executive
Order, VA has completed hiring and training of additional staff to
increase the capacity of the Veterans Crisis Line by 50 percent.
However, VCL is only one component of the VA overarching suicide
prevention program that is based on the premise that ready access to
high quality care can prevent suicide.
VA has placed Suicide Prevention Teams at each facility. The
leaders of these teams, the Suicide Prevention Coordinators, are
specifically devoted to preventing suicide among Veterans, and the
implementation of the program at their facilities. The coordinators
play a key role in VA's work to prevent suicide both in individual
patients and in the entire Veteran population. Among many other
functions, coordinators ensure that referrals from all sources,
including the Crisis Line, e-mail, and word of mouth referrals are
appropriately responded to in a timely manner. Coordinators educate
their colleagues, Veterans and families about risks for suicide,
coordinate staff education programs about suicide prevention, and
verify that clinical providers are trained. They provide enhanced
treatment monitoring for veterans at risk. They assure continued care
and treatment by verifying that each ``high risk'' Veteran has a
medical record notification entered; that they receive a suicide-
specific enhanced care package, and any missed appointments are
followed up on. The coordinators track and monitor all suicide-related
events in an internal data collection system. This allows VA to
determine trends and common risk factors, and provides information on
where and how best to address concerns.
VA has developed two hubs of expertise, one at the Canandaigua
Center of Excellence for Suicide Prevention (Canandaigua, NY), and
another at the VISN 19 Mental Illness Research Education and Clinical
Center (Denver, CO), to conduct research regarding intervention,
treatments and messaging approaches and has developed a Suicide
Consultation Program for practitioners that opened in 2013 and is
already in use.
On February 1, 2013, VA released a report on Veteran suicides, a
result of the most comprehensive review of Veteran suicide rates ever
undertaken by the VA. The report shows current interventions and
programs have been able to maintain relatively stable rates despite
increasing rates of suicide in like populations in America. With
assistance from state partners providing real-time data, VA is now
better able to assess the effectiveness of its suicide prevention
programs and identify specific populations that need targeted
interventions. This new information will assist VA to identify where at
risk Veterans may be located and improve the Department's ability to
target specific suicide interventions and outreach activities in order
to reach Veterans early and proactively. The data will also help VA
continue to examine the effectiveness of suicide prevention programs
being implemented in specific geographic locations (e.g., rural areas),
as well as care settings, such as primary care in order to replicate
effective programs in other areas.
II. Mental Health Care Access
At VA, we have the opportunity, and the responsibility, to
anticipate the needs of returning Veterans. Mental health care at VA is
an unparalleled system of comprehensive treatments and services to meet
the individual mental health needs of Veterans. We have many entry
points for VHA mental health care: through our 152 medical centers, 821
community-based outpatient clinics, 300 Vet Centers that provide
readjustment counseling, the Veterans Crisis Line, VA staff on college
and university campuses and other outreach efforts.
Since FY 2006, the number of Veterans receiving specialized mental
health treatment has risen each year, from 927,052 to more than 1.3
million in FY 2012, partly due to proactive screening to identify
Veterans who may have symptoms of depression, PTSD, problematic use of
alcohol, or who have experienced MST. Outpatient visits have increased
from 14 million in FY 2009 to over 17 million in FY 2012. Vet Centers
are another avenue for access, providing services to 193,665 Veterans
and their families in FY 2012. The Vet Center Combat Call Center, an
around-the-clock confidential call center where combat Veterans and
their families can talk with staff, comprised of fellow combat Veterans
from several eras, has handled over 37,300 calls in FY 2012. The Vet
Center Combat Call Center is a peer support line, providing a
complementary resource to the Veterans Crisis Line, which provides 24/7
crisis intervention services. This represents a nearly 470 percent
increase from FY 2011.
In response to increased demand over the last four years, VA has
enhanced its capacity to deliver needed mental health services and to
improve the system of care so that services can be more readily
accessed by Veterans. VA believes that mental health care must
constantly evolve and improve as new research knowledge becomes
available. As more Veterans access our services, we recognize their
unique needs and needs of their families--many of whom have been
affected by multiple, lengthy deployments. In addition, proactive
screening and an enhanced sensitivity to issues being raised by
Veterans have identified areas for improvement.
For example, in August 2011, VA conducted an informal survey of
line-level staff at several facilities, and learned of concerns that
Veterans' ability to schedule timely appointments may not match data
gathered by VA's performance management system. These providers
articulated constraints on their ability to best serve Veterans,
including inadequate staffing, space shortages, limited hours of
operation, and competing demands for other types of appointments,
particularly for compensation and pension or disability evaluations. In
response to this finding, VA took three major actions. First, VA
developed a comprehensive action plan aimed at overcoming barriers to
access, and addressing the concerns raised by its staff in the survey
as well as concerns raised by Veterans and Veterans groups. Second, VA
conducted focus groups with Veterans and VA staff, conducted through a
contract with Altarum, to better understand the issues raised by front-
line providers. Third, VA conducted a comprehensive first-hand
assessment of the mental health program at every VA medical center and
is working within its facilities and Veterans Integrated Service
Networks (VISNs) to improve mental health programs and share best
practices.
Ensuring access to appropriate care is essential to helping
Veterans recover from the injuries or illnesses they incurred during
their military service. Access can be realized in many ways and through
many modalities, including:
through face-to-face visits;
telehealth;
phone calls;
online systems;
mobile apps and technology;
readjustment counseling;
outreach;
community partnerships; and
academic affiliations.
Face-to-Face Visits
In an effort to increase access to mental health care and reduce
the stigma of seeking such care, VA has integrated mental health into
primary care settings. The ongoing transfer of VA primary care to
Patient Aligned Care Teams will facilitate the delivery of an
unprecedented level of mental health services. As the recent IOM report
on Treatment for Posttraumatic Stress Disorder in Military and Veteran
Populations noted, it is VA policy to screen every patient seen in
primary care in VA medical settings for PTSD, MST, depression, and
problem drinking. \2\ The screening takes place during a patient's
first appointment, and screenings for depression and problem drinking
are repeated annually for as long as the Veteran uses VA services.
Furthermore, PTSD screening is repeated annually for the first 5 years
after the most recent separation from service and every 5 years
thereafter. Systematic screening of Veterans for conditions such as
depression, PTSD, problem drinking, and MST has helped VA identify more
Veterans at risk for these conditions and provided opportunities to
refer them to specially trained experts. The PTSD screening tool used
by VA has been shown to have high levels of sensitivity and
specificity.
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\2\ Institute of Medicine of the National Academies. Treatment for
Posttraumatic Stress Disorder in Military and Veteran Populations
Initial Assessment. July 13, 2012.
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Since the start of FY 2008, VA has provided more than 2.5 million
Primary Care-Mental Health Integration (PC-MHI) clinical visits to more
than 700,000 unique Veterans. This improves both access by bringing
care closer to where the Veteran can most easily receive these
services, and quality of care by increasing the coordination of all
aspects of care, both physical and mental. Among primary care patients
with positive screens for depression, those who receive same-day PC-MHI
services are more than twice as likely to receive depression treatment
than those who did not. Treatment works and there is hope for recovery
for Veterans who need mental health care. These are important advances,
particularly given the rising numbers of Veterans seeking mental health
care.
Telehealth
VA offers expanded access to mental health services with longer
clinic hours, telemental health capability to deliver services, and
standards that mandate rapid access to mental health services.
Telemental health allows VA to leverage technology to provide Veterans
quicker and more efficient access to mental health care by reducing the
distance they have to travel, increasing the flexibility of the system
they use, and improving their overall quality of life. This technology
improves access to general and specialty services in geographically
remote areas where it can be difficult to recruit mental health
professionals. Currently, the clinic-based telehealth program involves
the more than 580 VA community-based outpatient clinics (CBOCs) where
many Veterans receive primary care. In areas where the CBOCs do not
have a mental health care provider available, VA is implementing a new
program to use secure video teleconferencing technology to connect the
Veteran to a provider within VA's nationwide system of care. Further,
the program is expanding directly into the home of the Veteran with
VA's goal to connect approximately 2,000 patients by the end of FY2013
using Internet Protocol (IP) video on Veterans' personal computers.
Mobile Apps and Technology
VA has made massive strides towards providing all of those in need
with evidence-based treatments, and we are now working to optimize the
delivery of these tools by using novel technologies. From delivery of
the treatments to rural Veterans in their homes, to supporting
treatment protocols with mobile apps, VA's objective is to consistently
deliver the highest quality mental health care to Veterans wherever
they are. The multi-award winning PTSD Coach, co-developed with the
DOD, has been downloaded nearly 100,000 times in 74 countries since
mid-2011. It is being adapted by government agencies and non-profit
organizations in 7 other countries including Canada and Australia. This
app is notable as it aims to assist Veterans with recognizing and
managing PTSD symptoms, whether or not they are comfortable engaging
with VA mental health care.
For those who are kept from needed care because of logistics or
fear of stigma, PTSD Coach provides an opportunity to better understand
and manage the symptoms associated with PTSD as a first step toward
recovery. For those who are working with VA providers, whether in
specialty clinics or primary care, this app provides evidence-informed
tools for self-management and symptom tracking between sessions. VA is
planning to shortly roll out a version of this app that is connected to
the electronic health record for active VA patients.
A wide array of mobile applications to support the evidence-based
mental and behavioral health care of Veterans will be rolled out over
the course of 2013. These apps are intended to be used in the context
of clinical care with trained professionals and are based on gold-
standard protocols for addressing smoking cessation, PTSD and
suicidality.
Apps for self-management of the consequences of traumatic brain
injury and crisis management, some of the more challenging issues
facing Veterans and our healthcare system, will follow later in the
year. Mobile apps can help Veterans build resilience and manage day-to-
day challenges even in the absence of mental health disorders. Working
with DOD, VA will release mobile apps for problem-solving and parenting
in 2013 to help Veterans navigate common post-deployment challenges.
Because we understand that healthy families are at the center of a
healthy life, we are creating tools for families and caregivers of
Veterans as well, including the PTSD Family Coach, a mobile app geared
towards friends and families that is expected to be rolled out in mid-
2013.
Technology allows us to extend our reach, not just beyond the
clinic walls but to those who need help but have not yet sought our
services, and to those who care for them and support their personal and
professional missions. In November 2012, VA and DoD launched
www.startmovingforward.org, interactive Web-based educational life-
coaching program based on the principles of Problem Solving Therapy. It
allows for anonymous, self-paced, 24-hour-a-day access that can be used
independently or in conjunction with mental health treatment.
Readjustment Counseling - Vet Centers
In addition to integrating mental health care with primary care, VA
provides a full range of face-to-face readjustment counseling services
through the network of 300 community-based Vet Centers located in all
50 states, the District of Columbia, American Samoa, Guam, Puerto Rico,
and the U.S. Virgin Islands. In FY 2012, the Vet Centers experienced
over 1.5 million visits from Veterans and their families, a 9 percent
increase in visits from FY 2011. The Vet Center program has
cumulatively provided services to 458,795 OEF/OIF/OND Veterans and
their families. This represents over 30 percent of the OEF/OIF/OND
Veterans that have left active duty.
The Vet Centers provide targeted outreach to returning combat
Veterans through a fleet of 70 Mobile Vet Centers that can provide
confidential counseling and outreach to Veterans who live
geographically distant from VA facilities, ensuring availability of
access to mental health care for Veterans, no matter where they may
live. In 2010, Public Law 111-163 expanded eligibility of Vet Center
services to members of the Armed Forces (and their family members),
including members of the National Guard or Reserve, who served on
active duty in the Armed Forces in OEF/OIF/OND. VA and DOD are working
together to implement this expansion of services.
The recently passed FY 2013 NDAA also includes provisions that
expand the peer support counseling program to members of the Armed
Forces and expand the Vet Center program to include counseling to
certain members of the Armed Forces and their family members. One
cornerstone of the Vet Center program's success is the added level of
confidentiality for Veterans and their families. Vet Centers maintain a
separate system of record which affords the confidentiality vital to
serving a combat-exposed warrior population. Without the Veteran's
voluntary signed authorization, the Vet Centers will not disclose
Veteran client information unless required by law. Early access to
readjustment counseling in a safe and confidential setting goes a long
way to reducing the risk of suicide and promotes the recovery of
Servicemembers returning from combat. Furthermore, more than 72 percent
of all Vet Center staff are Veterans themselves. This allows the Vet
Center staff to make an early empathic connection with Veterans who
might not otherwise seek services even if they are much needed.
Outreach
In November 2011, VA launched an award-winning, national public
awareness campaign, Make the Connection, aimed at reducing the stigma
associated with seeking mental health care and informing Veterans,
their families, friends, and members of their communities about VA
resources (www.maketheconnection.net). The candid Veteran videos on the
Web site have been viewed over 4 million times, and over 1.5 million
individuals have ``liked'' the Facebook page for the campaign
(www.facebook.com/VeteransMTC). AboutFace, launched in May 2012, is a
complementary public awareness campaign created by the National Center
for PTSD (www.ptsd.va.gov/public/about--face.html). This initiative
aims to help Veterans recognize whether the problems they are dealing
with may be PTSD related and to make them aware that effective
treatment can help them ``turn their lives around.'' The National
Center for PTSD has been using social media to reach out to Veterans
utilizing both Facebook and Twitter. In FY 2012, there were 18,000
Facebook ``fans'' (up from 1,800 in 2011), making 16 posts per month
and almost 7,000 Twitter followers (up from 1,700 in 2011) with 20
``tweets'' per month. The PTSD Web site, www.ptsd.va.gov, received 2.3
million visits during FY2012.
VA, in collaboration with DOD, continues to focus on suicide
prevention though its year-long public awareness campaign, ``Stand By
Them,'' which encourages family members and friends of Veterans to know
the signs of crisis and encourage Veterans to seek help, or to reach
out themselves on behalf of the Veteran using online services on
www.veteranscrisisline.net. VA's current suicide awareness and
education Public Service Announcement titled ``Common Journey'' has
been running in the top one percent of the PSA Nielsen ratings since
before the holidays. It is now being replaced with a PSA designed
specifically to augment the Stand By Them Campaign titled ``Side By
Side,'' which was launched nationally in January 2013.
In order to further serve family members who are concerned about a
Veteran, VA has expanded the ``Coaching Into Care'' call line
nationally after a successful pilot in two VISNs. Since the inception
of the service January 2010 through November 2012, ``Coaching Into
Care'' has logged 5,154 total calls and contacts. Seventy percent of
the callers are female, and most callers are spouses or family members.
On 49 percent of the calls, the target is a Veteran of OEF/OIF/OND
conflicts; Vietnam or immediately post-Vietnam era Veterans comprises
the next highest portion (27 percent).
Community Partnerships
VA recently developed and released a ``Community Provider Toolkit''
which is an on-line resource for community mental health providers to
learn more about mental health needs and treatments for Veterans. The
Veterans Crisis Line has approximately 50 Memoranda of Agreement with
community and internal VA organizations to refer callers, accept calls,
and provide and receive services for callers. Furthermore, suicide
Prevention Coordinators at each VA facility are required to provide a
minimum of 5 outreach activities a month to their communities to
increase awareness of suicide and promote community involvement in the
area of Veteran suicide prevention.
VA has been working closely with outside resources to address gaps
and create a more patient-centric network of care focused on wellness-
based outcomes. In response to the Executive Order, VA is working
closely with HHS to establish 15 pilot projects with community-based
providers, such as community mental health clinics, community health
centers, substance abuse treatment facilities, and rural health
clinics, to test the effectiveness of community partnerships in helping
to meet the mental health needs of Veterans in a timely way. These are
being established in areas where there are access issues or staffing
concerns.
VHA will continue to work closely with DOD to educate
Servicemembers, VA staff, Veterans and their families, public
officials, Veterans Service Organizations, and other stakeholders about
all mental health resources that are available in VA and with other
community partners. VA has partnered with DOD to develop the VA/DOD
Integrated Mental Health Strategy (IMHS) to advance a coordinated
public health model to improve access, quality, effectiveness and
efficiency of mental health services for Servicemembers, National Guard
and Reserve, Veterans, and their families.
Academic Affiliations and Training
VA is strategically working with universities, colleges and health
professional training institutions across the country to expand their
curricula to address the new science related to meeting the mental and
behavioral needs of our Nation's Veterans, Servicemembers, Wounded
Warriors, and their family members. In addition to ongoing job
placement and outreach efforts through VetSuccess, VA has implemented a
new outreach program, ``Veterans Integration to Academic Leadership,''
that places VA mental health staff at 21 colleges and universities to
work with Veterans attending school on the GI Bill.
VA's Office of Academic Affiliations trains roughly 6,400 trainees
in mental health occupations per year (including 3,400 in psychiatry,
1,900 in psychology, and 1,100 in social work, plus clinical pastoral
education positions). Currently, VA has one of only two accredited
psychology internship programs in the entire state of Alaska. VA is
committed to expanding training opportunities in mental health
professions in order to build a pipeline of future VA health care
providers. VA continues to expand mental health training opportunities
in Nursing, Pharmacy, Psychiatry, Psychology, and Social Work. For
example, over 202 positions were approved to begin in academic year
2013-2014 at 43 VHA facilities focused on the expansion of existing
accredited programs in integrated care settings such as General
Outpatient Mental Health Clinics or Patient Aligned Care Teams (PACT).
These include over 86 training positions for Outpatient Mental Health
Interprofessional Teams and 116 training positions for PACTs with
Mental Health Integration, specifically 12 positions in Nursing, 43 in
Pharmacy, over 34 in Psychiatry, 62 in Psychology, and 51 in Social
Work. The Office of Academic Affiliations is scheduled to release the
Phase II Mental Health Training Expansion Request for Proposals in
Spring 2013 which will further assist with VA future workforce needs.
III. Mental Health Care Staffing and Hiring
VA is committed to hiring and utilizing more mental health
professionals to improve access to mental health care for Veterans. To
serve the growing number of Veterans seeking mental health care, VA has
deployed significant resources and is increasing the number of staff in
support of mental health services. VA has taken aggressive action to
recruit, hire, and retain mental health professionals to improve
Veterans' access to mental health care. The department has also used
many tools to hire the mental health workforce, including pay-setting
authorities, loan repayment, scholarship programs and partnerships with
health care workforce training programs to recruit and retain one of
the largest mental health care workforces in the Nation. As a result,
VA is able to serve Veterans better by providing enhanced services,
expanded access, longer clinic hours, and increased telemental health
capability to deliver services.
Mental Health Staffing
VHA began collecting monthly vacancy data in January 2012 to assess
the impact of vacancies on operations and to develop recommendations
for further improvement. In addition, VA is ensuring that accurate
projections for future needs for mental health services are generated.
Finally, VA is planning proactively for the expected needs of Veterans
who will soon separate from active duty status as they return from
Afghanistan.
Since there are no industry standards defining accurate mental
health staffing ratios, VHA is setting the standard, as we have for
other dimensions of mental health care. VHA has developed a prototype
staffing model for general mental health delivery and is expanding the
model to include specialty mental health care. VHA developed and
implemented an aggressive recruitment and marketing effort to fill
existing vacancies in mental health care occupations. To support
implementation of the guidance, VHA announced the hiring of 1,600 new
mental health professionals and 300 support staff in April 2012. Key
initiatives include targeted advertising and outreach, aggressive
recruitment from a pipeline of qualified trainees/residents to leverage
against mission critical mental health vacancies, and providing
consultative services to VISN and VA stakeholders. Despite the national
challenges with recruitment of mental health care professionals, VHA
continues to make significant improvements in its recruitment and
retention efforts. Focused efforts are underway to expand the pool of
applicants for those professions and sites where hiring is most
difficult, such as creating expanded mental health training programs in
rural areas and through recruitment and retention incentives.
As part of our ongoing comprehensive review of mental health
operations, VHA has considered a number of factors to determine
additional staffing levels distributed across the system, including:
Veteran population in the service area;
The mental health needs of Veterans in that population;
and
Range and complexity of mental health services provided
in the service area.
Specialty mental health care occupations, such as psychologists,
psychiatrists, and others, are difficult to fill and will require a
very aggressive recruitment and marketing effort. VHA has developed a
strategy for this effort focusing on the following key factors:
Implementing a highly visible, multi-faceted, and
sustained marketing and outreach campaign targeted to mental health
care providers;
Engaging VHA's National Health Care Recruiters for the
most difficult to recruit positions;
Recruiting from an active pipeline of qualified
candidates to leverage against vacancies; and
Ensuring complete involvement and support from VA
leadership.
Mental Health Hiring
In April 2012, VA announced a goal to hire an additional 1,600
clinical providers and 300 administrative support staff. As of January
29, 2013, VA has hired 1,058 clinical providers and 223 administrative
staff in support of this specific goal. President Obama's August 31,
2012, executive order requires the positions to be filled by June 30,
2013.
In order to provide greater access to mental health services, VHA
knew that it would have to set aggressive goals to fill these new
positions as well as existing mental health staff vacancies. Like any
large health care system, VHA is constantly managing changes within its
existing mental health workforce levels (e.g., retirements, transfers,
promotions and resignations) to ensure providers are available to
deliver care. Therefore, VHA set a hiring target of 5,000 mental health
providers and administrative support staff to: 1) hire for new
positions; 2) fill existing vacancies; and 3) replenish naturally
occurring turnover. This ensures a robust flow into the workforce as we
anticipate and respond to the needs of both workforce staffing and our
Veterans. VHA has made significant progress to this end, by hiring a
total of 3,262 clinical and administrative support staff to directly
serve Veterans since May 2012. This progress has improved the
Department's ability to provide timely, quality mental health care for
Veterans.
In March 2012, VHA reported a core mental health workforce of
20,590. This calculation was based upon data from VHA's Allocation
Resource Center (ARC), which reports monthly updates of Full Time
Equivalent Employees (FTEE) based on departmental accounting of
accumulated mental health clinical and administrative workload costs.
Using this methodology demonstrates a core mental health workforce of
21,502, an increase of 912, as of November 30, 2012.
In our continued efforts to ensure we are providing effective
direct care to our Veterans, VHA re-evaluated this methodology and
concluded that the inpatient mental health care data in ARC was
adequate - it measured what it was designed to measure. However, FTEE
is not a head count of the workforce, and the data for outpatient
mental health care included some non-clinical activities such as
workload associated with mental health education, research, and
administration. Additionally, a small amount of mental health clinical
workload which is provided outside of core mental health was not
included in the original workforce calculation. The ARC data also uses
year-to-date methodology, which essentially prorates gains made over
the year and does not adequately reflect hiring in real time. For these
reasons, VHA developed an improved methodology for capturing mental
health on-board strength. This methodology permits provider-level
detail - including comparisons of staffing over time - to ensure
accurate reporting of the direct care clinical workforce providing
mental health services.
This improved methodology required VA to develop a new system of
accountability by combining information from three existing databases,
which enhances our accuracy and allows VHA to:
1) Ensure better visibility of mental health clinical outpatient
data to the provider-level;
2) Ensure that non-clinical workload is properly accounted for and
not included in direct care calculations; and
3) Obtain consistency in the application of the current
comprehensive definition of mental health providers across VA.
Using this improved accounting methodology, VA determined the
mental health workforce providing direct patient care to be 18,587 as
of March 2012. Applying this accounting methodology to the November
2012 data provides a more accurate picture of the on board strength,
which has increased from 18,587 to 19,743 mental health FTEE, for a
total, net increase of 1,156 providing direct care to our Veterans.
Regardless of accounting methodology used, the data reflects a net
increase in the number of mental health professionals providing
clinical health services thus increasing the access to quality mental
health care for our Nation's Veterans. We always strive to improve our
data collection to better serve Veterans, and to ensure that our
methods are transparent.
Peer Support
There are many Veterans who are willing to seek treatment and to
share their experiences with mental health issues when they share a
common bond of duty, honor, and service with the provider. While
providing evidence-based psychotherapies is critical, VA understands
Veterans benefit from supportive services other Veterans can provide.
To meet this need in accordance with the Executive Order and as part of
VA's efforts to implement section 304 of Public Law 111-163 (Caregivers
and Veterans Omnibus Health Services Act of 2010), VA has hired over
100 Peer Specialists in recent months, and is hiring and training
nearly 700 more. Additionally, VA has awarded a contract to the
Depression and Bipolar Support Alliance to provide certification
training for Peer Specialists. This peer staff is expected to be hired
by December 31, 2013, and will work as members of mental health teams.
Simultaneously, VA is providing additional resources to expand peer
support services across the Nation to support full-time, paid peer
support technicians.
Performance Measures
VA is reengineering its performance measurement methodologies to
evaluate and revamp its programs. Performance measurement and
accountability will remain the cornerstones of our program to ensure
that resources are being devoted where they need to go and are being
used to the benefit of Veterans. Our priority is leading the Nation in
patient satisfaction regarding the quality, effectiveness of care and
timeliness of their appointments.
Recognizing the benefit that would come from improving Veteran
access, VA is modifying the current appointment performance measurement
system to include a combination of measures that better captures each
Veteran's needs. VA will ensure this approach is structured around a
thoughtful, individualized treatment plan developed for each Veteran to
inform the timing of appointments.
In April 2012, VA's Office of Inspector General (OIG) report on
VA's mental health programs gave four recommendations: 1) a need for
improvement in our wait time measurements, 2) improvement in patient
experience metrics, 3) development of a staffing model, and 4)
provision of data to improve clinic management. Further, in January
2013, the U.S. Government Accountability Office reviewed VA's
healthcare outpatient medical appointment scheduling and appointment
notification processes, specifically focusing on Veterans wait times,
local VA Medical Center implementation of national scheduling policies
and processes as well as VHA initiatives to improve Veterans' access to
medical appointments.
In direct response, VA is using OIG and GAO results along with our
internal reviews to implement important enhancements to VA mental
health care. Based on OIG and GAO findings, VA is updating scheduling
practices, and strengthening performance measures to ensure
accountability. VA has examined how best to measure Veterans' wait time
experiences and how to improve scheduling processes to define how our
facilities should respond to Veterans' needs and commissioned a study
to measure timely appointment access and resulting patient
satisfaction. Based on the results of this study, VA is changing its
timeliness measures to best track different populations (new vs.
established patients) using the approach which best predicts patient
satisfaction and clinical care outcomes. In addition, VA is developing
measures based on timeliness after referral to mental health services,
patient perceptions of barriers to care, and measures of clinic
capacity. By taking these steps, we are confident that we will be able
to deliver accessible, high quality mental health care to Veterans.
The development of improved performance metrics, more reliable
reporting tools, and an initial mental health staffing model, will
enable VHA to better track wait times, assess productivity, and
determine capacity for mental health services. All of these tools will
continue to be evaluated and improved with experience in their use.
Conclusion
Mr. Chairman, we know our work to improve the delivery of mental
health care to Veterans will never be truly finished. However, we are
confident that we are building a more accessible system that will be
responsive to the needs of our Veterans while being responsible with
the resources appropriated by Congress. We appreciate your support and
encouragement in identifying and resolving challenges as we find new
ways to care for Veterans. VA is committed to providing the high
quality of care that our Veterans have earned and deserve, and we
continue to take every available action to improve access to mental
health care services. We appreciate the opportunity to appear before
you today, and my colleagues and I are prepared to respond to any
questions you may have.
Statements For The Record
Office of Inspector General
Mr. Chairman, Ranking Member Michaud, and members of the Committee,
thank you for the opportunity to provide information to the Committee
on the work of the Office of Inspector General (OIG) regarding the
delivery and efficacy of mental health care by the Department of
Veterans Affairs (VA).
VA provides medical care to eligible veterans throughout the United
States through VA medical centers, VA community based outpatient
clinics, and private providers in the community under the Non-VA Fee
Care Program (``Fee Basis''). The activation of National Guard and
Reserve units from across the country and the duration of the conflicts
in Iraq and Afghanistan, combined with the increased utilization of VA
mental health services by prior service-era veterans have stressed the
ability of VA to provide ready and reliable access to necessary mental
health care for returning veterans. The OIG has continued to report on
the challenges that VA faces in delivering health care to address
complex mental health issues including preventing suicides among
returning veterans, addressing post traumatic stress and related
clinical issues that result from prolonged combat, assisting female
veterans to overcome the issues related to military sexual trauma, and
providing appropriate treatment for substance use disorders while
treating chronic pain conditions. Attached is a list of selected OIG
reports dealing with these issues, which can be found on our website,
www.va.gov/oig.
The Committee requested the OIG comment on five areas:
Fulfilling the promise to hire additional mental health
personnel and fill the large number of existing vacancies - In April
2012, VA announced a hiring initiative for mental health providers. As
of December 26, 2012, which is the most recent information that VA
provided to the OIG, less than half of the desired psychiatrists (260
of 558) have been hired and less than 70 percent of the desired
psychologists (507 of 854), social workers (686 of 981) and mental
health nurses (688 of 1032) have been hired. The goals identified in
VA's plan are very ambitious given the limited number of mental health
professionals trained each year and the increased competition for
qualified mental health providers as economic and related conditions
increase the non-governmental need for mental health professionals.
VA has exceeded the hiring goal for non-clinical support staff (341
against a goal of 300). However, hiring more non-clinical staff than
required does not compensate for the lack of clinical staff and may not
improve efficiency.
Implementing the Executive Order on ``Improving Access to
Mental Health Services for Veterans, Service Members, and Military
Families'' - The OIG has not reviewed VA's actions related to the
requirements in the Executive Order.
Addressing the recommendations of the recent VA Inspector
General and Government Accountability Office reports - As of today, all
four recommendations from the OIG report, Veterans Health
Administration - Review of Veterans' Access to Mental Health Care
(April 23, 2012) remain open. The recommendations relate to improving
the metrics used by VA to measure appointment wait times and the
utilization of related metrics designed to effectively reflect the
patient experience of access to mental health care and to improve
management oversight of these clinical activities. In addition, VA
committed to performing a staffing analysis to determine the personnel
needs to provide the required mental health services. VA indicates that
progress has been made toward accomplishing these goals but VA has not
provided evidence of those efforts to the OIG to verify.
Correcting lengthy wait times, misleading access
measures, and cumbersome scheduling processes and procedures - As the
OIG reports have indicated, VA mental health access times are not
accurately reported and may not be the most useful measures to monitor
clinical performance. While workgroups have been established and move
ahead, changes to these metrics have not been finalized and/or
implemented.
The OIG has reported on the inefficiencies of the current patient
appointment system for many years. The business rules of the current
system also limit the usefulness of management data derived from the
system. The installation of a new patient appointment system will take
many months if not years to occur.
Effectively partnering with non-VA resources to address
gaps and create a more patient-centric network of care focused on
wellness-based outcomes - VA has an inconsistent record of contracting
effectively with non-VA providers to obtain health care for veterans.
At present, the procurement of specialty medical services through Fee
Basis does not provide a seamless compliment to in-house VA medical
care. The use of the current Fee Basis business rules is cumbersome for
VA facilities, and in practice, the business rules do not create
certainty in the minds of veterans or Fee Basis providers that the goal
of timely, appropriate health care will be delivered and paid for.
The OIG has consistently reported on contracting issues with both
in-patient and out-patient fee care. Weaknesses include reviewing bills
to ensure the proper payment is made and ensuring clinical data is
easily incorporated within the VA medical record. OIG has reported on
instances of improper payment and/or inadequate integration of the
treatment through purchased care into the veteran's medical records.
With the return of servicemen and servicewomen from our ongoing
conflicts and the aging veteran population, VA faces a number of
critical challenges in order to improve current performance and
increasingly and consistently meet the complex mental health needs of
veterans. The OIG will continue to review and report on VA actions at
this critical time. Our veterans deserve no less.
SELECTED OIG REPORTS
Healthcare Inspection - Appointment Scheduling and Access Patient
Call Center, VA San Diego Healthcare System, San Diego, California - 1/
28/2013
Healthcare Inspection - Inpatient and Residential Programs for
Female Veterans with Mental Health Conditions Related to Military
Sexual Trauma- 12/5/2012
Healthcare Inspection - Alleged Clinical and Administrative Issues,
VA Loma Linda Healthcare System, Loma Linda, California - 11/19/2012
Healthcare Inspection - Delays for Outpatient Specialty Procedures,
VA North Texas Health Care System, Dallas, Texas - 10/23/2012
Healthcare Inspection - Delay in Treatment, Louis Stokes VA Medical
Center, Cleveland, Ohio - 10/12/2012
Healthcare Inspection - Consultation Mismanagement and Care Delays,
Spokane VA Medical Center, Spokane, Washington - 9/25/2012
Healthcare Inspection - Alleged Staffing and Quality of Care
Issues, VA Black Hills Health Care System, Hot Springs, South Dakota -
9/11/2012
Healthcare Inspection - Access and Coordination of Care at
Harlingen Community Based Outpatient Clinic, VA Texas Valley Coastal
Bend Health Care System, Harlingen, Texas - 8/22/2012
Healthcare Inspection - Management of Chronic Opioid Therapy at a
VA Maine Healthcare System Community Based Outpatient Clinic, Calais,
Maine - 8/21/2012
Healthcare Inspection - Service Delivery and Follow-up After a
Patient's Suicide Attempt, Minneapolis VA Health Care System,
Minneapolis, Minnesota -7/19/2012
Homeless Incidence and Risk Factors for Becoming Homeless in
Veterans - 5/4/2012
Healthcare Inspection - Suicide of a Veteran Enrolled in VA
Supported Housing, Bay Pines VA Healthcare System, Bay Pines, FL - 4/
18/2012
Healthcare Inspection - Alleged Mental Health Access and Treatment
Issues at a VA Medical Center - 3/21/2012
Healthcare Inspection - Select Patient Care Delays and Reusable
Medical Equipment Review Central Texas Veterans Health Care System
Temple, Texas - 1/6/2012
Healthcare Inspection - Clinical and Administrative Issues in the
Suicide Prevention Program Alexandria VA Medical Center Pineville,
Louisiana - 8/30/2011
Healthcare Inspection - Attempted Suicide During Treatment West
Palm Beach VA Medical Center, West Palm Beach, Florida - 7/25/2011
Healthcare Inspection - Electronic Waiting List Management for
Mental Health Clinics Atlanta VA Medical Center Atlanta, Georgia - 7/
12/2011
Healthcare Inspection - A Follow-Up Review of VHA Mental Health
Residential Rehabilitation Treatment Programs (MH RRTP) - 6/22/2011
Healthcare Inspection - Prescribing Practices in the Pain
Management Clinic, John D. Dingell VA Medical Center, Detroit, Michigan
- 6/15/2011
Healthcare Inspection - Post Traumatic Stress Disorder Counseling
Services at Vet Centers - 5/17/2011
Review of Combat Stress in Women Veterans Receiving VA Health Care
and Disability Benefits - 12/16/2010
Government Accountability Office
Chairman Miller, Ranking Member Michaud, and Members of the
Committee:
I am pleased to have the opportunity to comment on overcoming
barriers for quality mental health care for veterans--particularly
those who are returning from deployment. In 2011, we reported that the
number of veterans receiving mental health care had increased each year
from fiscal year 2006 to 2010, and veterans who served in Afghanistan
and Iraq accounted for an increasing proportion of veterans receiving
mental health care during this period. \1\ We also reported on the key
barriers that may hinder veterans from accessing mental health care
from the Department of Veterans Affairs (VA), which included difficulty
scheduling appointments. \2\ More recently, in December 2012, we
reported on problems with VA's oversight of outpatient medical
appointment scheduling processes and measurement of outpatient medical
appointment wait times. \3\
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\1\ GAO, VA Mental Health: Number of Veterans Receiving Care,
Barriers Faced, and Efforts to Increase Access, GAO-12-12 (Washington,
D.C.: Oct. 14, 2011).
\2\ We identified key barriers from the literature, and
corroborated the barriers through interviews with VA officials.
\3\ GAO, VA Health Care: Reliability of Reported Outpatient Medical
Appointment Wait Times and Scheduling Oversight Need Improvement, GAO-
13-130 (Washington, D.C.: Dec. 21, 2012).
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In fiscal year 2011, there were more than 8 million veterans
enrolled in VA's health system, which is operated by the Veterans
Health Administration (VHA). VHA provided nearly 80 million outpatient
medical appointments to veterans through its primary and specialty care
clinics. \4\ Although access to timely medical appointments is critical
to ensuring that veterans obtain needed medical care, long wait times
and inadequate scheduling processes at VA medical centers (VAMC) have
been long-standing problems that persist today. For example, in 2001,
we reported on the timeliness of medical appointments and found that
two-thirds of the specialty care clinics visited had wait times longer
than 30 days, although some clinics had made progress in reducing wait
times, primarily by improving their scheduling processes and making
better use of their staff. \5\ Later, in 2007, the VA Office of
Inspector General (OIG) reported that VHA facilities did not always
follow VHA's scheduling policies and processes and that the accuracy of
VHA's reported wait times for medical appointments was unreliable. \6\
Most recently, in 2012, the VA OIG reported that VHA was not providing
all new veterans with timely access to full mental health evaluations,
and had overstated its success in providing veterans with timely new
and follow-up appointments for mental health treatment. \7\ Although
VHA has reported continued improvements in measuring and achieving
timely access to medical appointments, patient complaints and media
reports about long wait times have persisted, prompting renewed
concerns about excessive medical appointment wait times.
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\4\ Outpatient clinics offer services to patients that do not
require a hospital stay. Primary care addresses patients' routine
health needs and specialty care is focused on a specific specialty
service such as orthopedics, dermatology, or psychiatry. Throughout
this statement we will use the term ``medical appointments'' to refer
to outpatient medical appointments.
\5\ GAO, VA Health Care: More National Action Needed to Reduce
Waiting Times, but Some Clinics Have Made Progress, GAO-01-953
(Washington, D.C.: Aug. 31, 2001).
\6\ Department of Veterans Affairs, Office of Inspector General,
Audit of the Veterans Health Administration's Outpatient Waiting Times,
Report No. 07-00616-199, (Washington, D.C.: Sept. 10, 2007).
\7\ Department of Veterans Affairs, Office of Inspector General,
Veterans Health Administration: Review of Veterans' Access to Mental
Health Care, Report No. 12-00900-168, (Washington, D.C.: Apr. 23,
2012).
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VHA has a scheduling policy intended to help its VAMCs meet its
commitment to scheduling medical appointments with no undue waits or
delays. \8\ The policy establishes processes and procedures for
scheduling medical appointments and ensuring the competency of staff
directly or indirectly involved in the scheduling process. It includes
several requirements that affect timely appointment scheduling, as well
as accurate wait time measurement. \9\ For example, the policy requires
schedulers to record appointments in VHA's Veterans Health Information
Systems and Technology Architecture (VistA) medical appointment
scheduling system, including the date on which the patient or provider
wants the patient to be seen--known as the desired date. \10\
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\8\ VHA medical appointment scheduling policy is documented in VHA
Directive 2010-027, VHA Outpatient Scheduling Processes and Procedures
(June 9, 2010). We refer to the directive as ``VHA's scheduling
policy'' from this point forward.
\9\ VHA has a separate directive that establishes policy on the
provision of telephone service related to clinical care, including
facilitating telephone access for medical appointment management. VHA
Directive 2007-033, Telephone Service for Clinical Care (Oct. 11,
2007).
\10\ VistA is the single integrated health information system used
throughout VHA in all of its health care settings. There are many
different VistA applications for clinical, administrative, and
financial functions, including the scheduling system.
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At the time of our review, VHA measured medical appointment wait
times as the number of days elapsed from the patient's or provider's
desired date, as recorded in the VistA scheduling system by VAMCs'
schedulers. According to VHA central office officials, VHA measures
wait times based on desired date in order to capture the patient's
experience waiting and to reflect the patient's or provider's wishes.
In fiscal year 2012, VHA had a goal of completing primary care
appointments within 7 days of the desired date, and scheduling
specialty care appointments within 14 days of the desired date. \11\
VHA established these goals based on its performance reported in
previous years. \12\ To help facilitate accountability for achieving
its wait time goals, VHA includes wait time measures--referred to as
performance measures--in its Veterans Integrated Service Network (VISN)
directors' and VAMC directors' performance contracts, \13\ and VA
includes measures in its budget submissions and performance reports to
Congress and stakeholders. \14\
---------------------------------------------------------------------------
\11\ In 2012, VA also had several additional goals related to
measuring access to mental health appointments specifically, such as
screening eligible patients for depression, post-traumatic stress
disorder, and alcohol misuse at required intervals; and documenting
that all first-time patients referred for or requesting mental health
services receive a full mental health evaluation within 14 days of
their initial encounter. As noted earlier, in its Report No. 12-00900-
168, the VA OIG found that some of the mental health performance data
were not reliable. VA is dropping several of these mental health
measures in 2013.
\12\ In 1995, VHA established a goal of scheduling primary and
specialty care medical appointments within 30 days to ensure veterans'
timely access to care. In fiscal year 2011, VHA shortened the wait time
goal to 14 days for both primary and specialty care medical
appointments. In fiscal year 2012, VHA added a goal of completing
primary care medical appointments within 7 days of the desired date.
\13\ Each of VA's 21 VISNs is responsible for managing and
overseeing medical facilities within a defined geographic area. VISN
and VAMC directors' performance contracts include measures against
which directors are rated at the end of the fiscal year, which
determine their performance pay.
\14\ VA prepares a congressional budget justification that provides
details supporting the policy and funding decisions in the President's
budget request submitted to Congress prior to the beginning of each
fiscal year. The budget justification articulates what VA plans to
achieve with the resources requested; it includes performance measures
by program area. VA also publishes an annual performance report--the
performance and accountability report-- which contains performance
targets and results achieved compared with those targets in the
previous year.
---------------------------------------------------------------------------
This statement highlights key findings from our December 2012
report that describes needed improvements in the reliability of VHA's
reported medical appointment wait times, scheduling oversight, and VHA
initiatives to improve access to timely medical appointments. \15\ For
that report, we reviewed VHA's scheduling policy and methods for
measuring medical appointment wait times and interviewed VHA central
office officials responsible for developing them. We did not include
mental health appointments in the scope of our work, because this issue
was already being reviewed by VA's Office of Inspector General. We also
visited 23 high-volume outpatient clinics at four VAMCs selected for
variation in size, complexity, and location; these four VAMCs were
located in Dayton, Ohio; Fort Harrison, Montana; Los Angeles,
California; and Washington, D.C. At each VAMC we interviewed leadership
and other officials about how they manage and improve medical
appointment timeliness, their oversight to ensure accuracy of
scheduling data and compliance with scheduling policy, and problems
staff experience in scheduling timely medical appointments. We examined
each VAMC's and clinic's implementation of elements of VHA's scheduling
policy and obtained documentation of scheduler training completion. In
addition, we interviewed schedulers from 19 of the 23 clinics visited,
and also reviewed patient complaints about telephone responsiveness,
which is integral to timely medical appointment scheduling. We
interviewed the directors and relevant staff of the four VISNs for the
sites we visited. We also interviewed VHA central office officials and
officials at the VAMCs we visited about selected initiatives to improve
veterans' access to timely medical appointments. We performed this work
from February 2012 through December 2012 in accordance with generally
accepted government auditing standards.
---------------------------------------------------------------------------
\15\ GAO-13-130.
---------------------------------------------------------------------------
In brief, we found that (1) VHA's reported outpatient medical
appointment wait times are unreliable, (2) there was inconsistent
implementation of certain elements of VHA's scheduling policy that
could result in increased wait times or delays in scheduling timely
medical appointments, and
(3) VHA is implementing or piloting a number of initiatives to
improve veterans' access to medical appointments. Specifically, VHA's
reported outpatient medical appointment wait times are unreliable
because of problems with correctly recording the appointment desired
date--the date on which the patient or provider would like the
appointment to be scheduled--in the VistA scheduling system. Since, at
the time of our review, VHA measured medical appointment wait times as
the number of days elapsed from the desired date, the reliability of
reported wait time performance is dependent on the consistency with
which VAMC schedulers record the desired date in the VistA scheduling
system. However, aspects of VHA's scheduling policy and related
training documents on how to determine and record the desired date are
unclear and do not ensure replicable and reliable recording of the
desired date by the large number of staff across VHA who can schedule
medical appointments, which at the time of our review was estimated to
be more than 50,000. During our site visits, we found that at least one
scheduler at each VAMC did not record the desired date correctly,
which, in certain cases, would have resulted in a reported wait time
that was shorter than the patient actually experienced for that
appointment. Moreover, staff at some clinics told us they change
medical appointment desired dates to show clinic wait times within
VHA's performance goals. Although VHA officials acknowledged
limitations of measuring wait times based on desired date, and told us
that they use additional information, such as patient satisfaction
survey results, to monitor veterans' access to medical appointments,
reliable measurement of how long veterans wait for appointments is
essential for identifying and mitigating problems that contribute to
wait times.
At the VAMCs we visited, we also found inconsistent implementation
of VHA's scheduling policy, which can result in increased wait times or
delays in scheduling timely medical appointments. For example, four
clinics across three VAMCs did not use the electronic wait list to
track new patients that needed medical appointments as required by
VHA's scheduling policy, putting these clinics at risk for losing track
of these patients. Furthermore, VAMCs' oversight of compliance with
VHA's scheduling policy was inconsistent across the facilities we
visited. Specifically, certain VAMCs did not ensure the completion of
scheduler training by all staff required to complete it even though
officials stressed the importance of the training for ensuring correct
implementation of VHA's scheduling policy. VAMCs also described other
problems that impede the timely scheduling of medical appointments,
including VA's outdated and inefficient VistA scheduling system, gaps
in scheduler staffing, and issues with telephone access. The current
VistA scheduling system is more than 25 years old, and VAMC officials
reported that using the system is cumbersome and can lead to errors.
\16\ In addition, shortages or turnover of scheduling staff, identified
as a problem by all of the VAMCs we visited, can result in appointment
scheduling delays and incorrect scheduling practices. Officials at all
VAMCs we visited also reported that high call volumes and a lack of
staff dedicated to answering the telephones impede the scheduling of
timely medical appointments. Although we did not specifically review
mental health clinic wait times, some of the problems we identified
were pervasive, and may also affect clinics other than those we
visited.
---------------------------------------------------------------------------
\16\ In October 2012, VA announced a contest seeking proposals for
a new medical appointment scheduling system from commercial software
developers.
---------------------------------------------------------------------------
VHA is implementing or piloting a number of initiatives to improve
veterans' access to medical appointments that focus on more patient-
centered care; using technology to provide care, through means such as
telehealth and secure messaging between patients and their health care
providers; and using care outside of VHA to reduce travel and wait
times for veterans who are unable to receive certain types of
outpatient care in a timely way through local VHA facilities. For
example, VHA is piloting a new initiative to provide health care
services through contracts with community providers that aims to reduce
travel and wait times for veterans who are unable to receive certain
types of care from VHA in a timely way. Although VHA collects
information on wait times for medical appointments provided through
this initiative, these wait times may not accurately reflect how long
patients are waiting for appointments because they are counted from the
time the contracted provider receives an authorization from VA, rather
than from the time the patient or provider first requests an
appointment from VHA.
In conclusion, VHA officials have expressed an ongoing commitment
to providing veterans with timely access to medical appointments and
have reported continued improvements in achieving this goal. However,
unreliable wait time measurement has resulted in a discrepancy between
the positive wait time performance VA has reported and veterans' actual
experiences. More consistent adherence to VHA's scheduling policy and
oversight of the scheduling process, allocation of staff resources to
match clinics' scheduling demands, and resolution of problems with
telephone access would potentially reduce medical appointment wait
times. VHA's ability to ensure and accurately monitor access to timely
medical appointments is critical to ensuring quality health care to
veterans, who may have medical conditions that worsen if access is
delayed.
To ensure reliable measurement of how long veterans are waiting for
appointments and improve timely medical appointment scheduling, we
recommended that the Secretary of VA direct the Under Secretary for
Health to take actions to (1) improve the reliability of its medical
appointment wait time measures, (2) ensure VAMCs consistently implement
VHA's scheduling policy, (3) require VAMCs to routinely assess
scheduling needs for purposes of allocation of staffing resources, and
(4) ensure that VAMCs provide oversight of telephone access and
implement best practices to improve telephone access for clinical care.
VA concurred with our recommendations and identified actions planned or
underway to address them.
This concludes my statement for the record.
GAO Contacts and Staff Acknowledgments
For questions about this statement, please contact Debra A. Draper
at (202) 512-7114 or [email protected]. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this statement. Individuals making key contributions to this
statement include Bonnie Anderson, Assistant Director; Rebecca Abela;
Jennie Apter; Lisa Motley; Sara Rudow; and Ann Tynan.
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The American Counseling Association
Chairman Miller, Ranking Member Michaud and Members of the
Committee, I want to thank you for inviting me to submit testimony to
the Committee today. It is an honor and a privilege to speak on behalf
of the American Counseling Association and we appreciate the
opportunity to contribute to this very important discussion. We share
the concerns of this committee regarding the well-being of our service
members, and we consider it a national tragedy that on average, one of
our veterans commits suicide every 80 minutes. I can think of no more
pressing concern for this committee than stopping this terrible toll.
The American Counseling Association is the country's largest and
oldest professional association representing the counseling profession,
with over 52,000 members across the United States and overseas. Our
members have diverse backgrounds and many of them specialize in
treating substance abuse disorders, mental health issues, trauma,
family issues and depression among others.
There are more than 120,000 licensed professional counselors
(LPC's) nationwide, authorized under licensure laws enacted in all 50
states and other U.S. jurisdictions to practice independently. As with
the profession of social work, states use slightly differing titles for
those licensed as professional mental health counselors, the most
commonly used title being ``licensed professional counselor.'' LPCs
meet education, training, and examination requirements similar to--and
in many states, more stringent than--those of marriage and family
therapists and clinical social workers. Licensed professional
counselors have to have a master's degree in counseling or a related
field, pass a national exam (in some cases two exams), and accumulate
thousands of hours of post-degree supervised experience. As with other
health care professionals, counselors must adhere to a code of ethics,
are required to practice within the scope of their expertise, and
practice subject to the oversight and approval of their state's
licensure board. Counselors provide outpatient psychotherapy
independently under private sector health plans nationwide, as
authorized by state licensure laws, and form a significant part of the
nation's mental health workforce.
Licensed professional counselors can make a valuable contribution
to treating the mental health concerns of service members, and as the
committee knows, psychological and cognitive injuries and their
consequences are the signature wounds of the Iraq and Afghanistan
conflicts. Policymakers both inside and outside the Department of
Veterans Affairs have repeatedly said that there aren't enough mental
health providers available to meet veterans' treatment needs. From our
perspective this problem is to a large extent a self-inflicted wound,
because despite a past press release to the contrary, the VA has
effectively decided not to utilize LPCs as part of its mental health
workforce. The VA's rules and policies have kept far too many
counselors from operating under either of those two areas at a time
when we need them most. And these rules could be changed by the
Administration in a fairly simple and quick manner so that we can begin
to deliver the care and treatment that our troops need right now.
As I mentioned, there are more than 120,000 licensed professional
counselors across the country, all meeting stringent education,
training, experience, examination, and ethical standards. In all of
2012, a grand total of 58 LPMHC (``licensed professional mental health
counselor'') VA positions were posted on USAJobs.com. In comparison,
1,527 clinical social worker positions were posted. In terms of the
number of licensees at the highest level of licensure, the ratio for
the two professions nationwide isn't 26 to 1; it's roughly 1.7 to 1.
While we understand that the local needs of VA Medical Centers and
Community-Based Outpatient Clinics are varied and that the local staff
or those facilities are positioned to identify and meet those needs, it
is clear to us that LPCs are an overlooked solution to the staffing
problem. Also, in many cases, both VAMCs and CBOCs are unable to
integrate LPCs into their staff due to the fact that there are barriers
that have been created by the VA itself. To cite one important example,
the VA's Office of Academic Affiliations each year establishes paid
traineeship positions for both psychologists and clinical social
workers counselors, which serve as a pathway to service in the VA
health care system. The Office of Academic Affiliations has denied our
request that they establish paid traineeship positions for professional
counselors. The most recent justification given for this denial is the
unsubstantiated, false claim that there is a different ``community
standard'' regarding paid internships within the mental health
counseling profession than exists for the clinical social work and
psychology professions. Less than a year ago, the justification given
was that there was ``not a need'' for professional mental health
counselors at VA facilities.
Despite the current crisis in veterans' mental health care, the VA
is using overly restrictive eligibility criteria for LPMHC positions,
which includes graduation from counseling programs that are
specifically named. ACA supports the highest standards of
accreditation. In fact, organizations such as the Council on
Accreditation of Counseling and Related Educational Programs (CACREP)
is one that our organization helped to create. However, while we
understand the VA's interest in relying on national accreditation to
ensure provider quality, large numbers of highly qualified, experienced
LPCs will be denied the ability to provide critical mental health
services of our returning wounded warriors. We believe this is
unconscionable.
By mandating such a strict accreditation requirement, the VA is
shutting out many highly-trained mental health counselors--many of them
veterans themselves--at a time when veterans are literally dying for
want of help. We have asked the VA to increase job listings for LPCs
and adopt grand parenting standards to allow an alternative route to
eligibility for LPMHC positions for the tens of thousands of fully-
licensed counselors who right now can't apply, but the VA has said they
are not interested. The result is that our members are being told that
they should go back to school and obtain another degree if they wish to
work in a VA facility, if and when the VA decides to begin hiring
LPMHCs in large numbers.
ACA recommends that the VA expand the eligibility criteria for
LPMHC positions to include mental health counselors who:
1) Holds at least a master's degree in counseling from a regionally
accredited program;
2) Is licensed as a professional counselor in a U.S. jurisdiction
at the highest level of licensure offered; and
3) Passes the National Clinical Mental Health Counseling (NCMHCE)
Exam.
ACA believes that by adopting grandfathering provisions such as
these, at least during this time of severe need for more clinicians,
the VA can recruit more LPCs without sacrificing the quality of care to
our veterans. It could also allow many veterans who are counselors to
serve their country and their compatriots.
In addition to adopting these grandfathering provisions, ACA has
several other specific policy recommendations that we have recommended
to the VA and would like to share with the committee. And while these
recommendations may seem like small steps that the VA could take, they
would be huge strides for the LPC community and would go a long way
toward opening the door to members of our profession who want to care
for our veterans:
The VA's Office of Academic Affiliations should include
counselors in its paid trainee program. These positions are a well-trod
pathway to careers within the VA, and counselors are being unfairly and
arbitrarily discriminated against by being excluded from the program.
That the VA collaborate with ACA and other groups to help
fill vacancies in the VA. ACA has a national network and an office of
professional affairs that can help find applicants for these positions.
That the VA appoint a liaison to work with the counseling
community toward hiring more LPCs in the VA.
VA Secretary Eric Shinseki should issue a public notice
to the entire VA healthcare system (Specifically to VISN Directors,
VMAC Directors and HR Directors) reminding them that they are empowered
to hire counselors, and asking them not to shut-out an entire
profession that can provide desperately needed help to our vets.
All of these recommendations could be undertaken by the VA
immediately, and without the need for congressional authorization. They
could be acted upon today and thus hasten the ability for the VA to
expand the opportunities for our service members to receive quality
mental healthcare.
I hope that by sharing these recommendations with you, we can work
together toward implementing these recommendations and get more LPCs
into the VA. More LPCs in the system would mean that we are increasing
the availability of mental health clinicians to our veterans and their
family members. In the end, improving the quality and accessibility of
mental health services for our veterans and their families should be
what we are all focused on.
The American Legion
Chairman Miller, Ranking Member Michaud and distinguished Members
of the Committee:
The United States of America lost 22 veterans to suicide every day
in 2010 according to the Department of Veterans Affairs (VA) study
released earlier this month. According to the report's estimations, a
veteran took his or her own life every 66 minutes \1\. With veteran
suicide at an all time high, naturally we must question whether VA's
mental health care system is equipped to meet the demands of the
veteran population it was created to serve. The VA may offer veterans
the best mental health care option available, but if we face difficult
barriers to access that care, then veterans are not really being
served.
---------------------------------------------------------------------------
\1\ ``Suicide Data Report, 2012'' Department of Veterans Affairs
Mental Health Services Suicide Prevention Program, p 15
---------------------------------------------------------------------------
On behalf of Commander James Koutz and the 2.4 million veterans of
The American Legion, we would like to thank you for this opportunity to
provide testimony for the record in order to highlight issues with
overcoming barriers to quality mental health care provided by VA.
Specifically, we will address the following five issues:
1) Fulfilling the promise to hire additional mental health
personnel and fill the large number of vacancies
2) Implementation of the E.O to improve access to mental health
care for veterans and their families
3) Addressing the recommendations in the IG and GAO report
4) Correcting lengthy wait times and misleading access measures,
and cumbersome scheduling processes, and
5) Effective partnering with non-VA resources to address gaps and
create a more patient-centric network of care focused on wellness-based
outcomes
The Large Number of Existing Vacancies
During the past half decade, VA has nearly doubled their mental
health care staff, jumping from just over 13,500 providers in 2005 to
over 20,000 providers in 2011. However, during that time there has been
a massive influx of veterans into the system, with a growing need for
psychiatric services. With over 1.5 million veterans separating from
service in the past decade, 690,844 have not utilized VA for treatment
or evaluation. The American Legion is deeply concerned about nearly
700,000 veterans who are slipping through the cracks unable to access
the health care system they have earned through their service.
On June 11th, 2012, a VA Press Release outlined an aggressive
recruitment effort to hire 1,600 mental health professionals and 300
support staff. The release stated that all of the positions would be
filled by the 2nd Quarter of FY2013. Unfortunately, despite repeated
requests for updates on the progress of the hiring, The American Legion
had not received any numbers or date until a belated, eleventh hour
press release from VA that was released just hours before this hearing.
In order to instill confidence in the veterans' mental health care
stakeholders, VA must improve the transparency of their process and
work to foster meaningful two-way communication. The veteran community
wants to work with VA to ensure the needs of our veterans are being
met, yet effective communication is impossible without open access to
the information we need to discuss. The American Legion urges VA to
provide more information on the status of hiring for these positions,
throughout the entire process. If the concerned veterans' community
only learns of unfilled positions after a deadline is missed, it will
be too late for stakeholders and partners to work together to achieve
meaningful solutions.
Implementing the Executive Order on Improving Access to Mental Health
Services for Veterans, Servicemembers and Military Families
The Executive Order on Improving Access to Mental Health Services
for Veterans, Servicemembers and Military Families dealt with suicide
prevention, enhancing partnerships between the VA and community
providers, expanding VA mental health services staffing, improved
research & development, and the creation of a Military and Veterans
Mental Health Interagency Task Force.
After reviewing the Executive Order and examining the
implementation, The American Legion has identified certain gaps that
may need to be considered in the future development and implementation
of this Executive Order.
The Executive Order Section 1: Policy order states that ``as part
of our ongoing efforts to improve all facets of military mental health,
this order directs the Secretary of Defense, Health and Human Services,
Education, Veterans Affairs, and Homeland Security to expand suicide
prevention strategies and take steps to meet the current and future
demand for mental health and substance abuse treatment services for
veterans, service members and their families.''
However, The American Legion is gravely concerned about the
February 5, 2012 decision by VA and DOD to abandon efforts to create a
single medical records system. Rather than supporting the vision of the
Executive Order to work with multiple agencies, this decision can only
lead to greater distance and fragmentation. With veterans waiting on
average 374 days for Medical Evaluation Board (MEB)/Physical Evaluation
Board (PEB) claims and 257 days for a traditional VA claim, veterans
need faster processing which will only come from a smooth transition of
records. These records are needed for decisions and the lack of a
shareable record is hurting veterans.
Suicide Prevention
According the Executive Order, the Veterans Crisis Line was to be
increased by 50%, which The American Legion applauds because it
increases the capacity to serve veterans in a timely manner. It also
called for the creation of a 12 month national suicide prevention
campaign, and on bringing down the negative stigma associated with
mental health needs for the veteran, but the American Legion is
concerned this campaign does not adequately target families and
community members. Because PTSD is comparable to other societal issues
such as substance abuse, where the victim may not recognize their own
problem, reaching out to the existing support structures around those
victims is all the more critical. Veterans may have a lack of
understanding or awareness of mental health care, and may not
understand their conditions or may feel that their mental health
conditions are not severe enough to warrant asking for help. Family and
community members can help increase awareness and encourage the veteran
to seek help \2\.
---------------------------------------------------------------------------
\2\ GAO Report 13-130, December 2012
---------------------------------------------------------------------------
One of the impediments VA has faced has been with the collecting
and tracking of accurate suicide data. In the Suicide report, it found
that ``as of November 2012, data had only been received from 34 states
and data use agreements have been approved by an additional eight
states.'' However, agreements are still under approval or development
by other states which impacts VA's ability to accurately calculate the
total number of veteran suicides. In order to improve the collection
and reporting of suicide data, Congress should urge the states to share
this information with VA. Without accurate suicide prevention and
mortality data, the estimates that 18 to 21 veterans commit suicide are
not truly accurate and these estimates in reality in all actuality
could be much higher or lower.
Enhanced Partnerships Between the VA and Community Providers
VA and Health & Human Services (HHS) were asked to establish at
least 15 pilot programs with community providers in order to ensure
that the needs of veterans are being met, by providing access to mental
health services within 14 days of the patient's requested date.
While DOD has led the effort in utilizing pro-bono community
provider programs to treat service members for mental health
conditions, including PTSD; Senate testimony from a November 30th, 2011
Veterans Affairs Committee hearing \3\ made it clear that VA was not
working with non-profit organizations to minimize patient wait times
for appointments, thus exacerbating the problem of the veterans ability
to receive care in a timely manner.
---------------------------------------------------------------------------
\3\ Testimony of Dr. Van Dahlen - 11/30/11 Senate Veterans Affairs
Committee
---------------------------------------------------------------------------
In a congressional hearing, VA Fee Basis Care: Examining Solutions
to a Flawed System, on September 14, 2012 The American Legion found
many problems with VA's non-VA purchased care programs such as:
need for VA to develop and implement fee-basis policies
and procedures with a patient-centered strategy that takes veterans'
interest and travel distance into account;
lack of training and education programs for non-VA
providers; lack of integration of VA's computer patient record system
with non-VA providers which creates delay in contractors submitting
appointment documentation;
VA does not have a process to ensure all VA and non-VA
purchased care contracts are inputted into a tracking system to ensure
they do not lapse.
Without these VA reforms and improvements, VA cannot adequately
leverage non-VA and community partnerships.
The American Legion demands that veterans have access to quality
and timely mental health care, which should be based in an adequately
funded budget for mental health. However, the VA should be leveraging
community resources to help alleviate the issue associated with wait
times whenever possible. In addition, it is crucial that the VA ensure
that the community providers performing this important work are trained
to provide the quality of care equal to what is delivered by VA
providers. Ultimately, given the experience in dealing with military
matters such as the unique complexities of PTSD, VA and DOD providers
are, and should be, the gold standard of care, and VA planning should
have the ultimate goal of fulfilling the needs of veterans within the
VA system. While working to achieve that goal VA should ensure that no
veterans slip through the cracks by leveraging all available community
resources until the care can be completely met by VA resources.
It should be noted that the VA is working with community providers
through the five-site, 3-year pilot program, Project Access Received
Closer to Home (ARCH), which is administered through the Office of
Rural Health. This program utilizes contracting and a fee-basis payment
system to help meet the needs of rural veterans. The American Legion
notes that processing the authorizations for certain services were
concerns that were brought up in April 2012 during the evaluation of
the Montana Project ARCH program. The 2012 System Worth Saving Task
Force Report on Rural Health recognized that the ARCH project was a
three year pilot, yet concerns existed regarding effective utilization
of budget for patient care, a lack of outreach guidelines and
communication and the difference in structures between VA care and non-
VA care.
While Community providers are an option, The American Legion is
concerned that a main issue associated with using community providers
lies in the continuity of care. To address this concern, the VA is
implementing a program that will address the lack of providers, while
increasing the continuity of care, called; VA Specialty Care Access
Networks - Extension for Community Healthcare Outcomes (SCAN-ECHO).
This unique program utilizes primary care physicians to provide
specialty care to veterans who choose to enroll in the program. The
primary care physician presents the veteran's case to a panel of
medical professionals, including specialists, who discuss diagnoses and
treatments. By incorporating the primary care physician in the
treatment, there is an increased level of continuity of care. Primary
care physicians bring in a more holistic approach of the veteran that
The American Legion believes will benefit the veteran patient.
Expanding VA Mental Health Services Staffing
The Executive Order also calls for the addition of 800 peer-to-peer
counselors by December 2013, while providing hiring incentives and
evaluating reporting requirements to reduce paperwork requirements to
bring on new staff.
Peer-to-peer counseling has been used as an effective treatment to
help veterans in the rehabilitation process, which is clearly
exemplified by the Vet Center program implemented across the nation.
The American Legion advocates expanding the program of peer-to-peer
support networks, and believe this would be very instrumental in moving
from a treatment based model to a recovery model.
The American Legion continues to encourage the Secretary of
Veterans Affairs to utilize returning service members for positions as
peer support specialists in the effort to provide treatment, support
services and readjustment counseling for those veterans requiring these
services. If appropriately skilled unemployed veterans can receive
training to fulfill staffing needs in the mental health care system, VA
will be solving multiple problems with a single, forward thinking
solution. Robust recruitment and vocational training in this area
should be a priority and The American feels so strongly about this
issue that we passed a resolution during our National Convention last
year specifically to call upon VA to institute a peer to peer outreach
program \4\.
---------------------------------------------------------------------------
\4\ American Legion Resolution No. 136: The Department of Veterans
Affairs to Develop Outreach and Peer to Peer Programs for
Rehabilitation
---------------------------------------------------------------------------
Hiring incentives may entice providers to apply to work for the VA
over the private sector, and reducing the cumbersome process of
credentialing and privileging to bring providers on board more quickly
could help meet VA's needs, provided it is done in a manner that does
not sacrifice quality and competency of care. VHA needs to conduct a
staffing analysis to determine if psychiatrists or other mental health
provider vacancies are systemic issues impending VHA's ability to meet
mental health timeliness goals \5\. Many facilities visited through The
American Legion's System Worth Saving program have demonstrated
difficulties competing with the private sector, and complained that the
Credentialing & Privileging process for physicians is too lengthy.
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\5\ OIG Report 12-00900-168, April 23, 2012
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Improved Research & Development
The Executive Order called for the creation of a National Research
Action Plan to be developed within 8 months by DOD, VA, HHS, and the
Office of Science & Technology Policy (OSTP). This plan was supposed to
develop better prevention, diagnosis, and treatment for PTSD, other
mental health conditions, and Traumatic Brain Injury (TBI).
Additionally it calls for DOD and HHS to engage in a comprehensive
longitudinal health study on PTSD, TBI, and related injuries with
minimum enrollment of 100,000 service members.
The American Legion applauds this effort, because it is inclusive
of TBI which has a high level of co-morbidity with PTSD. It also looks
at long term effects of TBI, PTSD, and other mental health conditions,
while focusing on the whole process of prevention, diagnosis, and
treatment. The American Legion has long supported research efforts that
address the signature wounds of the Iraq and Afghanistan conflicts and
supports these efforts through a series of membership based resolutions
that were passed during our National Convention last summer \6\.
---------------------------------------------------------------------------
\6\ Resolution No. 108: Request Congress Provide the Department of
Veterans Affairs Adequate Funding for Medical and Prosthetic Research,
Resolution No. 285: Traumatic Brain Injury and Post Traumatic Stress
Disorder Programs
---------------------------------------------------------------------------
In addition to traditional treatment measures currently in use
through the VA and DOD health care systems, The American Legion urges
Congress to provide oversight and funding to the DOD and VA for
innovative TBI and PTSD research currently used in the private sector,
such as Hyperbaric Oxygen Therapy and Virtual Reality Exposure Therapy,
as well as other non-pharmacological treatments. The American Legion
also recommends the creation of a joint office for DOD & VA research in
order to increase agency collaboration and communication. Finally, The
American Legion finds it troubling that DOD and VA are not designated
as the lead agencies for this effort, with HHS and OSTP providing
advisory roles.
Military and Veterans Mental Health Interagency Task Force
The creation of a taskforce, which is designed to implement the
Executive Order, met with all the stakeholders in January. The American
Legion encourages the Task Force to continue to involve VSOs at all
stages of their work.
Addressing the recommendations in recent VA Inspector General (OIG) and
Government Accountability Office (GAO) reports
Since 2005, multiple reports from the OIG have stated that the
schedulers were entering incorrect desired appointment dates for
veterans who were requesting mental health appointments.
Recommendations have repeatedly directed VA to reassess their training,
competency, and oversight methods to ensure reliable and accurate
appointment data is captured.
The American Legion is extremely concerned that an overall lack of
accountability will make this goal difficult to achieve. Much like the
school system, the VA medical centers are trying to meet a standard
they are mandated to achieve, and as in the case of the school systems,
tests can be modified by the states to show success that is not
occurring. The American Legion is further concerned that VHA statistics
and data are being manipulated in order to show the desired results,
and that this data is not accurately depicting the situation. Policies
and measurements are created in order to monitor the information, but
if individuals feel that their performance is based upon this measure,
then the predilection to alter the data becomes problematic.
The American Legion also notes that the measurements are not always
the issue. Staffing, technology, and veteran perceptions &
circumstances also can play a big role in delaying treatment provided
to veterans.
The VHA system has multiple issues with scheduling that could be
alleviated with more funding \7\. Chief among these concerns are an
outdated VistA Scheduling System, problems with scheduler turnover, and
the ongoing provider staffing gaps. As the primary scheduling system,
the outdated VistA can cause difficulties in scheduling due to a lack
of multitasking ability inherent to the software. A more modern system
could alleviate this, and will require funding to develop and
implement. Consistency with staffing, not only of providers but also
with schedulers, will ensure more consistency delivering appointments.
---------------------------------------------------------------------------
\7\ GAO Report13-130, December 2012
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Although not mentioned in the report, the centralization of
Informational Technology (IT) has created a shared pot where the
different VA entities are now competing for the same technology storage
space and resources. This creates and issue with updating programs such
as the VistA Scheduling System or other IT solutions for scheduling.
Facilities need to have flexibility in meeting their IT needs.
The more recent GAO report focuses on barriers faced and efforts to
increase access \8\. The report mainly addresses the negative stigma,
lack of understanding of mental health, logistical challenges, and
concerns about the VA that may hinder veterans from accessing care.
---------------------------------------------------------------------------
\8\ Ibid
---------------------------------------------------------------------------
Most notable in this report was the information regarding the
values and priorities that veterans may have. For example, due to
family, work, or schooling commitments, many veterans have concerns
about scheduling VA appointments during traditional hours of operation.
VA attempted to address this issue with a Directive issued on
September 5th, 2012 developed by the VHA \9\, however, the directive
was rescinded less than a week later on September 11th, 2012 through
VHA Notice 2012-13, and the changes never took place. On January 9,
2013, VHA Directive 2013-001 was sent to the field to extend hours
access for veterans requiring primary care, including women's health
and mental health services. Unfortunately, the implementation of this
regular is expected by July 31, 2013 and they are only required to have
one weekend shift that is limited to only two hours. In addition,
extended hours are only required in VA Medical Centers and Community
Based Outpatient Clinics with 10,000 unique patients or greater. The
American Legion is concerned about the impact of this on veterans,
particularly in rural areas.
---------------------------------------------------------------------------
\9\ Directive 2012-023, ``Extended Hours Access for Veterans
Requiring Primary Care Including Women's Health and Mental Health
Services at Department of Veterans Affairs Medical Centers and Selected
Community Based Outpatient Clinics''
---------------------------------------------------------------------------
Correcting lengthy wait times, misleading access measures, and
cumbersome scheduling processes and procedures.
Thus far, VA is taking a multi pronged approach to address the
scheduling issue, by looking at the issues associated with technology,
access measures, training, and funding.
Technology
The VA announced in the Federal Register in October of 2012 the
opportunity for companies to provide adjustments to the open-source
VistA electronic health system, and all submissions are due by June
2013. By creating the Medical Appointment Scheduling System (MASS)
contest, the VA appears to be moving ahead on this issue.
Additionally, the GAO has determined that the VA telephone system
is outdated \10\. The VHA directed all VISN directors to provide plans
to assess their current phone system needs, and develop strategic
improvements plans with a target completion of March 30th, 2013, 6
weeks from now.
---------------------------------------------------------------------------
\10\ GAO Report13-130, December 2012
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Because the correction of the substandard VistA system and phone
systems is vital to helping alleviate some of the associated
difficulties with access to mental health care, The American Legion
urges Congress to ensure VA's budget receives adequate funding to
address these issues.
Access Measures and Training
The VA is scheduled to have both the new measurements and the
training package for schedulers by November 1st, 2013. The American
Legion would like the VA to be more transparent regarding the updates
associated with any progress associated with scheduling procedures.
Furthermore, as VA develops these methods, The American Legion
encourages strong cooperation with veterans' groups and other
stakeholders throughout the entire process.
Funding
In FY 2012 H.R. 2646 authorized the VA sufficient appropriations to
continue to fund and operate leased facility projects that support our
veterans all across the country. In November of 2012 the FY 2013
appropriations for the same facilities was eliminated from
appropriations due to a ``scoring change'' initiated by the
Congressional Budget Office (CBO). While the locations, projects,
leases, and funding requirements did not change - the way in which CBO
scored the projects did, which resulted in the appearance that the
project would cost more than 10 times the actual needed revenue.
According to VA, CBO refuses to share their evaluation process and will
only issue the final score. As a result of CBO's adjustment in scoring
review, Congress refused to introduce the FY 2013 appropriations bill
needed to keep these community based centers open. As these leases now
become due, there are 15 major medical facilities that will be forced
to close unless Congress acts quickly to provide the appropriate
funding to these centers.
If these centers are allowed to close due to insufficient funding,
the impact on our veterans, and the VA would be devastating. Not only
would the center employees have to either relocate within the VA or be
terminated, the VA could be subject to legal action for prematurely
defaulting on their leases. The veterans currently being served by
these facilities would then have to either travel long distances to the
nearest VA facility, or would have to find care at local hospital that
the VA would be required to pay for, at a fee-for-services basis. This
would ultimately cost the VA an estimated 4 times what the original
appropriations would have cost for these shuttered facilities. The
facilities currently in jeopardy are located in; Albuquerque, New
Mexico, Brick, New Jersey, Charleston, South Carolina, Cobb County,
Georgia, Honolulu, Hawaii, Lafayette, Louisiana, Lake Charles,
Louisiana, New Port Richey, Florida, Ponce, Puerto Rico, San Antonio,
Texas, West Haven, Connecticut, Worchester, Massachusetts, Johnson
County, Kansas, San Diego, California, and Tyler, Texas.
The American Legion implores Congress to fund these centers as
originally planned. The funds that these centers need has already been
obligated, and refusal to fund these centers will cause a false
perception of excess monies to exist within the federal budget, which
The American Legion is afraid will be falsely reported as a money
saving initiative.
Effectively partnering with non-VA resources to address gaps and create
a more patient-centric network of care focused on wellness-
based outcomes
The Department of veteran Affairs has not engaged The American
Legion in the development of any of the 15 pilot programs that VA is
engaging in, pursuant to the Presidential Executive Order. As such, we
have concerns regarding the quality and viability of the non-VA
resources. The American Legion has made clear that they would prefer to
be one of the VA's primary resources for dealing with mental health
care for veterans, for a variety of reasons which should be obvious.
The VA health care program is a holistic program as it takes into
account all of the patient's doctors, to develop an approach that
recognizes the interconnectivity of multiple or complicated disorders.
Doctors in the VA system have access to all of a patient's records,
which is helpful and relevant when dealing with disorders having co-
morbid symptoms such as PTSD and TBI. Furthermore, VA mental health
care providers are perhaps the most uniquely qualified practitioners
available to address military related PTSD and other related emotional
conditions. Civilian providers may lack the requisite experience and
finite training to deal with these issues.
Because outside providers lack the sharing of information and
military experience inherent to the VA system, the ideal solution is to
ensure that veterans receive their care in the VA system. They have
earned access to this system through their service, and deserve to be
able to benefit from the VA's healthcare system, sans scheduling
difficulties or unreasonable and potentially deadly delays. However,
when that system proves unable to cope with the demand, outside help
may be needed until the VA system can be adjusted to once again handle
the scope and scale of the influx of veterans who need mental health
care assistance.
The American public has expressed a tremendous outpouring of
support for those who serve and there is a vast and growing assortment
of community based groups who are eager to provide help to veterans who
are suffering. Given this level of community support veterans should be
able to find the help they need within their communities. Understanding
that the VA health care system is uniquely qualified to meet the needs
of the veterans, and the ultimate goal should be to ensure that the
system has the capacity to serve all veterans; local resources can and
should be used to fill in the gaps until a suitable system is in place.
Conclusion
In conclusion, The American Legion is deeply concerned about the
issues associated with the barriers to access, the timeliness, and
quality of care available to our veterans, many of whom are suffering.
The Legion urges VA to work with stakeholders, the Veterans Service
Organizations, and Congress to develop a plan to increase transparency
and address existing barriers to quality healthcare so we can all work
together to ensure that veterans receive the timely and quality mental
health services they deserve - especially for those veterans located in
remote rural areas.
The American Legion recognizes that the VA is working hard to
fulfill its mission; however they will only be successful if they are
able to enjoy the full support of Congress, the VSOs, and the
community.
Iraq and Afghanistan Veterans of America
Chairman Miller, Ranking Member Michaud and distinguished members
of the committee, on behalf of Iraq and Afghanistan Veterans of America
(IAVA) I would like to extend our gratitude for being given the
opportunity to share with you our views and recommendations regarding
Honoring the Commitment: Overcoming Barriers to Quality Mental Health
Care for Veterans. IAVA applauds the committee's continued dedication
in addressing the critical issues surrounding mental health care and
IAVA looks forward to working closely with the committee in addressing
these and other issues throughout the 113th congressional session.
IAVA is the country's first and largest nonprofit, nonpartisan
organization for veterans of the wars in Iraq and Afghanistan and has
more than 200,000 member veterans and supporters nationwide. Founded in
2004, our mission is to improve the lives of Iraq and Afghanistan
veterans and their families. Through assistance, awareness and
advocacy, we strive to create a country which honors and supports
veterans of all generations.
The veteran suicide rate is a national crisis. According to a
recent VA report approximately 22 veterans a day are taking their own
lives. Unfortunately, IAVA fears that these numbers may actually still
be lower than the true number of veterans we lose to suicide, as some
states don't report veteran suicide and are not included in VA's 2013
report. Regardless of the exact number, IAVA strongly believes that
even one veteran or servicemember life lost to suicide is one too many.
Since 2008, nearly 1.5 million servicemembers of Operation Iraqi
Freedom (OIF), Operation Enduring Freedom (OEF) and Operation New Dawn
(OND) have transitioned back into the civilian population. According to
multiple studies performed by the National Institute of Health,
Department of Veterans Affairs (VA) and Department of Defense (DoD),
upwards of 43 percent of veterans who served in OIF/OEF/OND will have
experienced traumatic events causing Post Traumatic Stress Disorder
(PTSD) or other psychological disorders such as depression. Left
untreated, these invisible wounds can have a devastating impact on the
lives of those veterans and servicemembers who suffer in silence.
As the suicide numbers show and as the prevalence of these
invisible injuries demonstrate, our country must start better
addressing the psychological wounds of war. Up to this point, VA and
DoD have taken a very reactionary approach to addressing the
psychological wounds of war. IAVA believes that it is time to start
addressing these wounds in a proactive way. While our country has made
significant strides in improving the care for veterans, there is still
a long way to go.
There are two main approaches to providing treatment for the
psychological wounds of war and the prevention of suicide. The first
approach is treating psychological wounds and suicide as a public
health issue and approaching it as any other public health issues, such
as an influenza outbreak or HIV. This approach requires public outreach
educating all sectors of the public, involving the public in solutions
to the problem and ensuring that services are widely available
throughout the community. The second approach is the clinical, or
medical, approach. This approach focuses on intensive clinical care,
prescribing medications and regular appointments with psychiatrists and
psychologists. Unfortunately though, we often focus on one rather than
the other. Together, both approaches provide the best quality of care
and successful outcomes. The public health approach helps veterans and
servicemembers understand the resources that are available to them and
how to easily access the care they may need. The clinical approach
ensures they receive proper treatment once there. If we are to
successfully address the mental health care shortfalls and prevent
suicide in our nation, it will require both approaches.
The partnering of the two approaches is also particularly
important, because suicide is a tragic conclusion of the failure to
address the spectrum of challenges returning veterans face. These
challenges are not just mental health injuries; they include finding
employment, reintegrating to family and community life, dealing with
health care and benefits bureaucracy and many others. Fighting suicide
is not just about preventing the act of suicide, it is about providing
a ``soft and productive landing'' for our veterans when they return
home. The bottom line is we must treat and offer resources to the
entire veteran, including their community and families, and move away
from treating individual symptoms, as if they are somehow mutually
exclusive of one another.
Stigma is a significant barrier to veterans and servicemembers
seeking mental health care. Unfortunately, even though there has been
an effort to remove the stigma associated with psychological wounds in
recent years by VA and DoD leadership, their message has failed to
reach all ranks of servicemembers and the entire veteran population.
Despite these efforts, the stigma still seems to be ever so present,
and seeking mental health care is often viewed as a sign of weakness or
lack of resiliency among those who have been trained to be strong and
fearless.
Multiple studies confirm that veterans and servicemembers are
concerned about how seeking care could impact their careers, both in
and out of the military. Concerns include the effect on their ability
to get security clearances and how co-workers and supervisors would
perceive them. It is critical that we continue to work to reduce this
stigma. We must step up our efforts in removing stigmas and immediately
develop and implement newer, more confidential ways of offering
assistance to those who need it most if we wish to end the cycle of
preventable suicides plaguing today's veteran and military communities.
To combat the stigma, IAVA recommends that VA and DoD partner with
experts in the private and nonprofit sector to develop a robust and
aggressive outreach campaign. This campaign should focus on directing
veterans to services such as Vet Centers, as well as local community
and state based services. It should be integrated into local campaigns
such as San Francisco's veterans 311 campaign. This campaign should be
well-funded and reflect the best practices and expertise of experts in
both the mental health and advertising fields. For our part, IAVA has
partnered with the Ad Council to launch a public service awareness
campaign that is focused on the mental health and invisible injuries
facing veterans of Iraq and Afghanistan. Part of this campaign focuses
on reducing the stigma of seeking mental health care. This is only one
example of the multiple programs and resources IAVA has established to
help combat the stigma associated with seeking care for invisible
wounds.
Community partnerships will play a key role in providing quality
mental health care to veterans throughout the country. Nationwide, we
have private sector and non-profit organizations that are already
providing mental health care and resources to the members of their
individual communities. These organizations are easily accessible and
have staff who are trained to address most of the unique and common
mental health needs within their communities. Establishing partnerships
with those organizations will ensure that veterans, servicemembers and
their families receive quality care in their communities, regardless if
they start seeking care at their local VA or with one of these
providers.
Another critical aspect to preventing suicide, and where VA is
still falling short, is ensuring timely access to care and having
properly trained staff at every VA facility. This is often the
difference between life and death for many veterans. According to VHA's
Strategic Plan, VHA requires suicide prevention training for all VHA
staff who interact with veterans, plus additional training for health
care providers. However, while this may be a policy, IAVA has doubts as
to whether or not it is actually be enforced at every VA facility. The
importance and need in ensuring timely care and proper training of all
staff is clearly illustrated by the experience of Army veteran Jacob
Manning in early 2012. Here is Jacob's story, as told in part by Leo
Shane of Stars and Stripes:
Jacob Manning waited until his wife and teenage son had left the
house, then walked into his garage to kill himself. The former soldier
had been distraught for weeks, frustrated by family problems,
unemployment and his lingering service injuries. He was long ago
diagnosed with traumatic brain injury, caused by a military training
accident, and post-traumatic stress disorder stemming from the
aftermath. He had battled depression before, but never an episode this
bad.
He tossed one end of an extension cord over the rafters above and
then fashioned a noose. The cord snapped. It couldn't handle his
weight.
He called Christina Roof, a friend and national veterans policy
adviser who helped him years before, and rambled about trying again
with a bigger cord or a gun. She urged him to calm down sand tried to
get him to call the veterans crisis line. Ms. Roof sent a message to
Manning's wife, Charity, telling her to rush home. The two of them
tried for more than a day to persuade him to get professional help. Ms.
Roof eventually got Manning to agree to call the veterans hospital in
Columbia, Mo., near his home, after telling him that he had two
choices: ``Either call VA or I have no choice but to call the police,''
Roof said.
When a VA staffer at the mental health clinic answered the phone,
Manning explained what he had done, and asked if he could be taken into
care. The VA staffer asked if Manning was still suicidal. He wavered,
saying he wasn't trying to kill himself right then. The hospital
employee told him the office was closing in an hour, and asked if
Manning could wait until the next day to deal with the problem. Ms.
Roof told Manning she didn't care what this VA staffer told him and
that she was sending a car within the hour to pick him up and bring him
to the VA Medical Center. She told him to pack a bag.
Mr. Manning made it safely to the emergency room and was checked in
upon his arrival. Nevertheless, this one experience raises so many
other questions as to what other problems veterans in crisis are
experiencing when they reach out for help.
Sadly, Manning's story is all too familiar. In April 2012, VA's
Office of the Inspector General (OIG) found VA officials had been
inflating the success rates for providing timely mental health services
to veterans. VA had repeatedly reported to Congress that 95 percent of
new patients seeking mental health treatment received full evaluations
for care within the department's required window of 14 days. However,
VA OIG found that just 49 percent were seen within that period, and the
average wait time for most veterans seeking any type of mental health
care was over 50 days. IAVA strongly believes that VA must be ready and
equipped with the proper care models, policies and personnel to address
the huge influx of veterans they will care for in the coming years.
According to the American Psychological Association, there are
``significant barriers to receiving mental health care in the
Department of Defense (DOD) and Veterans Affairs (VA) system.'' Mental
health professionals are often unavailable to servicemembers,
especially those in theatre, and to veterans, particularly those in
rural areas. Even veterans in urban areas encounter lengthy wait times
when seeking mental health care.
VA must ensure that every employee is trained to respond to a
veteran in crisis. VA employees across the administration interact with
veterans, and each employee must be aware of the signs of a veteran in
crisis and be aware of all of the resources available to support a
veteran in crisis. All VA employees must also be trained to provide
quality customer service to every veteran they encounter. For a
veteran, like Mr. Manning, to have the strength and resilience to
actually seek help, only to be met by a dismissive attitude at the one
place he should always be able to count on, is in itself a tragedy.
IAVA has to wonder, and so too should our nation, how many other
veterans in crisis are being turned away and how many other veterans
have not received the care they needed due to an encounter with an
untrained VA staff member?
Additionally, IAVA has real concerns as to how many veterans have
we may have lost due to inadequate training and procedures within the
VA mental health care system? For a veteran, like Mr. Manning, to have
the strength and resilience to actually seek help, only to be met with
a dismissive attitude by a staff member at the one place he should
always be able to turn to is a tragedy. IAVA believes it is critical
for VA to ensure that all of their staff be properly trained to respond
to a veteran in crisis and that every veteran in crisis has immediate
access to emergency mental health services.
Specifically within VA, there needs to be numerous changes and
corrections in the policies and procedures within the Veterans Health
Administration (VHA) and the Veterans benefit Administration (VBA). In
an effort to address VA's and DoD's issues, on August 31, 2012,
President Obama signed an Executive Order (EO) entitled ``Improving
Access to Mental Health Services for Veterans, Service Members, and
Military Families.'' While IAVA applauds the President's actions and
believes that it was a good first step to implementing solid solutions
that stand to make a significant difference in the mental health care
available to veterans across the country, we believe the real test will
be its impact within the veteran and military communities. However,
IAVA also notes that the Executive Order's success will also be
determined by how effectively and timely it is implemented. As of this
hearing, there are lingering questions on the status of the
implementation of several key parts of the Executive Order.
For example, the August 2012 Executive Order includes some previous
VA initiatives, notably the expansion of mental health care providers
and their plan to hire 1,600 new mental health clinicians and 300
mental health support staff. While this is definitely a step in the
right direction, IAVA has serious concerns about VA's ability to meet
this mandate given the problems they have encountered in the past, both
in finding and keeping qualified mental health care providers.
Moreover, IAVA respectfully asks for clarification on VA's recent press
release stating they have hired an additional 1,000 mental health care
providers. IAVA respectfully asks if these new employees were put
through an expedited hiring process given the quickness of their
hiring? Further, we respectfully ask if these 1,000 new mental health
providers were hired to fill the current mental health care provider
vacancies VA has had many years filling or if these 1,000 new providers
are intended to be a part of the 1,600 new providers mandated by the
Executive Order?
The Executive Order also requires the VA and DoD to establish a
national suicide prevention campaign. The order reads, that ``No later
than September 1, 2012, the Departments of Defense and Veterans Affairs
shall jointly develop and implement a 12 month national suicide
prevention campaign, focused on connecting veterans and service members
to mental health services.'' However, IAVA has been left to wonder as
to whether or not this deadline was met. By all accounts, we have yet
to see any solid evidence that this campaign was rolled out.
Another part of the Executive Order that has had a deadline pass,
states: ``By December 31, 2012, the Department of Veterans Affairs, in
continued collaboration with the Department of Health and Human
Services, shall expand the capacity of the Veterans Crisis Line by 50
percent to ensure that veterans have timely access, including by
telephone, text, or online chat, to qualified, caring responders who
can help address immediate crises and direct veterans to appropriate
care. Further, the Department of Veterans Affairs shall ensure that any
veteran identifying him or herself as being in crisis connects with a
mental health professional or trained mental health worker within 24
hours. The Department of Veterans Affairs also shall expand the number
of mental health professionals who are available to see veterans beyond
traditional business hours.'' IAVA has yet to receive a response from
VA as to whether or not this goal was met. We look to this committee to
ensure that this part of the Executive Order was met, and if it was
not, we are also interested to learn about what plans are in place to
ensure its completion.
These lingering questions underscore the critical importance of
strong Congressional oversight of the implementation of this Executive
Order. This committee has the authority to ensure VA, DoD and the other
agencies tasked with improving mental health care for our veterans and
military communities are held accountable to doing so. IAVA cannot
stress enough the importance of strict Congressional oversight in
ensuring all programs and policies mandated by the 2012 mental health
executive order are fully developed, implemented, and that all of the
agencies involved are held accountable to meeting the mandated time
lines.
For our part, IAVA will continue to be a critical partner in
holding VA and DoD accountable for the goals outlined in the Executive
Order, but we look to the members of the 113th Congress to stand up for
our veterans, servicemembers and their families through real actions in
bringing about change to the health care services, resources and
benefits they depend on.
Finally, given the wide array of issues the Committee requested we
address in this testimony IAVA makes the following recommendations on
ways we can improve the mental health care system:
1. VA and DoD must immediately establish a new employee education
and mentoring program to overcome the practical problems new staff and
longtime staff have in establishing and implementing new programs and
policies related to mental health care, especially when they are
unfamiliar with VA or federal procedures. We believe the current
policies and procedures being used have proved ineffective in the
establishment of uniformed mental health care.
2. Involve the families in a veterans or servicemembers mental
health care plan. Despite progress, the current level of effort and
provision of services remains inadequate in making treatment planning a
true partnership between the veteran, family members, and provider.
3. Establish national partnerships to roll out a nationwide
education and public service announcement campaign focusing on reducing
the stigmas attached to seeking mental health care and addressing the
psychological wounds of war. All wounds sustained in war are equally
important and need treatment, be they visible or invisible. We need to
ensure this is done through clear and concise messaging. For example,
if you had a physical injury, you would certainly seek medical care to
address it. So why would you hesitate to do the same with a
physiological injury?
4. Integrate mental health care screenings and resources into all
aspects of a veterans and servicemember's primary health care.
5. Implement uniformed evidence-based care in all VHA facilities
and CBOCs. Veterans should have equal access to high quality mental
health care regardless of where they live.
6. Conduct a thorough review of VHA Handbook 1160.01, to ensure
every VA facility is in compliance. This includes ensuring that every
VA facility has a trained mental health care provider on staff at all
times or is readily available to care for a veteran in crisis via a
page or phone call.
7. Provide easily accessible mental health care or support programs
for family members who have a loved one undergoing mental health care
or treatment.
8. Increase awareness efforts at the local level to educate all
members of the community on the signs associated with suicidal
behaviors or tendencies.
9. Conduct robust public outreach campaigns to educate the general
public or the realities of the invisible wounds of war by removing all
of the misinformation and myths the general public has been exposed to
through inaccurate media portrayals' of veterans.
10. Expand the peer-to-peer counseling program and immediately
train more veterans to be peer support counselors.
11. Expand upon VA's Community Toolkit Provider program by further
developing and actively promoting a nationally recognized certification
program which would train mental health professionals in military
culture and the unique challenges faced by service members, veterans
and their families. This should include best practices in providing
care to this community and the nuances of military culture.
12. Integrate robust mental health awareness and suicide prevention
training into DoD's enlisted education system, as well as VA's current
employee continuing education system.
In closing, caring for the men and women who defend our freedom is
a solemn responsibility that belongs to lawmakers, business leaders,
and every citizen alike. Despite numerous successes, veterans' and
servicemembers' mental health programs and care options are still not
where they should be. We must remain ever vigilant and continue to show
the men and women who volunteer to serve their country that we have
their backs, through swift actions in correcting the gaps and
shortfalls in mental health care. IAVA looks forward to working closely
with this committee, VA, DoD and communities across our nation in a
combined effort to finally close the gaps in our mental health care
system. IAVA will also continue to work tirelessly to ensure that no
veteran, servicemember or their family ever have to suffer in silence
while carrying the burdens of our nation's 11 years of war.
National Guard Association of the United States (NGAUS)
Thank you for all you have done for our veterans since 9/11 and for
this opportunity to present this statement for the record.
Background - Unique Citizen Service Member/Veteran
The National Guard is unique among components of the Department of
Defense (DoD) in that it has the dual state and federal missions. While
serving operationally on Title 10 active duty status in Operation Iraqi
Freedom (OIF) or Operation Enduring Freedom (OEF), National Guard units
are under the command and control of the President. However, upon
release from active duty, members of the National Guard return as
veterans to the far reaches of their states, where most continuing to
serve in over 3,000 armories across the country under the command and
control of their governors. As a special branch of the Selected
Reserves they train not just for their federal missions, but for their
potential state active duty missions such as fire fighting, flood
control, and providing assistance to civil authorities in a variety of
possible disaster scenarios.
Since 9/11, nearly a half a million National Guard members have
deployed in contingency operations to gain veteran status. When they
return from deployment, they are not located within the closed
structure of a 24/7 supported active military installation, but rather
reside in their home town communities where they rely heavily on the
medical support of the Veterans Administration (VA) when they can
overcome time and distance barriers to obtain it.
Using the National Guard as an operational force will require a
more accessible mental health program for members and their families
post-deployment in order both to provide the care they deserve as
veterans and to maintain the necessary medical readiness required by
deployment cycles. It cannot be a simple post-deployment send off by
the active military of ``Good job. See you in five years.'' To create a
seamless medical transition from active duty to the VA, an improved
medical screening of our members before they are released from active
duty is essential to identify the medical issues that will be passed to
the VA. The Department of Defense must also recognize its
responsibility of sharing the burden with the VA in funding mental
health care for our National Guard members between deployments, which
remains an unmet readiness need.
The Department of Defense must also be called to task for the
mishandling and disappearance of National Guard medical records in the
OIF/OEF theaters and the shoddy administration of Guard and Reserve
demobilization. Statistics published last year by the VA show that the
VA denies National Guard and Reserve disability benefit compensation
claims at four times the rate of those filed by active duty veterans.
Lacking clear records to establish the service connection for their
injuries, our Guard members face failure when they later file their VA
disability claims for undocumented physical and behavioral injuries.
This is a blot on the integrity of our federal government in its
treatment of our veterans. This Committee must seriously and separately
in another hearing consider legislation to establish a presumption of
service connection for certain war common injuries of National Guard
and Reserve veterans who later file disability benefit compensation
claims based upon those injuries.
Military service in the National Guard is uniquely community based.
The culture of the National Guard remains little understood outside of
its own circles. When the Department of Defense testifies before
Congress stating its programmatic needs, it will likely recognize the
indispensable role of the more cost efficient National Guard as a vital
operational force, but it will say little about, and seek less to,
redress the benefit disparities, training challenges, and unmet medical
readiness issues for National Guard members and their families at the
state level before, during, and after deployment. We continue to ask
Congress to give the Guard a fresh look with the best interests of the
National Guard members, their families, and the defense of the homeland
in mind.
FULLY LEVERAGE THE VET CENTER MODEL
For behavioral support, Guard veterans often look to the stellar
Vet Centers located throughout the country where they and their
families can obtain confidential peer to peer counseling as well as
behavioral treatment from on site clinicians; telehealth programs; or
from referrals to fee based clinicians paid for and pre approved by the
Vet Centers.
Confidentiality is vital in bringing our veterans still serving in
the Guard to treatment in order to assuage real concerns about the
sharing of medical records with the Department of Defense which VA
Medical Centers are authorized to do. The fee basing of referred care
by the Vet Center to community providers establishes a model for this
Committee to consider expanding to close the treatment gaps in our
rural communities. A voucher program administered by the Vet Centers
authorizing paid for treatment to qualified community providers would
maximize scheduling flexibility and plug direct access gaps to care for
our Guard veterans.
IMPLEMENT A VOUCHER PROGRAM FOR VETERAN COMMUNITY BASED MENTAL HEALTH
CARE
The issues of veterans' unemployment and mental health maintenance
cannot be separated. Before veterans can maintain gainful employment in
a challenging job environment, they must be able to maintain a healthy
mental status and establish supportive social networks.
In 2007, the Rand Corporation published a study titled, ``The
Invisible wounds of War.'' It found that at the time 300,000 veterans
of Operation Iraqi Freedom and Operation enduring Freedom suffered from
either PTSD or major depression. This number can only have grown after
five more years of war. The harmful effects of these untreated
invisible wounds on our veterans hinder their ability to reintegrate
with their families and communities, work productively, and to live
independently and peacefully.
Rand recommended that a network of local, state, and federal
resources centered at the community level be available to deliver
evidence-based care to veterans whenever and wherever they are located.
Veterans must have the ability to utilize trained and certified
services in their communities. In addition to training providers, the
VA must educate veterans and their families on how to recognize the
signs of behavioral illness and how and where to obtain treatment.
VA and Vet Center facilities are often located hundreds of miles
from our National Guard veterans living in rural areas. Requiring a
veteran, once employed, to drive hundreds of miles to obtain care at a
VA facility necessitates the veteran taking time off from work for
reasons likely difficult to explain to an employer. Most employees can
ill afford to miss work, particularly after an extended absence from
deployment in the case of our Guard veterans. The VA needs to leverage
community resources to proactively engage veterans in caring for their
mental health needs in a confidential and convenient manner that does
not require long distance travel or delayed appointments.
To facilitate the leveraging of mental health care providers in our
communities, the VA through its Office of Mental Health Services or
through its highly effective Vet Centers can actively exercise its
authority to contract with private entities in local communities, or
creatively implement a voucher program that would allow our veterans to
seek fee-based treatment locally with certified providers outside the
brick and mortar of the Veterans Administration facilities and even the
Vet Centers.
The Vet Center in Spokane for example serves an area as big as the
state of Pennsylvania. It is not practical for veterans in this
catchment area to drive hundreds of miles to seek counseling or
behavioral clinical care. That Vet Center pre screens fee based
providers to whom it will refer veterans for confidential treatment in
its management area. It also monitors the process to make sure the
veteran is actually receiving care paid for by the Vet Center. This
system already works. However, a voucher process would improve
efficiencies by relieving the Vet Center of its scheduling burden by
allowing the veteran to directly make his or her own appointment with
providers as needed.
The VA and Vet Centers also need to fully leverage existing state
administrative mental health and veteran networks. Working with the
state mental health care provider licensing authorities, community
providers certified by the VA or Vet Center to treat veterans could be
identified at the state agency level with vouchers to pay for treatment
by those providers administered by the state department of veterans
affairs who likely may have an even greater list of veterans in the
state than the VA or Vet Center.
Several of our veterans have fallen through the cracks of the VA
health care system, and will continue to do so. According to the
Vietnam Veterans of America, last year only 30% of our veteran
population had enrolled in VA medical programs. Many veterans end up in
the care of state social service programs in cooperation with state and
national veteran organizations. The VA has the authority to assist in
maintaining this safety net of care for veterans in a stressful
economic climate for our states with a voucher program or expanded
contracting with private entities. It needs to act.
HIPPA CONFIDENTIALITY MUST BE OBSERVED WITH MENTAL HEALTH CARE
Most of our National Guard veterans of OIF/OEF eligible for VA care
post-deployment are still serving with their units and subject to
redeployment. Given the evolving electronic medical records
interoperability between the VA and the Department of Defense (DoD), a
confidentiality issue exists relative to mental health treatment
records for these veterans who remain in the military who do not want
their records shared by the VA with their military commanders for fear
of career reprisals.
It is essential that HIPPA confidentiality be maintained by the VA
for the mental health treatment records of these veterans to encourage
their treatment with VA providers. Our Vet Centers already operate with
full confidentiality which makes them the service center of choice for
Guard members who want to maintain confidentiality of their mental
health counseling records relative to protect against perceived
negative repercussions in their units. HIPPA rules observe
confidentiality but draw the line with patients who are dangers to
themselves or their communities whose cases must be reported. Prevent.
It is critical that confidentiality this be established as soon as
possible legislatively with the VA much the same as it is currently
observed in Vet Centers. We believe that the VA is operating under
advice from its legal staff that all VA medical records can be
transferred to DoD. Lack of confidentiality will chill the treatment
process and is likely contributed to the under utilization of VA
medical care by our veterans.
REQUIRE THE VA TO FULLY IMPLEMENT SECTION 304 OF THE CAREGIVERS AND
VETERANS OMNIBUS HEALTH SERVICES ACT 0F 2009, PUBLIC LAW 111-
163, TO PROVIDE MENTAL HEALTH SERVICES TO VETERAN AND
THEIIMMEDIATE FAMILY MEMBERS OF OIF/OEF VETERANS USING PRIVATE
ENTITIES
Post-deployment, our National Guard members and their families
heavily rely on the VA for mental health care. Congress recognized as
much in passing The Caregivers and Veterans Omnibus Health Services Act
of 2009, Public Law 111-163, enacted May 6, 2010, now requires the VA
to reach out not just to veterans but to their immediate families as
well to assist in the reintegration process.
The law also authorized the VA Secretary the Secretary to contract
with community mental health centers and other qualified entities to
provide the subject services only in areas the Secretary determines are
not adequately served by other health care facilities or vet centers of
the Department of Veterans Affairs. It is not clear how thoroughly the
VA has fully taken advantage of this authority to contract with private
entities to deliver community based mental health services.
Section 304 of the Family Caregiver Act (reproduced in the
Appendix) required the VA to make full mental health services available
also to the immediate family members of OIF/OEF veteran for three years
post-deployment. However, the VA delayed for at least two years in
making the full range of its Office of Mental Health Services (OMHS)
programs available to immediate to families as required by Section 304.
It is not clear today that the program has been fully implemented.
Section 304 was enacted on May 6, 2010. For many, the three year
post-deployment period will begin to lapse in 2013. The VA OMHS needed
to fully comply with Section 304 in a timely manner. Because the VA's
unreasonably delayed implementation of this important program, this
Committee needs to consider extending the subject three year post
deployment limitation period another three years to allow family
members to access their care.
It also needs to lean harder on the VA to fully utilize its
contracting to better leverage private entities and to use a voucher
system described above to make community based treatment more
accessible and convenient. Our veterans and their immediate families
may be a small subset, but they are worth it.
THE DEPARTMENT OF DEFENSE MUST COOPERATIVELY WORK WITH THE VA IN
SCREENING BEHAVIORAL HEALTH CARE NEEDS OF OUR MEMBERS BEFORE
THEY ARE RELEASED FROM ACTIVE DUTY
At all stages of PTSD and depression, treatment is time sensitive.
However, this is particularly important after onset, as the illness
could persist for a lifetime if not promptly and adequately treated,
and could render the member permanently disabled. The effects of this
permanent disability on the member's entire family can be devastating.
It is absolutely imperative that members returning from deployment be
screened with full confidentiality at the home station while still on
active duty by trained and qualified mental health care providers from
VA staff and/or qualified health care providers from the civilian
community. These providers could include primary care physicians,
physician assistants, and nurse practitioners who have training in
assessing psychological health presentations. Prompt diagnosis and
treatment will help to mitigate the lasting effects of mental illness.
This examination process must be managed by the VA in coordination with
the National Guard Director of Psychological Health for the respective
state, and the state's Department of Mental Health to allow transition
for follow up treatment by the full VA and civilian network of
providers within the state.
As an American Legion staffer at Walter Reed once stated, the main
problem for Reserve Component injured service members is that they are
``rushed out of the system'' before their service connected injuries
and disability claims have been resolved. Our injured members should
not be given the ``bum's rush'' and released from active duty until a
copy of their complete military medical file, including any field
treatment notes, has been transferred to the VA, their discoverable
service connected military medical issues have been identified, any
service connected VA disability physicals have been performed similar
to what is provided to the active forces before they are released from
active duty, and the initial determination of any service connected VA
disability claim has been rendered. Unless medically not feasible, our
members should be retained on active duty in their home state for
treatment to discourage them from reporting injures out of fear of
being retained at a distant demobilization site.
It is absolutely necessary to allow home station screening for all
returning members by trained health care professionals who can screen,
observe, and ask relevant questions with the skill necessary to elicit
medical issues either unknown to the self-reporting member, or
unreported for fear of being retained at a far removed demobilization
site. In performing their due diligence before the issuance of an
insurance policy, insurance companies do not allow individuals to self
assess their health. Neither should the military. If geographical
separation from families is causing some to underreport, or not report,
physical or psychological combat injuries on the PDHA, then continuing
this process at the home station for those in need would likely produce
a better yield at a critical time when this information needs to be
captured in order for prompt and effective treatment to be
administered.
Please see the copy of a November 5, 2008 electronic message to
NGAUS from Dr. Dana Headapohl set forth in the Appendix that still
pertains. Dr. Headapohl strongly recommended a surveillance program for
our members before they are released from active duty. Dr. Headapohl
opines the obvious in stating that inadequate medical screening of our
members before they are released from active duty is ``unacceptable to
a group that has been asked to sacrifice for our country.'' (emphasis
added)
Conclusion
Thank you for that you have done for our veterans since 9/11.
Please view our efforts as part of a customer feedback process to
refine and improve the ongoing vital and enormous undertaking of the
VA. Our National Guard veterans, both still serving and separated, will
remain one of your largest base of customers who will continue to
require your attention. Thank you for this opportunity to testify.
E-mail from Dana Headapohl, MD, to NGAUS
Colonel Duffy - I am sending links to articles about the importance
of providing medical surveillance examinations for workers in jobs with
specific hazardous exposures. I believe this approach could be modified
to evaluate National Guard members returning from Iraq and Afghanistan
for PTSD, TBIs and depression.
The OSHA medical surveillance model includes the following basic
elements:
1. Identification of potential hazardous exposures (chemical,
physical, biologic).
2. Screening workers for appropriateness of placement into a
specific work environment with such exposures. For example, individuals
with compromised liver functions should not be placed in environments
with unprotected exposures to hepatotoxins.
3. Monitoring workers after unprotected exposure incidents.
Examples- monitoring pulmonary function in a worker exposed to a
chlorine gas spill, or following hepatitis and HIV markers in a nurse
after a needle stick injury.
4. Conducting exit examinations at the end of an assignment with
hazardous exposures, to ensure that workers have not suffered adverse
health effects from those exposures.
(including concussive explosions or other traumatic events).
Surveillance exams of all types (OSHA mandated surveillance
programs, population health screening for chronic disease risk factors)
have been a part of my practice of Occupational and Preventive Medicine
in Montana for the past 22 years. Early diagnosis and treatment is
especially essential for potential medical problems facing military
members serving in Iraq and Afghanistan - post traumatic stress
disorder (PTSD), traumatic brain injury (TBI) and depression. Timely
diagnosis and aggressive treatment is essential especially for these
problems, to maximize treatment success and functioning and to mitigate
suffering.
There are a number of organizations that design and implement
medical surveillance programs. There is no reason the same approach
could not be applied to the specific exposures and potential medical
problems facing National Guard troops in Iraq and Afghanistan. With
proper program design and local provider training, this program would
not need to be costly. In my clinical experience, male patients
especially are more likely to report symptoms of PTSD, TBI, or
depression in the context of an examination rather than questionnaire.
Findings can present subtly, but if untreated can have devastating
effects on the individual, family and work place.
In my practice, I have seen a number of Vietnam veterans, and more
recently National Guard members who have returned from deployment in
Iraq or Afghanistan, who have been inadequately screened and/or are
suffering unnecessarily because of geographical barriers to adequate
treatment. This is unacceptable treatment of group that has been asked
to sacrifice for our country. They deserve better.
I applaud your organization's efforts to lobby for better post
deployment screening and treatment of the National Guard members
returning from Iraq and Afghanistan.
Dana Headapohl MD
http://www.aafp.org/afp/20000501/2785.html
https://www.desc.dla.mil/DCM/Files/QSRHealth%20Medical%20Exam--
1.pdf This is about military surveillance exams.
http://www.lohp.org/graphics/pdf/hw24en06.pdf
http://www.cdc.gov/niosh/sbw/management/wald.html
http://www.ushealthworks.com/Page.aspx?Name=Services--MedSur
National Military Family Association
The National Military Family Association is the leading nonprofit
organization committed to strengthening and protecting military
families. Our over 40 years of accomplishments have made us a trusted
resource for families and the Nation's leaders. We have been at the
vanguard of promoting an appropriate quality of life for active duty,
National Guard, Reserve, retired service members, their families and
survivors from the seven uniformed services: Army, Navy, Air Force,
Marine Corps, Coast Guard, and the Commissioned Corps of the Public
Health Service and the National Oceanic and Atmospheric Administration.
Association Volunteers in military communities worldwide provide a
direct link between military families and the Association staff in the
Nation's capital. These volunteers are our ``eyes and ears,'' bringing
shared local concerns to national attention.
The Association does not have or receive federal grants or
contracts.
Our website is: www.MilitaryFamily.org.
Chairman Jeff Miller, Ranking Member Michael Michaud, and
Distinguished Members of the Veterans' Affairs Committee, the National
Military Family Association thanks you for the opportunity to submit
testimony for the record on ``Honoring the Commitment: Overcoming
Barriers to Quality Mental Health Care for Veterans.'' After 11 years
of war, we continue to see the impact of repeated deployments and
separations on our service members, veterans, and their families. We
appreciate your recognition of the service and sacrifice of these
families, as well as the unique mental health challenges facing them.
Our Association will take the opportunity to discuss the mental health
challenges and needs of our veterans and their families.
Behavioral Health Care
Our Nation must help veterans, transitioning service members,
National Guard and Reserve members, and their families cope with the
aftermath of over a decade of war. Frequent and lengthy deployments
have created a sharp need in behavioral health services. The Department
of Veterans Affairs (VA), Department of Defense (DoD), and State
agencies must partner in order to address behavioral health issues
early in the process and provide transitional mental health programs,
especially when leaving active duty and entering veteran status
(voluntary or involuntary). Partnering will also capture the National
Guard and Reserve member population and their families, who often
straddle these agencies' health care systems.
There are barriers to access for some in our population. Many
already live in rural areas, such as our National Guard and Reserve
members, or they will choose to relocate to rural areas lacking
available mental health providers. We need to address the distance
issues families face in finding mental health resources and obtaining
appropriate care. Isolated service members, National Guard and Reserve
members, veterans, and their families do not have the benefit of the
safety net of services and programs provided by the VA facilities,
Community-Based Outpatient Centers, and Vet Centers, or DoD's network
of care.
The VA should examine DoD's alternative methods of mental health
services as possible solutions to their access issues. DoD discovered
embedding mental health providers in medical home modeled clinics
allows for easier access for mental health services. DoD has created a
flexible pool of mental health providers that can increase or decrease
rapidly in numbers depending on demand on the Military Health System
side. Currently, Military Family Life Consultants and Military
OneSource non-medical counseling are providing this type of
preventative and entry-level service. DoD has been offering another
vehicle for service members, National Guard and Reserve members, and
their families through a web-based (Skype) medical and non-medical
mental health counseling. This works extremely well especially for
those who live far from counselors. Veterans and their families need
this flexibility of support.
The VA, along with the DoD, should examine the possibility of
adopting the United Kingdom's model of community involvement in
providing mental health services and programs to their military,
veterans, and their families. This model of care identifies local
resources and creates buy-in by the community to help their own. The
model creates a direct reporting line from the community to Parliament
and back to the community.
Families Impacted from Stresses of War
In the research they conducted for us, RAND found military children
reported higher anxiety signs and symptoms than their civilian
counterparts. A study by Gorman, et. al (2010), Wartime Military
Deployment and Increased Pediatric Mental and Behavioral Health
Complaints, found an 11 percent increase in outpatient mental health
and behavioral health visits for children from the ages of 3-8 during
2006-2007. Researchers found an 18 percent increase in pediatric
behavioral health visits and a 19 percent increase in stress disorders
when a parent was deployed. Additional research has found an increase
in mental health services by non-deployed spouses during deployment. A
study of TRICARE claims data from 2003-2006 published last year by the
New England Journal of Medicine showed an increase in mental health
diagnoses among Army spouses, especially for those whose service
members had deployed for more than one year. The VA needs to be aware
of the mental health needs of veterans' children when allowing access
to service and implementing support programs.
Our Association's research also found the mental health of the
caregiver directly affects the overall well-being of the children.
Therefore, we need to treat the family as a unit as well as
individuals. Communication is key in maintaining family unit balance.
Our study also found a direct correlation between decreased
communication and an increase in child and/or caregiver issues during
deployment. Research is beginning to validate the high level of stress
and mental strain our military families are experiencing. This stress
is carried over with them when they enter veteran status. The answer is
making sure our families have access to behavioral health providers
with the VA's system of care, as well.
Successful reintegration programs will require strong partnership
at all levels between the various mental health arms of the VA, DoD,
and State agencies. Opportunities for the entire family and for the
couple to reconnect and bond again must also be provided. Our
Association has recognized this need and established family retreats
under our Operation Purple program in the National Parks,
promoting families the opportunity to reintegrate and readjust
following the stresses of war and deployment. The VA should provide
similar types of venues for veterans and families to reintegrate.
Wounded Veterans have Wounded Families
Our Association asserts that behind every wounded service member
and veteran is a wounded family. It is our belief the government,
especially DoD and VA, must take a more inclusive view of military and
veterans' families. Those who have the responsibility to care for the
wounded, ill, or injured service member or veteran must also consider
the needs of the spouse, children, parents of single service members/
veterans, and their siblings, and their caregivers. The VA and DoD need
to think proactively as a team and one system, rather than separately,
and address problems and implementing initiatives upstream while the
service member and their family is still on active duty status.
Reintegration programs become a key ingredient in the wounded
service members, veterans, and their family's success. For the past
three years, we have held our Operation Purple Healing
Adventures camp to help wounded, ill, or injured service members and
their families learn to play again as a family. We hear from the
families who participate in this camp that many issues still create
difficulties for them well into the recovery period. Families find
themselves having to redefine their roles following the injury of the
service member. They must learn how to parent and become a spouse/lover
with an injury/illness. Each member needs to understand the unique
aspects the injury/illness brings to the family unit. Parenting from a
wheelchair brings a whole new challenge, especially when dealing with
teenagers. Parents need opportunities to get together with other
parents who are in similar situations and share their experiences and
successful coping methods. Our Association believes everyone must focus
on treating the whole family, with VA and DoD offering mental health
counseling and skill based training programs for coping, intervention,
resiliency, and overcoming adversities. Injury interrupts the normal
cycle of the reintegration process causing readjustment issues. The VA,
DoD, and non-governmental organizations must provide opportunities for
the entire family and for the couple to reconnect and bond, especially
during the rehabilitation and recovery phases.
The VA and DoD must do more to work together both during the
treatment phase and the wounded service member's transition to ease the
family's burden. They must continue to break down regulatory barriers
to care and expand support when appropriate through the Vet Centers,
the VA medical centers, and the community-based outpatient clinics
(CBOCs), along with DoD's system of care. We recommend the VA allow
veteran families access to mental health services throughout the VA's
entire network of care. Before expanding support services to families,
however, VA facilities must establish a holistic, family-centered
approach to care when providing mental health counseling and programs
to the wounded, ill, or injured service member or veteran. Family
members are a key component to a veteran's psychological well-being.
They must be included in mental health counseling and treatment
programs for veterans.
Caregivers of the Wounded
Caregivers need to be recognized for the important role they play
in the care of their loved one. Without them, the quality of life of
the wounded service members and veterans, such as physical, psycho-
social, and mental health, would be significantly compromised. They are
viewed as an invaluable resource to VA and DoD health care providers
because they tend to the needs of the service members and the veterans
on a regular basis. Their daily involvement saves VA, DoD, and State
agency health care dollars in the long run. However, their long-term
psychological care needs must be addressed. Caregivers of the severely
wounded, ill, or injured service members, who are now veterans, have a
long road ahead of them. In order to perform their job well, they will
require access to robust network of mental health services.
We have observed from our own Healing Adventure Camps the lack of
support and assistance to the spouse/caregiver of our wounded, ill, or
injured. Many feel frustrated with not being considered part of the
care team and not included in long-term care decisions. The level of
frustration displayed by the spouses/caregivers at our recent Healing
Adventure Camp at Ft. Campbell about lack of information and support
was disturbing. Even the Congressionally mandated Recovering Warrior
Task Force (RWTF) discovered the same level of frustration during their
site visit to Ft. Carson and raised their concerns to the Military
Treatment Facility (MTF) and Warrior Transition Unit (WTU) Commanders.
The VA and DoD need to make sure the spouse/caregiver and the family
are also cared for and provided them the support they need to perform
their role as a caregiver and provide them with the tools to care for
themselves as well. The VA and DoD need to establish spouse/caregiver
support groups and mentoring opportunities. Spouses/caregivers need a
platform where they can voice their concerns without the fear of
retribution.
The VA has made a strong effort in supporting veterans' caregivers.
Our Association still has several concerns with the VA's interpretation
of P.L.111-163. The VA's eligibility definition does not include
illness, which means it does not align with DoD's Special Compensation
for Service. This means the benefit ends once the ill service member
transfers to veteran status. We believe the VA is waiting too long to
provide valuable resources to caregivers of our wounded, ill, or
injured service members and veterans who served in Operation Iraqi
Freedom/Operation Enduring Freedom/Operation New Dawn (OIF/OEF/OND).
The intent of the law was to allow caregivers to receive value-added
benefits, such as mental health counseling, in a timely manner in order
to improve the caregiver's overall quality of life.
Educating Those Who Care for Veterans and their Families
The families of veterans must be educated about the effects of
Post-Traumatic Stress Disorder (PTSD), and suicide in order to help
accurately diagnose and treat the veteran's condition. These families
are at the ``pointy end of the spear'' and are more likely to pick up
on changes attributed to either condition and relay this information to
their health care providers. Programs are being developed by the VA and
each Branch of Service. However, DoD's are narrow in focus, targeting
line leaders and health care providers, but not broad enough to capture
our military family members and the communities they live in. The VA's
message is broader, but still lacks the direct outreach needed to
educate veterans' families.
There are many resources for veterans and their families provided
by DoD, VA, State agencies, and non-government agencies. However, there
is often difficulty navigating this sea of good will and knowing which
resource to access when. We recommend an extended outreach program to
veterans and their families of these available mental health resources.
Health care and behavioral health providers must also be educated
about our military culture. We recommend a course on military culture
be required in all health care and behavioral health care college
curriculums and to offer a standardized VA and DoD approved military
culture Continuing Education Unit (CEU) for providers who have already
graduated. Providers should be incentivized to take these courses. VA
providers must be educated about stigma among veteran families, who are
experiencing secondary PTSD. These families, often caregivers, are
afraid to tell someone they too have PTSD. Veterans' families must be
told it is okay to seek help for themselves.
Families want to be able to access care with a mental health
provider who understands or is sympathetic to the issues they face. We
appreciate the VA allowing family member access to Vet Centers.
However, families need to have access without gaining permission from
the veteran first. Once the service members become veterans, families
have fewer access points for mental health services. Barriers, such as
the requirement for families to first obtain the veteran's permission,
only further prevent access to timely mental health care. Treatment
through the VA should include access to medication along with therapy.
Currently, the VA is only allowing therapy for families and caregivers.
We also encourage the VA to develop more family-oriented programs and
offer web-based Skype group meetings.
The VA must also look beyond its own resources to increase mental
health access by working with other government agencies. We appreciate
President Obama's recent Executive Order allowing the VA to partner
with the Substance Abuse and Mental Health Services Administration
(SAMHSA). However, we encourage the VA to include SAMHSA's Military
Families Strategic Initiative and Service member, veteran, and family
Policy Academy States and Territories in their partnership. SAMHSA's
initiative encourages State agencies to provide already established
services and programs to service members, veterans, and family members.
Our Association has been actively working with SAMHSA providing
valuable input on military families and military culture. We encourage
committee members to ask fellow Members of Congress and the
Administration to fund SAMHSA's initiative so they may educate the
remaining States and Territories about the unique needs of the
military, veterans, and their families.
Survivors
The VA must work together to ensure surviving spouses and their
children can receive the mental health services they need through all
of VA's venues
Recommend the VA examine DoD's alternative methods of mental health
services and possibly adopt the United Kingdom's model of community
involvement as possible solutions to their access issues.
Recommend the VA be aware of the mental health needs of veterans'
children and families when allowing access to service and implementing
support programs.
Recommend the VA and DoD think proactively as one team and one
system, in order to successfully address problems and implement
initiatives upstream while the service member and their family is still
on active duty status.
Recommend the VA establish a holistic, family-centered approach to
care.
Recommend the VA and DoD establish spouse/caregiver support groups
and mentoring opportunities.
Recommend the VA educate family members of veterans about the
effects of Post-Traumatic Stress Disorder (PTSD) and suicide.
Recommend the VA create outreach programs to veterans and their
families about all of the available VA, DoD, State agencies, and non-
government agencies behavioral health resources.
Recommend the VA and DoD educate health care and behavioral health
providers about our military culture and stigma among veterans'
families.
Recommend committee members ask fellow Members of Congress and the
Administration to fund SAMHSA's initiative so they may educate the
remaining States and Territories about the unique needs of the
military, veterans, and their families.
Recommend the VA ensure surviving spouses and their children
receive the behavioral health services they need through all of VA's
venues.
Military Families - Our Nation's Families
The National Military Family Association would like to thank you
again for the opportunity to submit testimony on overcoming barriers to
quality mental health care for veterans and their families. Veteran
families have supported the Nation's military mission. The least their
country can do is make sure they have consistent access to high quality
behavioral health care. Wounded service members and veterans have
wounded families. The VA and DoD systems of care should work together
in providing quality behavioral health services. We ask this Committee
to assist in meeting that responsibility. We look forward to working
with you to improve the quality of life for service members, veterans,
their families and caregivers, and survivors.
Paralyzed Veterans of America
Chairman Miller, Ranking Member Michaud, and members of the
Committee, thank you for allowing Paralyzed Veterans of America (PVA)
to submit a statement for the record concerning the Department of
Veterans Affairs' (VA) mental health services. Overcoming barriers to
quality mental health care for veterans is extremely important as the
number of veterans enrolled in the VA health care system continues to
grow, and the newest generation of veterans and their families
acclimate to civilian life after war. PVA thanks the Committee for
their continued oversight and hard work on this important health care
issue.
The increased demand for VA mental health services has put greater
emphasis on the areas in which VA can improve upon its delivery and
approach to providing quality mental health care. In the past year,
both the VA Office of Inspector General and the Government
Accountability Office have released reports identifying issues that
preclude veterans from receiving timely, quality VA mental health care.
Such issues include inadequate staffing of VA mental health
professionals, unreasonable wait times for appointments, and inaccurate
reporting of mental health metrics and program outcomes.
In August 2012, the President issued an Executive Order #13625,
``Improving Access to Mental Health Services for Veterans, Service
Members, and Military Families.'' The Executive Order focuses on
suicide prevention, mental health research and development, VA mental
health staffing, and partnerships between the VA and mental health
community providers. PVA believes that the aforementioned report
findings, and the Executive Order substantiate the need for Congress,
the Administration, VA leadership, and the veteran community to work
together to develop innovative approaches for providing VA mental
health care that meets the evolving needs of all veterans.
As we work to improve VA mental health care, PVA believes that it
is important to recognize that VA is the best health care provider for
veterans. Providing primary care and specialized health services is an
integral component of VA's core mission and responsibility to veterans.
In the area of mental health it is vital that veterans receive care
that is tailored to their unique experiences and needs as veterans. The
VA has made tremendous strides in the quality of care and variety of
``veteran specific'' mental health services. These improvements include
incorporating mental health into VA's primary care delivery model,
increasing the number of Vet Centers, launching mental health public
awareness campaigns, and creating call centers that are available to
veterans 24 hours a day, 7 days a week. While these improvements were
much needed and have helped many veterans, we agree with this Committee
that more must be done.
The VA must focus on recruiting and retaining qualified mental
health professionals to meet the growing mental health care demand.
Last year, the VA announced its plan to increase the mental health
workforce by an additional 1,900 mental health professionals. In
response to this hiring goal, PVA recommends that the VA conduct a
comprehensive analysis of the mental health care needs of veterans, and
create a mental health strategic plan for staffing to accurately assess
current staffing needs and appropriately place newly hired employees.
In addition to increased staffing, PVA recommends that the VA work
to improve and expand current mental health services that have proven
beneficial to veterans such as peer to peer support programs. As
recommended in the FY 2014 Independent Budget, VA medical centers
should work to hire veterans as peer counselors to provide individual
counseling, as well as reach out to veterans to promote the importance
of mental health, and help veterans currently receiving VA mental
health services sustain treatment. Additionally, as the VA works to
improve and increase access to mental health care, it must identify and
adapt to the varying needs of the different generations of veterans.
The VA must work to address the mental health needs of veterans
returning from the most recent conflicts, as well as the larger
population of disabled veterans who are dealing with severe illnesses
and catastrophic injuries.
To meet the varying mental health needs of veterans, the VA must
work with veterans, veteran service organizations, and stakeholders in
the community to create innovative ways to provide quality mental
health services. In fact, the President's Executive Order mandates
enhanced partnerships between the VA and community mental health
providers to ensure that veterans are able to receive care in a timely
manner. Specifically, it states that the VA and the Department of
Health and Human Services shall establish pilot projects to contract
with community based providers to help meet veterans' mental health
care needs in a timely manner. While PVA understands the urgent nature
of providing veterans with timely mental health care, we believe that
the quality of that care is equally important.
As it relates to contracted care, mental health services are unique
in that it is difficult to move from one provider to another after
trust and a rapport have been established. It is important to consider
that when veterans are referred to providers outside of the VA for
mental health care, they may not return to the VA for those services,
and ensuring that veterans seek additional mental health services
through the VA may become more difficult. When developing community
partnerships with non-VA providers there must be a balance that allows
VA to provide contracted services for mental health care without
discouraging veterans from utilizing other VA mental health services,
or VA's primary care and specialized services that are readily
available to them. Therefore, PVA strongly recommends that the first
phase of implementation of the Executive Order should require VA to
work closely with veteran service organizations to determine the
guidelines and policies under which the VA may provide a veteran with
mental health care in the community setting. Specifically, PVA believes
that before the VA provides veterans with care through contracted
services, mechanisms must be in place to ensure care coordination, and
allow VA to monitor the quality of care provided. The VA must also make
certain that the professionals providing the care meet VA standards and
are familiar with cultural norms of military service and experiences of
veterans.
While PVA believes that the greatest need is still for qualified VA
mental health professionals to provide veterans with the care they
need, veterans should not have to wait for such essential care. The VA
must work to hire and officially assign mental health staff, improve
administrative processes that lead to lengthy wait times, and develop
ways to increase access to VA mental health services while maintaining
VA's high quality of care and providing care that is centered on the
unique needs of veterans. When veterans have timely access to quality
mental health care services they in turn have the opportunity to
establish productive personal and professional lives.
PVA would like to once again thank this Committee for the
opportunity to provide a statement for the record, and we look forward
to working with you to improve VA mental health services for our
veterans.
Information Required by Rule XI 2(g)(4) of the House of Representatives
Pursuant to Rule XI 2(g)(4) of the House of Representatives, the
following information is provided regarding federal grants and
contracts.
Fiscal Year 2013
No federal grants or contracts received.
Fiscal Year 2012
No federal grants or contracts received.
Fiscal Year 2011
Court of Appeals for Veterans Claims, administered by the Legal
Services Corporation--National Veterans Legal Services Program--
$262,787.
Vietnam Veterans of America
Chairman Miller, Ranking Member Michaud, and Distinguished Members
of the House Veterans Affairs Committee, Vietnam Veterans of America
(VVA) thanks you for the opportunity to present our statement for the
record on ``Honoring the Commitment: Overcoming Barriers to Quality
Mental Health Care for Veterans''.
First, VVA recognizes that the Veterans Health Administration (VHA)
has made some significant progress in its efforts to improve the
quality of mental health care for America's veterans. For example,
although not all mental health clinical staff has yet been trained, VA
should be commended for its system-wide adoption (finally) of evidence-
based cognitive behavioral treatment modalities for PTSD. In addition,
the development of various web-based program applications and social
media mental health outreach campaigns reflect a much better effort to
reach America's veterans. While these efforts are laudable, VVA
continues to believe they have not gone far enough.
VVA remains very concerned about three related mental health areas:
suicides, especially among the older veterans' cohort; recruitment,
hiring, and retention of VA mental health staff; and timely access to
VA mental health clinical facilities and programs, especially for our
rural veterans.
To be fair, since media reports of suicide deaths and suicide
attempts began to surface back in 2003, the VA has developed a number
of strategies to reduce suicides and suicide behaviors which include:
the development of the Veterans Crisis Hotline and Chatline (in
partnership with the Substance Abuse and Mental Health Administration)
and a social media campaign emphasizing VA crisis support services; the
creation of suicide prevention coordinator (SPCs) positions at all VA
medical facilities whose duties include education, training, and
clinical quality improvement for VHA staff members; and the hiring and
training of additional staff to increase the capacity of the Veterans
Crisis Line by 50 percent.
However, the VA's report of February 1, 2013 on veterans who die by
suicide paints a shocking portrait of what's happening among our older
vets (see chart below).
Percentage of suicides by age and veteran status among males
----------------------------------------------------------------------------------------------------------------
Age group Non-veteran Veteran
----------------------------------------------------------------------------------------------------------------
29 and younger 24.4% 5.8%
----------------------------------------------------------------------------------------------------------------
30-39 20.0 8.9
----------------------------------------------------------------------------------------------------------------
40-49 23.5 15.0
----------------------------------------------------------------------------------------------------------------
50-59 16.9 20.0
----------------------------------------------------------------------------------------------------------------
60-69 7.4 16.8
----------------------------------------------------------------------------------------------------------------
70-79 4.2 19.0
----------------------------------------------------------------------------------------------------------------
80 and older 3.6 14.5
----------------------------------------------------------------------------------------------------------------
Over two-thirds of veterans who commit suicide are age 50 or older.
Among the report's other findings:
The average age of veterans who die of suicide is just
short of 60; for nonveterans, it's 43.
Female veterans who commit suicide generally do so at
younger ages than males. Two-thirds of women who killed themselves were
under 50 years of age; one-third were under 40 and 13 percent were
under 30. For men, the comparable figures were 30 percent, 15 percent
and 6 percent.
About 15 percent of veterans who attempt suicide, but
don't succeed, try again within 12 months.
VVA asks why?
VVA understands that it is very challenging to determine an exact
number of suicides. Some troops who return from deployment become
stronger from having survived their experiences. Too many others are
wracked by memories of what they have experienced. This translates into
extreme issues and risk-taking behaviors when they return home, which
is one of the reasons why veteran suicides have attracted so much
attention in the media. Many times, suicides are not reported, and it
can be very difficult to determine whether or not a particular
individual's death was intentional. For a suicide to be recognized,
examiners must be able to say that the deceased meant to die. Other
factors that contribute to the difficulty are differences among states
as to who is mandated to report a death, as well as changes over time
in the coding of mortality data. In fact, previously published data on
veterans who died by suicide were only available for those who had
sought VA health care services. But for the first time, the February
1st report also includes some limited state data for veterans who had
not received health care services from VA.
Nevertheless, according to the American Foundation for Suicide
Prevention, in more than 120 studies of a series of completed suicides,
at least 90 percent of the individuals involved were suffering from a
mental illness at the time of their death. The most important
interventions are recognizing and treating these underlying illnesses,
such as depression, alcohol and substance abuse, post-traumatic stress
and traumatic brain injury. Many veterans (and active duty military)
resist seeking help because of the stigma associated with mental
illness, or they are unaware of the warning signs and treatment
options. These barriers must be identified and overcome.
VVA has long believed in a link between PTSD and suicide, and in
fact, studies suggest that suicide risk is higher in persons with PTSD.
For example, research has found that trauma survivors with PTSD have a
significantly higher risk of suicide than trauma survivors diagnosed
with other psychiatric illness or with no mental pathology (1). There
is also strong evidence that among veterans who experienced combat
trauma, the highest relative suicide risk is observed in those who were
wounded multiple times and/or hospitalized for a wound (2). This
suggests that the intensity of the combat trauma, and the number of
times it occurred, may indeed influence suicide risk in veterans,
although this study assessed only combat trauma, not a diagnosis of
PTSD, as a factor in the suicidal behavior.
Considerable debate exists about the reason for the heightened risk
of suicide in trauma survivors. Whereas some studies suggest that
suicide risk is higher due to the symptoms of PTSD (3,4,5), others
claim that suicide risk is higher in these individuals because of
related psychiatric conditions (6,7). However, a study analyzing data
from the National Co-morbidity Survey, a nationally representative
sample, showed that PTSD alone out of six anxiety diagnoses was
significantly associated with suicidal ideation or attempts (8). While
the study also found an association between suicidal behaviors and both
mood disorders and antisocial personality disorder, the findings
pointed to a robust relationship between PTSD and suicide after
controlling for co-morbid disorders. A later study using the Canadian
Community Health Survey data also found that respondents with PTSD were
at higher risk for suicide attempts after controlling for physical
illness and other mental disorders (9).
Some studies that point to PTSD as the cause of suicide suggest
that high levels of intrusive memories can predict the relative risk of
suicide (3). Anger and impulsivity have also been shown to predict
suicide risk in those with PTSD (10). Further, some cognitive styles of
coping such as using suppression to deal with stress may be
additionally predictive of suicide risk in individuals with PTSD (3).
Other research looking specifically at combat-related PTSD suggests
that the most significant predictor of both suicide attempts and
preoccupation with suicide is combat-related guilt, especially amongst
Vietnam veterans (11). Many veterans experience highly intrusive
thoughts and extreme guilt about acts committed during times of war,
and these thoughts can often overpower the emotional coping capacities
of veterans.
Researchers have also examined exposure to suicide as a traumatic
event. Studies show that trauma from exposure to suicide can contribute
to PTSD. In particular, adults and adolescents are more likely to
develop PTSD as a result of exposure to suicide if one or more of the
following conditions are true: if they witness the suicide, if they are
very connected with the person who dies, or if they have a history of
psychiatric illness (12,13,14). Studies also show that traumatic grief
is more likely to arise after exposure to traumatic death such as
suicide (15,16). Traumatic grief refers to a syndrome in which
individuals experience functional impairment, a decline in physical
health, and suicidal ideation. These symptoms occur independent of
other conditions such as depression and anxiety.
VVA strongly suggests that until VA mental health services develops
a nationwide strategy to address the problem of suicides among our
older veterans--particularly Vietnam-era veterans--it immediately adopt
and utilize the appropriate suicide risk and prevention factors for
veterans found in the ``National Strategy for Suicide Prevention 2012:
Goals and Objectives for Action: A Report of the U.S. Surgeon General
and of the National Action Alliance for Suicide Prevention'' that's
available on-line at the web sites for both the Surgeon General's
Office and SAMHSA.
The second item with which VVA has grave concerns is the
recruitment, hiring, and retention of VA mental health staff. In its
February 1st report, the VA claims to be ``currently engaged in an
aggressive hiring campaign to expand access to mental health services
with 1,600 new clinical staff, 300 new administrative staff, and is in
the process of hiring and training 800 peer-to-peer specialists, who
will work as members of mental health teams''. Nice words, but VVA
asks: Of these 1,600 clinical positions, do they represent new
additional staff, or replacements for those who've retired or left VA
employ? What mental health clinical job categories do these hires
represent? And what is the VA's staffing plan for these hires? In other
words how many staff is VA hiring, in what positions, and how many do
they currently have? It appears that we need a scorecard to determine
what is going on . . .
And last, but certainly not least, VVA remains concerned about
timely access to VA mental health services and programs, especially
since the 2012 Inspector General's report illustrated in incredible
clarity how top VA facility and VISN administrators ``game the system''
to make wait times appear shorter for the veterans they serve. The
I.G.'s report said that, rather than starting the clock from the moment
a vet asks for mental health care, the VA has been counting from
whenever the first appointment became available, adding weeks or months
to the wait time. So while the VA was saying 95 percent of vets were
seen as quickly as they were supposed to be, nearly 100,000 patients
had to wait much longer. At the VA Medical Center in Salisbury, N.C.,
for example, the average wait was three months.
Once again, on behalf of VVA's National Officers, Board, and
general membership, thank you for your leadership in holding this
important hearing on a topic that is literally of vital interest to so
many veterans, and should be of keen interest to all Americans who care
about our nation's veterans.
References
1. Knox, K.L. (2008). Epidemiology of the relationship between
traumatic experience and suicidal behaviors. PTSD Research Quarterly,
19(4).
2. Bullman, T. A., & Kang, H. K. (1995). A study of suicide among
Vietnam veterans. Federal Practitioner, 12(3), 9-13.
3. Amir, M., Kaplan, Z., Efroni, R., & Kotler, M. (1999). Suicide
risk and coping styles in posttraumatic stress disorder patients.
Psychotherapy and Psychosomatics, 68(2), 76-81.
4. Ben-Yaacov, Y., & Amir, M. (2004). Posttraumatic symptoms and
suicide risk. Personality and Individual Differences, 36, 1257-1264.
5. Thompson, M. E., Kaslow, N. J., Kingree, J. B., Puett, R.,
Thompson, N. J., & Meadows, L. (1999). Partner abuse and posttraumatic
stress disorder as risk factors for suicide attempts in a sample of
low-income, inner-city women. Journal of Traumatic Stress, 12(1), 59-
72.
6. Fontana, A., & Rosenheck, R. (1995). Attempted suicide among
Vietnam veterans: A model of etiology in a community sample. American
Journal of Psychiatry, 152(1), 102-109.
7. Robison, B. K. (2002). Suicide risk in Vietnam veterans with
posttraumatic stress disorder. Unpublished Doctoral Dissertation,
Pepperdine University.
8. Sareen, J., Houlahan, T., Cox, B., & Asmundson, G. J. G. (2005).
Anxiety Disorders Associated With Suicidal Ideation and Suicide
Attempts in the National Comorbidity Survey. Journal of Nervous and
Mental Disease. 193(7), 450-454.
9. Sareen, J., Cox, B.J., Stein, M.B., Afifi, T.O., Fleet, C., &
Asmundson, G.J.G. (2007). Physical and mental comorbidity, disability,
and suicidal behavior associated with posttraumatic stress disorder in
a large community sample. Psychosomatic Medicine. 69, 242-248.
10. Kotler, M., Iancu, I., Efroni, R., & Amir, M. (2001). Anger,
impulsivity, social support, and suicide risk in patients with
posttraumatic stress disorder. Journal of Nervous & Mental Disease,
189(3), 162-167.
11. Hendin, H., & Haas, A. P. (1991). Suicide and guilt as
manifestations of PTSD in Vietnam combat veterans. American Journal of
Psychiatry, 148(5), 586-591.
12. Andress, V. R., & Corey, D. M. (1978). Survivor-victims: Who
discovers or witnesses suicide? Psychological Reports, 42(3, Pt 1),
759-764.
13. Brent, D. A., Perper, J. A., Moritz, G., Friend, A., Schweers,
J., Allman, C., McQuiston, L., Boylan, M. B., Roth, C., & Balach, L.
(1993b). Adolescent witnesses to a peer suicide. Journal of the
American Academy of Child and Adolescent Psychiatry, 32(6), 1184-1188.
14. Brent, D. A., Perper, J. A., Moritz, G., Liotus, L.,
Richardson, D., Canobbio, R., Schweers, J., & Roth, C. (1995).
Posttraumatic stress disorder in peers of adolescent suicide victims:
Predisposing factors and phenomenology. Journal of the American Academy
of Child and Adolescent Psychiatry, 34(2), 209-215.
15. Melhem, N. M., Day, N., Shear, M. K., Day, R., Reynolds, C. F.,
& Brent, D. A. (2004). Traumatic grief among adolescents exposed to a
peer's suicide. American Journal of Psychiatry, 161(8), 1411-1416.
16. Prigerson, H. G., Shear, M. K., Jacobs, S. C., Reynolds, C. F.
I., Maciejewsk, P. K., Davidson, J. R., Rosenheck, R., Pilkonis, P. A.,
Wortman, C. B., Williams, J. B., Widiger, T. A., Frank, E., Kupfer, D.
J., & Zisook, S. (1999). Consensus criteria for traumatic grief: A
preliminary empirical test. British Journal of Psychiatry, 174, 67-73.
17. Posttraumatic Stress Disorder: Diagnosis and Assessment
Subcomittee on Posttraumatic Stress Disorder of the Committee on Gulf
War and Health: Physiologic, Psychologic, and Psychosocial Effects of
Deployment-Related Stress. Institutes of Medicine. National Academies
Press. 2006.
VIETNAM VETERANS OF AMERICA
Funding Statement
February 8, 2013
The national organization Vietnam Veterans of America (VVA) is a
non-profit veterans' membership organization registered as a 501(c)
(19) with the Internal Revenue Service. VVA is also appropriately
registered with the Secretary of the Senate and the Clerk of the House
of Representatives in compliance with the Lobbying Disclosure Act of
1995.
VVA is not currently in receipt of any federal grant or contract,
other than the routine allocation of office space and associated
resources in VA Regional Offices for outreach and direct services
through its Veterans Benefits Program (Service Representatives). This
is also true of the previous two fiscal years.
For Further Information, Contact: Executive Director for Policy and
Government Affairs, Vietnam Veterans of America, (301) 585-4000,
extension 127
Questions For The Record
Letter From: Hon. Jeff Miller, Chairman, To: Hon. Robert A. Petzel,
M.D., Under Secretary for Health, Department of Veterans
Affairs
March 1, 2013
The Honorable Robert A. Petzel, M.D.
Under Secretary for Health
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Dr. Petzel:
On Wednesday, February 13, 2013, you testified before the Committee
during an oversight hearing entitled, ``Honoring the Commitment:
Overcoming Barriers to Quality Mental Health Care for Veterans.'' As a
follow-up to the hearing, I request that you respond to the attached
questions and provide the requested materials in-full by no later than
close of business on Friday, April 1, 2013.
If you have any questions, please contact Dolores Dunn, Staff
Director for the Subcommittee on Health, at [email protected]
or by calling (202) 225-9154.
Your timely response to this matter and your commitment to our
nation's veterans and their families are both very much appreciated.
With warm personal regards,
Sincerely,
JEFF MILLER
Chairman
CJM/dd/sg
Questions From: Hon. Jeff Miller, Chairman, Congressman Jeff Denhan,
and Congresswoman Jackie Walorski To: Department of Veterans Affairs
1. In a Full Committee hearing on June 14, 2011, entitled, ``Mental
Health: Bridging the Gap Between Care and Compensation for Veterans,''
Dr. Karen Seal of the San Francisco Department of Veterans Affairs (VA)
Medical Center testified regarding a study she had recently published
in the Journal of Traumatic Stress regarding mental health services
utilization rate for veterans of Operations Enduring Freedom and Iraqi
Freedom (OEF/OIF) using VA healthcare from 2002-2008. Dr. Seal
testified that less than 10% of those newly diagnosed with post-
traumatic stress disorder (PTSD) received the recommended number and
intensity of VA evidence-based treatment sessions within the first year
of their diagnosis. She also testified that only about a quarter of
veterans received VA's recommended PTSD treatment protocol of nine or
more sessions, and only about 10% attended such sessions within VA's
recommended timeframe of fifteen weeks following their initial
diagnosis.
- Please provide, for each fiscal year (FY) 2008 through 2012, the
number of OEF/OIF veterans using VA healthcare who have: (1) been
diagnosed with PTSD, (2) received the recommended PTSD treatment
protocol of nine of more sessions following their initial diagnosis;
and, (3) attended such sessions within fifteen weeks of their initial
diagnosis.
2. Of the approximately 3,262 mental health professionals VA
alleges to have hired as of January 29, 2013, please provide the
following:
- the number of such providers broken down by occupation and status
(i.e., on-board, firm or tentative job offer, awaiting credentialing
and privileging, pending interview, etc.);
- the number of such providers broken down by Veterans Integrated
Service Network and VA medical center or clinic;
- the number of such providers who perform disability evaluations,
either full-time or part-time;
-the average length of time it takes the Department to credential
and privilege each such provider;
- the number of such providers who were transferred from other VA
facilities.
3. During the hearing, in response to my question about how VA
evaluates patient outcomes with regard to mental health care, you
stated that, `` . . . we have good evidence in literature that people
that go through [VA treatment programs] do indeed have less
symptomatology associated with their PTSD and are better adjusted to
living in society. There are many instances of the treatment protocols
that we have, where we can demonstrate the direct impact on those
individuals that have been through that therapy.''
- Please provide a copy of any and all of the ``literature'' that
you referred to in the above statement.
- Please describe each incident referenced in your above statement
where VA is able to demonstrate ``the direct impact'' of the mental
health care VA provides on the subsequent mental health of the veterans
who access that care.
4. In response to my question regarding how the Committee can
assist VA in providing quality and timely mental health care services
to veteran patients, you stated that the Committee may help in: (1)
facilitating interactions between VA and community health centers; (2)
helping VA interact better with private sector providers; and, (3)
addressing the shortage of psychiatrists.
- Please expand on how you believe the Committee could be of
assistance to the Department in each of the three areas listed above.
5. In response to my question regarding how VA has been able to
hire increased numbers of mental health providers, you stated that,
``[o]f all of the professionals in mental health, the most difficult
problem we are having is recruiting psychiatrists, and we have barely
been able to recruit half of the new ones that we said we wanted to do,
and that it is in spite of raising the salary quite substantially,
providing incentives for recruitment, bonuses, etc.''
- Please provide further details on the salary raises, recruitment
incentives, bonuses, and any and all other actions VA has taken in an
effort to recruit and retain psychiatrists.
- Please describe any and all actions beyond the ones referenced
above that VA has taken or is considering taking to alleviate the the
difficulties VA has experienced recruiting psychiatrists (i.e.
undertaking additional recruitment and retention incentives, increasing
partnerships with non-VA resources, recruiting increased numbers of
other mental health professionals, etc.).
6. In response to a question from Ranking Member Michaud regarding
Section 3 of the Executive Order on Improving Access to Mental Health
Servicemembers, Veterans, and Their Families, you stated that, `` . . .
15 pilots sites were selected . . . based upon the desire of the local
network to participate, our hospital to participate, and a need . . .
identified often by how rural the areas were. There is one urban center
where we are doing this in Atlanta to get a feel for what they might be
like, because there are many, many community mental health clinics in
the Atlanta area.'' You further stated that, ``[w]e think that this is
. . . going to be a viable alternative in the future to us cooperating
in the community with providing care in these again remote rural
areas.''
- Please name the location of each of the 15 selected pilot sites.
- Please describe, in detail, the criteria the Department used to
choose each of the sites named above.
- Please expand on your statement above that enhanced partnerships
between VA and community partners is going to be a ``viable
alternative'' to ``cooperating in the community,'' to include what you
see these partnerships as an alternative to and whether or not you see
them as an asset in rural areas only or, potentially, in urban
communities as well and why.
7. In response to a question from Ranking Member Michaud regarding
veteran suicide data, Dr. Janet Kemp, the Director of VA's Suicide
Prevention and Community Engagement Program, stated that, ``[t]here
[are] a couple of states that we are still working with over privacy
issues and how we are going to share data and I am confident that we
will get those soon.''
- Please name the states referenced above.
- Please describe any and all barriers, including privacy issues,
to the states referenced above providing VA with the requested data on
veteran suicide rates.
- When does the Department expect that complete veteran suicide
rate data will be received from all 50 states?
8. In response to a question from Ranking Member Michaud regarding
performance requirements for VA mental health providers, you stated
that, `` . . . .it is important to have performance measures, and I
think it is incumbent upon us as the leaders to make sure that there is
the proper balance between time available to do clinical care, and the
necessity of meeting performance measures.''
- Please name each of the current performance measures (including
any and all clinical reminders) currently in place for VA mental health
care providers, to include the justification for using each measure and
how long it has been in place.
- Please describe how you, as the Under Secretary for Health,
ensure a ``proper balance'' between measuring provider performance and
ensuring sufficient clinical care.
9. In response to a question from Representative Runyan regarding
the need to be proactive in addressing veterans' mental health needs,
you discussed the need to develop close, trusting relationships between
veteran patients and VA mental health providers. You stated that VA
needed to focus on, `` . . . developing the relationships where
[veteran patients] will tell us where there are things that may be
antecedents to suicide that are bothering them,'' and, ``[i]t is
getting the information, and the contact with the individual before
they have the difficulty as you have pointed is the problem.'' In
response to a similar question from Representative Brownley, you stated
that,'' . . . we have a newly organized task force that Dr. Kemp is
chairing that is going to look at how we can develop a different
paradigm if you will for the way we deliver care to people that have
chronic pain, sleep disorders, depression, etc., the things that have
the greatest impact on suicide.''
- How does VA foster such relationships between VA providers and
veteran patients?
- What different paradigms is the taskforce referenced above
looking at regarding the delivery of mental health care and when is
that work expected to be complete?
10. In response to a question from Representative Coffman regarding
VA mental health care providers, you stated that, `` . . . this spring
[we have] implemented our performance criteria for timeliness, the
intention is to go out and do three things. One, look at the measures.
Two, survey veterans as to whether or not they were - had timely access
as well as other satisfaction related questions. And three, to survey
the staff. Are they able to provide timely access for their patients,
are they adequately staffed, do they have enough people to do the work
that they are being required. So, yes, we are going to do it. And we
will be doing that on a regular basis''
- Please provide the timeliness performance criteria referenced
above.
- Please provide information regarding the survey of veteran
patients referenced above, to include the number of veteran patients
expected to be surveyed, the questions expected to be included on the
survey, the method expected to be used to conduct the survey (i.e., in
person, electronic, via telephone, etc.), the expected survey results,
the expected total cost of the survey, and any and all follow-up
actions expected to result from the survey.
- Please provide information regarding the survey of VA mental
health care providers referenced above, to include the number of VA
mental health providers expected to be surveyed, the questions expected
to be included on the survey, the method expected to be used to conduct
the survey (i.e., in person, electronic, via telephone, etc.), the
expected survey results, the expected total cost of the survey, and any
and all follow-up actions expected to result from the survey.
- When does the Department expect all three of the above actions to
be completed?
- How often does the Department expect to conduct follow-up surveys
of veteran patients accessing VA mental health care?
- How often does VA expect to conduct follow-up surveys of VA
mental health providers?
Questions for the Record from Congressman Jeff Denham
1. As we have heard the hearing, the conflicts in Afghanistan and
Iraq have created extraordinary demands for care as veterans return
from theater. For those with PTSD or other mental health issues, long
waits for treatment can put them at risk for suicide or other
behavioral problems.
- Has VA considered short-term solutions to address the immediate
mental health need while it recruits and hires the staff it needs long
term?
2. I understand that VA has been conducting pilot programs designed
to provide veterans with access to community-based mental health
services in several rural communities like mine. For veterans that are
able to get into one of these programs, they provide needed care closer
to the veteran's home. However, I understand that use of these pilots
by VA facilities has been very low.
- What are you doing to encourage use of these programs in rural
communities?
- Are there any plans to expand these rural pilot programs, to
other rural communities across the country?
Questions for the Record from Congresswoman Jackie Walorski
1. During the hearing, we heard how veterans are discouraged with
long wait times in-between appointments and consequently drop out of
treatment.
- What is VA doing to improve mental health wait times for veteran
patients accessing VA mental health care?
- How is VA working to better accommodate veterans who have
transitioned into the civilian world and all the new responsibilities
they must deal with while trying to seek the health care they need?
Responses From the U.S. Department of Veterans Affairs
1. In a Full Committee hearing on June 14, 2011, entitled, ``Mental
Health: Bridging the Gap Between Care and Compensation for Veterans,''
???Dr. Karen Seal of the San Francisco Department of Veterans Affairs
(VA) Medical Center testified regarding a study she had recently
published in the Journal of Traumatic Stress regarding mental health
services utilization rate for veterans of Operations Enduring Freedom
and Iraqi Freedom (OEF/OIF) using VA healthcare from 2002-2008. Dr.
Seal testified that less than 10% of those newly diagnosed with post-
traumatic stress disorder (PTSD) received the recommended number and
intensity of VA evidence-based treatment sessions within the first year
of their diagnosis. She also testified that only about a quarter of
veterans received VA 's recommended PTSD treatment protocol of nine or
more sessions, and only about 10% attended such sessions within VA's
recommended timeframe of fifteen weeks following their initial
diagnosis.
Please provide, for each fiscal year (FY) 2008 through 2012, the
number of OEF/OIF veterans using VA healthcare who have: (1) been
diagnosed with PTSD, (2) received the recommended PTSD treatment
protocol of nine of more sessions following their initial diagnosis;
and, (3) attended such sessions within fifteen weeks of their initial
diagnosis.
VA Response:
We identified all Operation Enduring Freedom/Operation Iraqi
Freedom (OEF/OIF) Veterans who have enrolled in VA care and received
any outpatient VA services between the date of their separation from
military service (for regular Armed Forces), or the end date of their
last deployment (for Reserve and National Guard), and the end of fiscal
year (FY) 2011. \1\ The Veterans Health Administration (VHA) has
treated 728,705 of these Veterans.
---------------------------------------------------------------------------
\1\ The FY12 data are not included because the outcomes measures
(any care in one year, any psychotherapy in one year, and 9 visits in
15 weeks at any time within one year of diagnosis) required at least
one year in which to examine. Therefore, we included all Veterans
through the end of FY11 and examined their utilization through the end
of FY12.
---------------------------------------------------------------------------
Table 1 indicates the numbers that were diagnosed with Post-
traumatic Stress Disorder (PTSD) in the same time frame. Those
diagnosed with PTSD are those who had at least two outpatient visits,
or one inpatient or residential bed day, where a diagnosis of PTSD was
present. This methodology for counting those with a diagnosis of PTSD
differs from Dr. Seal's methodology, but is consistent with how Mental
Health Service and Office of Mental Health Operations report numbers on
PTSD. Over all of the years, a cumulative total of 166,604 (22.9
percent) OEF/OIF Veterans treated by VHA were diagnosed with PTSD.
Table 1. Number of OEF/OIF Veterans diagnosed with PTSD, by year of diagnosis
----------------------------------------------------------------------------------------------------------------
% of all OEF/OIF
Year Number with PTSD Veterans with PTSD
----------------------------------------------------------------------------------------------------------------
2002 10 0.01
2003 94 0.06
2004 2216 1.33
2005 8054 4.83
2006 12369 7.42
2007 19154 11.5
2008 26674 16.01
2009 30537 18.33
2010 32582 19.56
2011 34914 20.96
----------------------------------------------------------------------------------------------------------------
Next, we calculated the proportion of those who received a
diagnosis of PTSD who also had at least nine outpatient mental health
visits in the year after their initial diagnosis. That data is
presented in Table 2. Note that while Dr. Seal's analysis included only
mental health visits to sub-specialty PTSD, mood disorder, or substance
use clinics, and visits to mental health clinicians embedded in primary
care, she did not include a number of settings where evidence-based
PTSD treatment can be delivered, such as psychology and psychiatry
individual visits and general mental health clinics. We included these
locations in our analysis of mental health care utilization.
Table 2. Number and proportion of OEF/OIF Veterans diagnosed with PTSD who received at least nine visits in the
year after initial diagnosis
----------------------------------------------------------------------------------------------------------------
Number of OEF/OIF % of all OEF/OIF
Year Veterans with PTSD who Veterans with PTSD in
had 9 visits in a year the year
----------------------------------------------------------------------------------------------------------------
2002 4 40.00
2003 46 48.94
2004 817 36.87
2005 2374 29.48
2006 3530 28.54
2007 5551 28.98
2008 7654 28.69
2009 9196 30.11
2010 9711 29.80
2011 9905 28.37
----------------------------------------------------------------------------------------------------------------
Finally, we calculated the proportion of those diagnosed with PTSD
who received nine visits within a 15 week period during the year after
their initial diagnosis. We used the same list of possible locations of
care as in Table 2. This data is in Table 3.
Table 3. Number and proportion of OEF/OIF Veterans diagnosed with PTSD who received at least nine visits within
a 15 week period in the year after initial diagnosis
----------------------------------------------------------------------------------------------------------------
% of all Veterans with
Year Number with PTSD who had initial PTSD diagnosis
9 visits in 15 weeks in the year
----------------------------------------------------------------------------------------------------------------
2002 2 20.00
2003 28 29.79
2004 501 22.61
2005 1403 17.42
2006 2082 16.83
2007 3222 16.82
2008 4396 16.48
2009 5512 18.05
2010 5957 18.28
2011 6156 17.63
----------------------------------------------------------------------------------------------------------------
2. Of the approximately 3,262 mental health professionals VA
alleges to have hired as of January 29, 2013, please provide the
following:
The number of such providers broken down by occupation and status
(i.e., on-board, firm or tentative job offer, awaiting credentialing
and privileging, pending interview, etc.);
VA Response:
All of the 4,308 mental health professionals hired as of June 30,
2013, reported by VA were brought are on-board to provide services to
our Veterans.
a) The break out of the occupations is as follows:
--------------------------------------------------------------------------------------------------------------------------------------------------------
Social Other Non- Grand
Occupations LMFT \1\ LPMHC \2\ Nurse Physician Psychologist Worker clinical \3\ clinical Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number 31 40 986 403 757 990 626 475 4,308
--------------------------------------------------------------------------------------------------------------------------------------------------------
TABLE 1: Mental Health Professionals Hired as of January 29, 2013
\1\ Licensed Marriage and Family Therapist.
\2\ Licensed Professional Mental Health Counselors.
\3\ Other Mental Health Professions include: Addiction Therapists,
Health Technicians, Health Science Specialists, Nurse Assistants,
Pharmacists, Occupational Therapists, Physician Assistants,
Recreational Therapists, and Vocational Rehabilitation Therapists.
b) Tentative job offer as of January 29, 2013: Already on board
c) Firm job offer as of January 29, 2013: Already on board
d) Pending interview as of January 29, 2013: Already on board
e) Awaiting credentialing and privileging: Already on board
The number of such providers broken down by Veterans Integrated
Service Network and VA medical center or clinic;
VA Response:
------------------------------------------------------------------------
VISN Hired
------------------------------------------------------------------------
1 128
------------------------------------------------------------------------
2 55
------------------------------------------------------------------------
3 144
------------------------------------------------------------------------
4 326
------------------------------------------------------------------------
5 59
------------------------------------------------------------------------
6 166
------------------------------------------------------------------------
7 345
------------------------------------------------------------------------
8 394
------------------------------------------------------------------------
9 280
------------------------------------------------------------------------
10 121
------------------------------------------------------------------------
11 167
------------------------------------------------------------------------
12 188
------------------------------------------------------------------------
15 132
------------------------------------------------------------------------
16 375
------------------------------------------------------------------------
17 243
------------------------------------------------------------------------
18 167
------------------------------------------------------------------------
19 127
------------------------------------------------------------------------
20 199
------------------------------------------------------------------------
21 176
------------------------------------------------------------------------
22 232
------------------------------------------------------------------------
23 176
------------------------------------------------------------------------
VCL \1\ 108
------------------------------------------------------------------------
Total 4,308
------------------------------------------------------------------------
\1\ Veterans Crisis Line
TABLE 2: Number of Mental Health Providers Hired by the VA
the number of such providers who perform disability evaluations,
either full-time or part-time;
VA Response:
That number is unknown, as the number of providers who perform
disability evaluations is only tracked locally.
the average length of time it takes the Department to credential
and privilege each such provider;
VA Response:
----------------------------------------------------------------------------------------------------------------
Average Days from Average Days from
Category enrollment in VetPro* to Submission in VetPro* to
Submission Complete Verification
----------------------------------------------------------------------------------------------------------------
All provider 10 35
----------------------------------------------------------------------------------------------------------------
Licensed independent provider (Physician) 20 48
----------------------------------------------------------------------------------------------------------------
Psychologist (licensed) 13 31
----------------------------------------------------------------------------------------------------------------
Psychologist (unlicensed) 10 32
----------------------------------------------------------------------------------------------------------------
Licensed Professional Mental Health Counselor 3 20
----------------------------------------------------------------------------------------------------------------
Marriage and Family Therapist 5 26
----------------------------------------------------------------------------------------------------------------
Social Worker (licensed) 5 27
----------------------------------------------------------------------------------------------------------------
Social Worker (other) 4 27
----------------------------------------------------------------------------------------------------------------
*VetPro is used in VA to credential and privilege VA providers
TABLE 3: Length of Time to Credential and Privilege VA Providers
the number of such providers who were transferred from other VA
facilities.
VA Response:
Of note, VA is tracking the backfills of these positions. If a
current VA provider transfers from one facility to a different VA
facility, VA does not count the transfer itself as a new hire. As
stated above in condition 3, a new hire is counted only when the
original position is backfilled with an external hire. In no instance
has VHA counted current VHA employees who vacated a mental health
position to fill a different mental health position as this would not
meet the intent of VHA's drive towards the initiative.
3. During the hearing, in response to my question about how VA
evaluates patient outcomes with regard to mental health care, you
stated that, ``...we have good evidence in literature that people that
go through [VA treatment programs] do indeed have less symptomatology
associated with their PTSD and are better adjusted to living in
society. There are many instances of the treatment protocols that we
have, where we can demonstrate the direct impact on those individuals
that have been through that therapy.''
Please provide a copy of any and all of the ``literature'' that you
referred to in the above statement.
VA Response:
The following is an annotated bibliography of research literature
supporting the efficacy of PTSD treatments provided at VA. Published
International Literature on Traumatic Stress (PILOTS) ID numbers noted
at the end of each reference are unique identifiers that can be used to
locate the reference within the National Center for PTSD's PILOTS
database.
Cognitive Processing Therapy (CPT)
1.Alvarez, J., McLean, C., Harris, A. H. S., Rosen, C. S., Ruzek,
J. I., and Kimerling, R. E. (2011). The comparative effectiveness of
cognitive processing therapy for male Veterans treated in a VHA
posttraumatic stress disorder residential rehabilitation program.
Journal of Consulting and Clinical Psychology, 79, 590-599.
doi:10.1037/a0024466 PILOTS ID: 37362
This was one of the first studies to demonstrate that CPT is more
effective than a usual care treatment within a VA clinical setting. The
104 Veterans treated with group CPT in a VA PTSD Residential
Rehabilitation Program had greater improvement in PTSD, depression, and
psychological quality of life, and were more likely to lose their PTSD
diagnosis than 93 Veterans treated with trauma-focused group therapy,
the usual treatment being delivered prior to CPT's implementation.
2.Chard, K. M., Schumm, J. A., Owens, G. P. and Cottingham, S. M.
(2010). A comparison of OEF and OIF Veterans and Vietnam Veterans
receiving cognitive processing therapy. Journal of Traumatic Stress,
23, 25-32. doi:10.1002/jts.20500 PILOTS ID: 83687
This study addressed the important question of whether OEF/OIF
Veterans respond differently to outpatient PTSD treatment than Vietnam
Veterans. The investigators found that compared with 50 Vietnam
Veterans, 51 OEF/OIF Veterans had lower PTSD severity after CPT, yet
attended fewer treatment sessions. The study suggests that the chronic
nature of PTSD among the Vietnam cohort may be more difficult to treat
and requires a longer course of therapy.
3.Chard, K. M., Schumm, J. A., McIlvain, S. M., Bailey, G. W., and
Parkinson, R. B. (2011). Exploring the efficacy of a residential
treatment program incorporating cognitive processing therapy-cognitive
for Veterans with PTSD and traumatic brain injury. Journal of Traumatic
Stress, 24, 347-351. doi:10.1002/jts.20644 PILOTS ID: 85169
To better understand how TBI affects response to PTSD-focused
treatment, this study of 42 Veterans examined outcomes from a
residential VA PTSD-TBI treatment program that incorporates CPT.
Results showed that the treatment led to better outcomes for Veterans
with mild TBI and Veterans with moderate/severe TBI, with no
differences between the TBI groups. This is the first study to show
that Veterans with PTSD and TBI experience decreased PTSD and
depression following participation in a residential trauma-focused
treatment program.
4.Chard, K. M., Ricksecker, E. G., Healy, E. T., Karlin, B. E., and
Resick, P. A. (2012). Dissemination and experience with cognitive
processing therapy. Journal of Rehabilitation Research & Development,
49, 667-678. doi:10.1682/JRRD.2011.10.0198 PILOTS ID: 86801
The study is a program evaluation of VA's national training rollout
of CPT. Outcome data from 374 Veterans who received CPT from therapists
trained via the program indicated statistically significant and
clinically meaningful improvements in PTSD. Veterans from Vietnam, OEF/
OIF, and the Persian Gulf War benefited equally from CPT.
5.Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J.,
Young-Xu, Y.,and Stevens, S. P. (2006). Cognitive processing therapy
for Veterans with military-related posttraumatic stress disorder.
Journal of Consulting and Clinical Psychology,74, 898-907. doi:10.1037/
0022-006X.74.5.898 PILOTS ID: 28862
The study is the first randomized controlled trial of CPT for
Veterans with PTSD. In the sample of 60 Veterans, CPT led to
significantly greater improvements in PTSD, depression, and social
adjustment, among other outcomes, compared to a wait-list control
group. Importantly, Veterans with PTSD-related disability improved just
as much as Veterans without PTSD-related disability.
6.Suris, A., Link-Malcolm, J., Chard, K., Ahn, C., and North, C.
(2013). A randomized clinical trial of cognitive processing therapy for
Veterans with PTSD related to military sexual trauma. Journal of
Traumatic Stress, 26, 28-37. doi:10.1002/jts.21765 PILOTS ID: TBD
This is the first randomized controlled trial of CPT for PTSD-
related to military sexual trauma (MST). This study found CPT to be
more effective than Present-Centered Therapy, a non-trauma-focused PTSD
treatment, in reducing self-reported PTSD symptoms in a sample of 86
Veterans (73 female, 13 male).
Prolonged Exposure (PE) and other Exposure Therapies
1. Rauch, S. A., Defever, E., Favorite, T., Duroe, A., Garrity, C.,
Martis, B., and Liberzon, I. (2009). Prolonged exposure for PTSD in a
Veterans Health Administration PTSD clinic. Journal of Traumatic
Stress, 22, 60-64. doi:10.1002/jts.20380 PILOTS ID: 82589
This pilot study showed that PE was effective in reducing PTSD and
depression in a small sample of 10 men and women Veterans from various
war eras seen in a VA PTSD clinic. Half the patients were seen by
therapists participating in the national VA training program in PE.
Outcomes for these patients were just as positive as those for patients
seen by clinicians experienced with PE.
2. Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea,
M. T., Chow, B. K., . . . Bernardy, N. C. (2007). Cognitive behavioral
therapy for posttraumatic stress disorder in women: A randomized
controlled trial. Journal of the American Medical Association, 297,
820-830. doi:10.1001/jama.297.8.820 PILOTS ID: 29137
This study is one of the largest clinical treatment trials
conducted, with a sample of 284 female Veterans and active duty
personnel, and the first of PTSD in female Servicemembers. Women who
received PE had greater improvements in PTSD, depression, anxiety, and
quality of life than women who received Present-Centered Therapy, a
non-trauma-focused PTSD treatment.
3.Strachan, M., Gros, D. F., Ruggiero, K. J., Lejuez, C.W., and
Acierno, R. E. (2011). An integrated approach to delivering exposure-
based treatment for symptoms of PTSD and depression in OIF/OEF
Veterans: Preliminary findings. Behavior Therapy, 43, 560-569.
doi:10.1016/j.beth.2011.03.003 PILOTS ID: 37822
This study presents preliminary data from an ongoing clinical trial
and indicates that a brief behavioral treatment incorporating exposure
was effective in significantly improving PTSD, depression, and anxiety
among 31 OEF/OIF Veterans, whether delivered using home-based
telehealth or in-person. The findings suggest that exposure treatment
can be effectively administered using telehealth technology, which may
expand the reach of this evidence-based approach.
4.Thorp, S. R., Stein, M. B., Jeste, D. V., Patterson, T. L., and
Wetherell, J. L. (2012). PE therapy for older Veterans with
posttraumatic stress disorder: A pilot study. American Journal of
Geriatric Psychiatry, 20, 276-280. doi:10.1097/JGP.0b013e3182435ee9
PILOTS ID: 38445
This preliminary study begins to fill the gap in research on PTSD
treatment in older Veterans. Findings indicated that PE was well
received by a small sample of 10 Veterans age 56 to 78 and effective in
improving PTSD symptoms to a significant and large degree. Dropout was
similar to that seen in other PTSD treatment studies. Improvement in
PTSD was larger in the PE group than in a nonrandomized comparison
sample of older Veterans receiving usual treatment (medication
appointments or case management) in the same clinic.
5.Tuerk, P. W.; Yoder, M.; Grubaugh, A. L.; Myrick, H.; Hamner, M.
B.; and Acierno, R. E. (2011). Prolonged exposure therapy for combat-
related posttraumatic stress disorder: An examination of treatment
effectiveness for Veterans of the wars in Afghanistan and Iraq. Journal
of Anxiety Disorders, 25, 397-403. doi:10.1016/j.janxdis.2010.11.002
PILOTS ID: 35452
This is one of the few studies of real-world treatment
effectiveness exclusively focused on OEF/OIF Veterans. The trial found
that a sample of 65 OEF/OIF Veterans treated with PE by VA PTSD
Clinical Teams (PCT) had significant improvements in PTSD that were
similar in size to those found in randomized controlled trials of PE in
civilians. Importantly, PTSD improved irrespective of service
connection disability status.
6.Tuerk, P. W., Yoder, M., Ruggiero, K. J., Gros, D. F., and
Acierno, R. E. (2010). A pilot study of prolonged exposure therapy for
posttraumatic stress disorder delivered via telehealth technology.
Journal of Traumatic Stress, 23, 116-123. doi:10.1002/jts.20494 PILOTS
ID: 83699
This is the first trial of PE delivered via telehealth technology.
Results indicated that 12 Veterans who received PE via telehealth at
their local VA Community-Based Outreach Clinic experienced large
reductions in PTSD and depression. These improvements were generally
similar to those experienced by a group of 35 Veterans who received the
treatment in-person at the main VA Medical Center (VAMC). PE via
telehealth was safe and feasible, with acceptable, albeit slightly
higher than in-person, rates of treatment completion.
7.Wolf, G. K., Strom, T. Q., Kehle, S. M., and Eftekhari, A.
(2012). A preliminary examination of prolonged exposure therapy with
Iraq and Afghanistan Veterans with a diagnosis of posttraumatic stress
disorder and mild to moderate traumatic brain injury. Journal of Head
Trauma Rehabilitation, 27, 26-32. doi:10.1097/HTR.0b013e31823cd01f
PILOTS ID: 37922
This small study demonstrated that prolonged exposure with minimal
procedural enhancements was feasible and effective for treating PTSD
and depression in OEF/OIF Veterans with traumatic brain injury.
Improvements were large and 9 out of the 10 Veterans no longer meeting
criteria for PTSD based on a self-report measure.
8.Yoder, M., Tuerk, P. W., Price, M., Grubaugh, A. L., Strachan,
M., Myrick, H., and Acierno, R. E. (2012). Prolonged exposure therapy
for combat-related posttraumatic stress disorder: Comparing outcomes
for Veterans of different wars. Psychological Services, 9, 16-25.
doi:10.1037/a0026279 PILOTS ID: 37575
This study added to the literature examining whether there is
variability in PTSD treatment response across different cohorts of
Veterans. The investigators examined archival data from 112 Veterans
treated with PE by a PCT. The treatment was very effective at reducing
PTSD and depression for the overall sample, although Gulf War Veterans
experienced less improvement compared with Vietnam or OEF/OIF Veterans
and also had a slower rate of improvement. The factors that may account
for this differential effectiveness have yet to be explored.
Other Cognitive-Behavioral Treatments
1.Beidel, D. C., Frueh, B. C., Uhde, T. W., Wong, N., and
Mentrikoski, J. M. (2011). Multicomponent behavioral treatment for
chronic combat-related posttraumatic stress disorder: A randomized
controlled trial. Journal of Anxiety Disorders, 25, 224-231.
doi:10.1016/j.janxdis.2010.09.006 PILOTS ID: 35248
The randomized clinical trial compared a multicomponent cognitive-
behavioral therapy, Trauma Management Therapy. This therapy combines
exposure therapy and social emotional rehabilitation, to exposure
therapy only in a group of 35 male combat Veterans with chronic PTSD.
Veterans in both conditions had moderate improvements in PTSD, with no
difference between groups. The Trauma Management Therapy group had
greater decreases in social impairment after receiving the treatment
component that focuses on social functioning.
2.Frueh, B. C., Monnier, J., Yim, E., Grubaugh, A. L., Hamner, M.
B., and Knapp, R. G. (2007). A randomized trial of telepsychiatry for
post-traumatic stress disorder. Journal of Telemedicine and Telecare,
13, 142-147. doi:10.1258/135763307780677604 PILOTS ID: 29644
This randomized clinical noninferiority trial of group therapy
compared video teleconferencing with in-person format in a sample of 38
male Veterans with PTSD. Change in self-reported PTSD from before to
after treatment was small in both groups and did not differ between
groups, who also did not differ in session attendance and treatment
satisfaction. However, the same-room group was more likely to complete
assigned homework and reported greater comfort when talking with their
therapist.
3.Jakupcak, M., Roberts, L. J., Martell, C., Mulick, P. S.,
Michael, S. T., Reed, R., McFall, M. E. (2006). A pilot study of
behavioral activation for Veterans with posttraumatic stress disorder.
Journal of Traumatic Stress, 19, 387-391. doi:10.1002/jts.20125 PILOTS
ID: 80064
This pilot study evaluated the feasibility and effectiveness of
behavioral activation for treating PTSD in 11 Veterans who received 16-
weekly individual sessions of treatment, 9 of whom completed the
protocol. There were moderate pre-post improvements in PTSD, but no
improvement in depression and quality of life.
4.Morland, L. A., Greene, C. J., Rosen, C. S., Foy, D. W., Reilly,
P. M., Shore, J. H., . . . Frueh, B. C. (2010). Telemedicine for anger
management therapy in a rural population of combat Veterans with
posttraumatic stress disorder: A randomized noninferiority trial.
Journal of Clinical Psychiatry, 71, 855-863. doi:10.4088/
JCP.09m05604blu PILOTS ID: 33947
This randomized clinical noninferiority trial of anger management
therapy for 125 Veterans with PTSD found that those who received
treatment by video teleconferencing had comparable symptom improvements
to those who received in-person therapy. There were no differences in
attrition, adherence, satisfaction, or treatment expectancy, although
Veterans in the in-person condition reported higher therapeutic
alliance.
5.Monson, C. M., Fredman, S. J., Macdonald, A., Pukay-Martin, N.
D., Resick, P. A., and Schnurr, P. P. (2012). Effect of cognitive-
behavioral couple therapy for PTSD: A randomized controlled trial.
Journal of the American Medical Association, 308, 700-709. doi:
10.1001/jama.2012.9307 PILOTS ID: 39124
Forty couples in which one partner had PTSD (including 9 couples in
which the PTSD partner was a Veteran) were randomized to receive couple
therapy or to a waitlist. Couple therapy resulted in greater decreases
in PTSD and other symptoms and increased relationship satisfaction in
the PTSD partners, but no differential improvement in relationship
satisfaction in the non-PTSD partners.
6.Rotunda, R.J., O'Farrell, T.J., Murphy, M., and Babey, S.H.
(2008). Behavioral couples therapy for comorbid substance use disorders
and combat-related posttraumatic stress disorder among male Veterans:
An initial evaluation. Addictive Behaviors, 33, 180-187. doi:10.1016/
j.addbeh.2007.06.001 PILOTS ID 30123
This randomized controlled trial compared outcomes of behavioral
couples therapy in 38 Veterans who had comorbid PTSD and alcohol use
disorder or alcohol use disorder only. There were similar improvements
in both groups in relationship satisfaction, alcohol consumption,
negative consequences of drinking male-to-female violence, and
psychological distress.
Supported Employment
1.Davis, L. L., Leon, A. C., Toscano, R., Drebing, C. E., Ward, L.
C., Parker, P. E., . . . Drake, R. E. (2012). A randomized controlled
trial of supported employment among Veterans with posttraumatic stress
disorder. Psychiatric Services,63,464-470. doi:10.1176/
appi.ps.201100340 PILOTS ID: 38033
A randomized clinical trial of 85 Veterans who were randomized to
receive either individual placement and support (IPS) or standard VHA
vocational rehabilitation found that found that Veterans who received
IPS were much more likely to gain competitive employment (approximately
76 percent in IPS vs. 28 percent in vocational rehabilitation).
Veterans who received IPS also spent more time in competitive
employment and had greater income.
Eye Movement Desensitization and Reprocessing (EMDR)
1.Carlson, J. G., Chemtob, C. M., Rusnak, K., Hedlund, N. L., and
Muraoka, M. Y. (1998). Eye movement desensitization and reprocessing
(EMDR) treatment for combat-related posttraumatic stress disorder.
Journal of Traumatic Stress, 11, 3-24. doi:10.1023/A:1024448814268
PILOTS ID: 13921
In this randomized clinical trial (RCT), 47 male combat Veterans
with PTSD were assigned to receive either EMDR, relaxation, or a wait
list. The authors reported greater improvements in PTSD and other
outcomes for the 35 Veterans who completed the trial; Intention-to-
Treat analysis was not reported.
2.Rogers, S., Silver, S. M., Goss, J., Obenchain, J. V., Willis,
A., and Whitney, R. L. (1999). A single session, group study of
exposure and eye movement desensitization and reprocessing in treating
posttraumatic stress disorder among Vietnam War Veterans: Preliminary
data. Journal of Anxiety Disorders, 13, 119-130. doi:10.1016/S0887-
6185(98)00043-7 PILOTS ID: 14686
In this small RCT, 12 Vietnam War Veterans with PTSD were either a
single session of exposure therapy or EMDR. Both groups showed
improvement in self-reported overall PTSD symptom severity but groups
did not differ. EMDR treatment resulted in greater positive changes in
within-session subjective units of discomfort levels and on self-
reported intrusive symptoms.
3.Silver, S. M., Brooks, A., and Obenchain, J. V. (1995). Treatment
of Vietnam War Veterans with PTSD: A comparison of eye movement
desensitization and reprocessing, biofeedback, and relaxation training.
Journal of Traumatic Stress, 8, 337-342. doi:10.1007/BF02109568 PILOTS
ID: 12519
Program evaluation of 100 Veterans treated in a VA specialized
inpatient program showed that those who received EMDR had greater
improvements than those who received relaxation or biofeedback in PTSD
and other symptoms.
Complementary and Alternative Medicine
1.Bormann, J. E., Thorp, S. R., Wetherell, J. L., Golshan, S., and
Lang, A. J. (2012, March 12). Meditation-based mantram intervention for
Veterans with posttraumatic stress disorder: A randomized trial.
Psychological Trauma: Theory, Research, Practice, and Policy. Advance
online publication. doi:10.1037/a0027522 PILOTS ID: 38465
In this RCT, 146 outpatient Veterans with PTSD were assigned to
receive usual care (medication and case management alone) or usual care
plus a mantram repetition program. Participants who received mantram
repetition had greater improvements in self-reported and clinician-
rated PTSD symptoms and in depression, mental health status, and
existential spiritual well-being.
2.Niles, B. L., Klunk-Gillis, J., Ryngala, D. J., Silberbogen, A.
K., Paysnick, A., and Wolf, E. J. (2012) November 14). Comparing
mindfulness and psychoeducation treatments for combat-related PTSD
using a telehealth approach. Psychological Trauma: Theory, Research,
Practice, and Policy, 4, 538-547. doi:10.1037/a0026161 PILOTS ID: 37920
In this RCT, 33 male combat Veterans with PTSD were assigned to one
of two telehealth treatment conditions: mindfulness or psychoeducation.
In the 24 participants who completed all assessments, participation in
the mindfulness intervention was associated with a temporary reduction
in PTSD symptoms. The authors concluded that a brief mindfulness
treatment may not be of adequate intensity to sustain effects on PTSD
symptoms.
Integrated Care
1.Cigrang, J. A., Rauch, S. A. M., Avila, L. L., Bryan, C. J.,
Goodie, J. L., Hryshko-Mullen, A., . . . STRONG, S. C. (2011).
Treatment of active-duty military with PTSD in primary care: Early
findings. Psychological Services, 8, 104-113. doi:10.1037/a0022740
PILOTS ID: 36597
This pilot study evaluated a brief cognitive behavioral therapy
protocol that included elements of PE and Cognitive Processing Therapy
for treating PTSD in 15 Veterans in a primary care setting. There were
large decreases in self-reported and clinician-rated PTSD but symptoms
still remained high after treatment.
2.Jakupcak, M., Wagner, A. W., Paulson, A., Varra, A. A., and
McFall, M. E. (2010). Behavioral activation as a primary care-based
treatment for PTSD and depression among returning Veterans. Journal of
Traumatic Stress, 23, 491-495. doi:10.1002/jts.20543 PILOTS ID: 80064
This pilot study of 8 OEF/OIF Veterans who received Behavioral
Activation as a primary care-based treatment for PTSD found that there
improvements in PTSD following treatment that were maintained at 3-
month follow up. The majority of Veterans demonstrated meaningful
improvements on depression and quality of life and reported high
treatment satisfaction.
3.McFall, M., Saxon, A. J., Malte, C. A., Chow, B., Bailey, S.,
Baker, D. G., Beckham, J. C., Boardman, K. D., et al., for the CSP 519
Study Team. (2010). Integrating tobacco cessation into mental health
care for posttraumatic stress disorder: A randomized controlled trial.
Journal of the American Medical Association, 304, 2485-2493.
doi:10.1001/jama.2010.1769 PILOTS ID: 35450
This randomized clinical of integrated smoking cessation for 943
smokers with military-related PTSD, recruited from outpatient PTSD
clinics at 10 VAMCs found that Veterans who were referred to integrated
smoking cessation treatment had better smoking outcomes relative to
Veterans who were referred to usual care VA smoking cessation clinics.
There was no worsening of PTSD symptoms in either group. Both groups
had small (10 percent) reductions in clinician-rated PTSD.
- Please describe each incident referenced in your above statement
where VA is able to demonstrate ``the direct impact'' of the mental
health care VA provides on the subsequent mental health of the veterans
who access that care.
VA Response:
As part of its strong commitment toward providing high quality
mental health care, VHA has been working to nationally disseminate and
implement specific evidence-based psychotherapies (EBP) for PTSD and
other mental and behavioral health conditions. As part of this effort
to make these treatments widely available to Veterans, VHA has
implemented competency-based staff training programs in PE therapy and
CPT for PTSD, as well as training programs in EBPs for other
conditions. Both PE and CPT are recommended in the VA/Department of
Defense Clinical Practice Guideline for PTSD at the highest level,
indicating ``a strong recommendation that the intervention is always
indicated and acceptable.'' As of March 1, 2013, VHA had provided
training in PE and/or CPT to more than 4,700 staff. Program evaluation
results indicate that the implementation of PE and CPT by newly-trained
staff has resulted in significant positive patient outcomes, with
average reductions of approximately 20 points on the PTSD checklist
(Chard, Ricksecker, Healy, Karlin, & Resick, 2012; Eftekhari, Ruzek,
Crowley, Rosen, Greenbaum, and Karlin, 2012). Program evaluation
results associated with the implementation of EBPs for other
conditions, including Cognitive Behavioral Therapy and Acceptance and
Commitment Therapy for depression and Cognitive Behavioral Therapy for
insomnia, indicate large overall reductions in symptoms and
improvements in quality of life among Veterans (Karlin et al., 2012, in
press; Karlin, Trockel, Taylor, Gimeno, and Manber, in press).
References
Chard, K. M., Ricksecker, E. G., Healy, E., Karlin, B. E., and
Resick, P. A. (2012). Dissemination and experience with Cognitive
Processing Therapy. Journal of Rehabilitation Research and Development,
49, 667-678.
Eftekhari, A., Ruzek, J. I., Crowley, J., Rosen, C., Greenbaum, M.
A., and Karlin, B. E. (2012). Effectiveness of national implementation
of Prolonged Exposure Therapy in VA care. Manuscript submitted for
publication.
Karlin, B. E., Brown, G. B., Trockel, M., Cunning, D., Zeiss, A.
M., and Taylor, C. B. (2012). National dissemination of Cognitive
Behavioral Therapy for depression in the Department of Veterans Affairs
health care system: Therapist and patient-level outcomes. Journal of
Consulting and Clinical Psychology, 80, 707-718.
Karlin, B. E., Trockel, M. Taylor, C. B., Gimeno, J., and Manber,
R. (in press). National dissemination of Cognitive Behavioral Therapy
for insomnia in Veterans: Clinician and patient-level outcomes. Journal
of Consulting and Clinical Psychology.
Karlin, B. E., Walser, R. D., Yesavage, J., Zhang, A., Trockel, M.,
and Taylor, C. B. (in press). Effectiveness of Acceptance and
Commitment Therapy for depression: Comparison among older and younger
veterans. Aging and Mental Health.
4. In response to my question regarding how the Committee can
assist VA in providing quality and timely mental health care services
to veteran patients, you stated that the Committee may help in: (1)
facilitating interactions between VA and community health centers; (2)
helping VA interact better with private sector providers; and, (3)
addressing the shortage of psychiatrists.
Please expand on how you believe the Committee could be of
assistance to the Department in each of the three areas listed above.
VA Response:
VA appreciates the on-going support of the Committee for its
mission of providing quality and timely mental health care to Veterans.
Regarding interactions between VA and community health centers and
interactions between VA and private sector providers, expanding
opportunities in both areas would benefit from improved information
technology (IT) capabilities. On-going support for graduate medical
education and training in psychiatry is important to continue.
5. In response to my question regarding how VA has been able to
hire increased numbers of mental health providers, you stated that,
``[o]f all of the professionals in mental health, the most difficult
problem we are having is recruiting psychiatrists, and we have barely
been able to recruit half of the new ones that we said we wanted to do,
and that it is in spite of raising the salary quite substantially,
providing incentives for recruitment, bonuses, etc.''
Please provide further details on the salary raises, recruitment
incentives, bonuses, and any and all other actions VA has taken in an
effort to recruit and retain psychiatrists.
Please describe any and all actions beyond the ones referenced
above that VA has taken or is considering taking to alleviate the
difficulties VA has experienced recruiting psychiatrists (i.e.
undertaking additional recruitment and retention incentives, increasing
partnerships with non-VA resources, recruiting increased numbers of
other mental health professionals, etc.).
VA Response:
VHA diligently uses the 3Rs (Recruitment, Relocation, Retention) to
recruit and retain psychiatrists, as well as providing competitive
salaries.
These are salary data for the psychiatrist (occupational series =
602 and assignment code = 31) at 5 points in time, presented as the
mean, minimum, and maximum at the end of each calendar year plus March
2012:
----------------------------------------------------------------------------------------------------------------
PSYCHIATRIST SALARY 12/31/2009 12/31/2010 12/31/2011 3/31/2012 12/31/2012
----------------------------------------------------------------------------------------------------------------
MEAN 175000 180487 182436 182991 186884
----------------------------------------------------------------------------------------------------------------
MIN 119000 124123 128117 129000 117589
----------------------------------------------------------------------------------------------------------------
MAX 277721 292987 250107 286848 286848
----------------------------------------------------------------------------------------------------------------
From 2009 to 2012 the psychiatrist average salary increased by
$11,884 or
6.3 percent, the minimum salary dropped by $1,411 or 1.2 percent,
and the maximum salary increased by $9,127 or 3.2 percent.
From March 31, 2012 to December 31, 2012, the psychiatrists'
average salary increased by $3,893 or 2 percent, the minimum salary
dropped by $11,411 or 9.7 percent, and the maximum salary stayed
steady.
These are the incentives the psychiatrist (occupational series =
602 and assignment code = 31) from the nature of action file (codes =
815, 816 and 827) for the 3Rs:
----------------------------------------------------------------------------------------------------------------
Grand Total
Time Period of Incentives Paid to Psychiatrists Recruitment Relocation Retention 3Rs
----------------------------------------------------------------------------------------------------------------
March 2012 - December 2012 $1,677,722 $503,674 $1,219,001 $3,400,397
----------------------------------------------------------------------------------------------------------------
CY 2011 $1,240,674 $332,752 $1,581,375 $3,154,801
----------------------------------------------------------------------------------------------------------------
CY 2012 $1,963,484 $543,174 $1,667,961 $4,174,619
----------------------------------------------------------------------------------------------------------------
From March 2012 to December 2012, VHA paid $3,400,397 in 3R
incentives to psychiatrists. In Calendar Year (CY) 2011, VHA paid
$3,154,801 in 3R incentives. In CY 2012, VHA paid $4,174,619 in 3R
incentives. This is an increase of $1,019,818 in 3R incentives, over a
single calendar year for this occupation.
VHA has implemented a robust and aggressive recruitment and
marketing strategy creating national awareness for the mental health
hiring initiative. Our practice opportunities were highlighted at 11
national and regional clinical conferences specifically targeting
psychiatrists and other mental health professionals. VHA requested that
its national recruiters recruit 170 psychiatrists for critical mental
health positions. They successfully recruited 166 psychiatrists against
that initial tasking. As a result of this success, VHA National
Recruiters have expanded their efforts with medical centers to
aggressively recruit the remaining psychiatrist vacancies. From March
2012 through June 2013, VHA has hired 403 psychiatrists.
Significant marketing milestones include national TV recruitment
commercials and public service announcements, 16 online campaigns, 15
direct mail campaigns (to include e-newsletters), 11 print advertising
campaigns, and an integrated social media plan on Facebook and Twitter.
We have established committed non-VA partnerships with 85 mental health
associations including American Psychological Association, 25
universities, and the National Rural Recruitment and Retention Network;
while continuing ongoing collaborative engagement with Veterans Service
Integrated Networks (VISN), program offices, and field public affairs
offices. Finally, we continue to adapt our strategy as needed, most
recently by implementing a Web form application feature on
www.vacareers.va.gov/mental-health/. Since finalizing the form on
February 26, 2013, we have processed over 1,000 online inquiries--
highlighting the tremendous interest from mental health practitioners.
Detailed Milestones in Effort to Hire Mental Health Professions:
VHA National Recruiters staffed booths at multiple mental
health professional association meetings nationwide from May to
November 2012 to collect contact information for candidates interested
in VHA mental health careers. Events included: American Psychiatric
Association, American Psychiatric Nurses Association, US Public Health
Service Scientific Symposium, VA for Veterans, Greil Mental Health
Hospital job fair, Career MD (multiple regions), NC Psychiatric
Association, International Association for Traumatic Stress Study, and
US Psychiatric and Mental Health Congress.
Print marketing templates targeted to Mental Health
available to facilities on May 30, 2012.
VISN, Program Office, and field Public Affairs Officers
were all briefed on the Mental Health Initiative.
VA Careers website updated to spotlight Mental Health
positions launched on May 18, 2012. Refresh of Mental Health banner on
VAcareers.va.gov.
Revised VHA Mental Health Hiring Initiative Poster
approved in collaboration with Office of Mental Health and uploaded on
AdCreator in VHA Recruiter Toolkit online for use in various sizes that
can be easily customized for local recruitment events to support the
initiative.
Mental Health Public Service Announcement featuring VA
Employee/ Olympic medalist Natalie Dell on VA YouTube. Distribution of
video nationally with hard copies to 200 media stations and digital
copies to 800 media outlets on October 1, 2012. Airings began on
October 10, 2012. Promotion on www.VAcareers.va.gov also went live
October 10, 2012. Reported as showing over 3800 times for a value
exceeding $1 million in free television advertising. This is currently
11 times the return on investment.
Mental Health Marketing Campaign has launched with
updates to www.VAcareers.va.gov making contact more readily accessible.
These efforts have already yielded more than 200 new leads in February
and March 2013. We are now targeting our efforts to the hard-to-fill
psychiatrists and PhD psychologists with leads assigned to VISN
Recruiters for follow-up. Enhanced Mental Health social media plan has
begun on Facebook and Twitter with record reach to over 68,000
prospects. Twitter #WorkatVA Launch: A twitter chat occurred on March
21, 2013, targeting Mental Health providers. VHA has promoted the event
as well.
VHA remains an ongoing partner with National Rural
Recruitment and Retention Network.
TV Recruitment Commercial has been awarded. Kickoff
meeting was conducted February 11, 2013. Existing content was aired
beginning the second week of March. Additional recruitment commercials
and public services announcements targeting health care providers will
be aired beginning in July to increase hiring and to increase hiring
awareness for VA hard-to-fill occupations nationwide.
Website Updates: We are developing a mockup of a material
download center that we will include on the VA Careers mental health
site. We feel that a designated download center on the mental health
hiring page will be the best way to ensure that our materials are
readily available to our target audience.
VHA's Workforce Management & Consulting Office (WMC) has
been actively working with the Office of Human Resource Management
(OHRM) to develop clear objectives for a Healthcare Recruitment
contract with a private sector search firm. OHRM has contacts with the
Office of Personnel Management (OPM) and the capability to establish
task orders against OPM contracts. Discussion with OPM regarding VA's
use of OPM contracts is ongoing. Since March 2012, the VHA National
Recruiters have successfully recruited 205 psychiatrists including the
initial 170 positions described above. Recruiters continue to actively
pursue candidates nationwide. When combined with the efforts of HR
staff nationwide, VHA has hired 403 psychiatrists since March 2012.
WMC continues to collaborate with the VHA Office of
Mental Health to market to relevant mental health provider associations
and recruitment events in FY 2013 as part of the Mental Health
marketing contract with partners Reingold and TMP Government.
Targeted Paid Media:
Psych News - quarter page, full-color print ad in the
June 15, 2012 issue (40,000+ circulation)
Psychiatric Times - quarter page, full-color print ad in
the June 2012 issue (40,000+ circulation)
Targeted email blast to 23,241 Psychiatry members of the
American Medical Association launched June 13, 2012
Psychiatric Times Career Opportunities eNewsletter
sponsorship reaching 65,000 Psychiatry opt-in subscribers - June 2012
issue
American Journal of Psychiatry eToc sponsorship reaching
30,000+ APA members - June 2012 issue
American Psychological Association (APA) also published
the following at no cost for VA:
-A lead news story in APA Access, APA's all member e-newsletter
-Placed the provided VA banner ad in APA Access
-Published a lead news story in PracticeUpdate, the e-newsletter of
the APA Practice Organization
Targeted Online Banner Advertising:
USAJobs Spotlight (received over 65,000 click-throughs to
VACareers)
AMHCA (American Mental Health Counselors Association)
NASW (National Association of Social Workers) through
June 2012
SocialWorkToday.com
American Psychiatric Association
American Counseling Association
Negotiated free 4-week banner run with HealtheCareers on
their Mental Health Specialty site
VA was November's featured Employer on National Rural
Recruitment and Retention Network (tie-in to Veterans Day)
Eleven website banner advertisements through Joining
Forces partnership across their networks
6. In response to a question from Ranking Member Michaud regarding
Section 3 of the Executive Order on Improving Access to Mental Health
Servicemembers, Veterans, and Their Families, you stated that, ``...15
pilots sites were selected ...based upon the desire of the local
network to participate, our hospital to participate, and a need
...identified often by how rural the areas were. There is one urban
center where we are doing this in Atlanta to get a feel for what they
might be like, because there are many, many community mental health
clinics in the Atlanta area.'' You further stated that, ``[w]e think
that this is...going to be a viable alternative in the future to us
cooperating in the community with providing care in these again remote
rural areas.''
Please name the location of each of the 15 selected pilot sites.
VA Response:
As of May 31, 2013, the Department of Veterans Affairs (VA) has
established pilot projects with 24 community-based mental health and
substance abuse providers across nine states and seven Veterans
Integrated Service Networks (VISNs). The twenty-four pilots have been
established across Georgia, Tennessee, Wisconsin, Mississippi, Alaska,
South Dakota, Nebraska, Indiana and Iowa. Pilot projects are varied and
may include provisions for inpatient, residential, and outpatient
mental health and substance abuse services. Sites may include
capabilities for tele-mental health, staff sharing, and space
utilization arrangements to allow VA providers to provide services
directly in communities that are distant from a VA facility. The pilot
project sites were established based upon community provider available
capacity and wait times, community treatment methodologies available,
Veteran acceptance of external care, location of care with respect to
the Veteran population, and mental health needs in specific areas.
MAY 31 PILOTS FOR VA COLLABORATION WITH COMMUNITY PROVIDERS
----------------------------------------------------------------------------------------------------------------
Geographic Location VISN VAMC Community Provider
----------------------------------------------------------------------------------------------------------------
1 Griffin, Georgia 7 Atlanta VAMC McIntosh Trail Community
Service Board (CSB)
----------------------------------------------------------------------------------------------------------------
2 Flowery Branch, Georgia 7 Atlanta VAMC Avita Community Partners
----------------------------------------------------------------------------------------------------------------
3 Atlanta, Georgia 7 Atlanta VAMC Peachford Behavioral
Health System
----------------------------------------------------------------------------------------------------------------
4 Atlanta, Georgia 7 Atlanta VAMC DeKalb Community Service
Board (CSB)
----------------------------------------------------------------------------------------------------------------
5 Canton, Georgia 7 Atlanta VAMC Highland Rivers
Community Service Board
(CSB)
----------------------------------------------------------------------------------------------------------------
6 Lawrenceville,7Georgia Atlanta VAMC View Point Health
----------------------------------------------------------------------------------------------------------------
7 Newport, Tennessee 9 James H. Quillen VAMC, Cherokee Health Systems
Mountain Home, TN
----------------------------------------------------------------------------------------------------------------
8 Mountain City, Tennessee 9 James H. Quillen VAMC, Frontier Health
Mountain Home, TN
----------------------------------------------------------------------------------------------------------------
9 Bedford, Indiana 11 Richard L. Roudebush Affiliated Service
VAMC, IndProviders of Indiana,
Inc. (ASPIN)
----------------------------------------------------------------------------------------------------------------
10 Columbus, Indiana 11 Richard L. Roudebush Affiliated Service
VAMC, IndProviders of Indiana,
Inc. (ASPIN)
----------------------------------------------------------------------------------------------------------------
11 Kokomo, Indiana 11 Richard L. Roudebush Affiliated Service
VAMC, IndProviders of Indiana,
Inc. (ASPIN)
----------------------------------------------------------------------------------------------------------------
12 Cashton, Wisconsin 12 Tomah VAMC Scenic Bluffs Health
Center
----------------------------------------------------------------------------------------------------------------
13 Bolivar County, 16 G. V. (Sonny) Montgomery Delta Community Mental
Mississippi VAMC, JacksHealth Services (DCMHS)
----------------------------------------------------------------------------------------------------------------
14 Gulfport/ Coastal 16 VA Gulf Coast Veterans Gulf Coast Community
Mississippi Health Care System,Mental Health Clinic
Biloxi, MS
----------------------------------------------------------------------------------------------------------------
15 Wrangall, Alaska 20 Alaska VA Healthcare Alaska Island Community
System Services (AICS)
----------------------------------------------------------------------------------------------------------------
16 Southeastern Alaska 20 Alaska VA Healthcare South East Alaska
System Regional Health
Consortium (SEARHC)
Behavioral Health
Department
----------------------------------------------------------------------------------------------------------------
17 Huron, South Dakota 23 Sioux Falls VA Health Community Counseling
Care System Services
----------------------------------------------------------------------------------------------------------------
18 Sioux Falls, South Dakota 23 Sioux Falls VA Health Southeastern Behavioral
Care System Health Care
----------------------------------------------------------------------------------------------------------------
19 Mitchell, South Dakota 23 Sioux Falls VA Health Dakota Counseling
Care System Institute
----------------------------------------------------------------------------------------------------------------
20 Cedar Rapids, Iowa 23 Iowa City VA Health Care Abbe Center for
System Community Mental Health
----------------------------------------------------------------------------------------------------------------
21 Des Moines, Iowa 23 Central Iowa VEyerly Ball Community
Care System Mental Health Center
----------------------------------------------------------------------------------------------------------------
22 Iowa City, Iowa 23 Iowa City VA Health Care Community Mental Health
System Center for Mid-Eastern
Iowa
----------------------------------------------------------------------------------------------------------------
23 Omaha, Nebraska 23 VA Nebraska-Western Iowa One World Community
Health Care System Health Center
----------------------------------------------------------------------------------------------------------------
24 Omaha, Nebraska 23 VA Nebraska-Western Iowa Charles Drew Health
Health Care System Center
----------------------------------------------------------------------------------------------------------------
Please describe, in detail, the criteria the Department used to
choose each of the sites named above.
VA Response:
To determine our top priorities for collaboration, VA assessed
recruitment success and difficulties as well as access to care issues
(performance measure information), such as wait times for appointments
and geographic distances to medical centers and/or Community-Based
Outpatient Clinics (CBOC). These factors were used as VA developed its
first round of pilot programs for community partnerships. Challenges in
recruitment vary across VHA due to the differences among VHA
facilities, patient need, and the local availability of mental health
professionals. Additionally, when developing the pilot programs VHA
considered not only community provider available capacity and wait
times, but treatment methodologies, Veteran acceptance of external
care, location of care with respect to the Veteran population, and
mental health needs in specific areas.
-Please expand on your statement above that enhanced partnerships
between VA and community partners is going to be a ``viable
alternative'' to ``cooperating in the community,'' to include what you
see these partnerships as an alternative to and whether or not you see
them as an asset in rural areas only or, potentially, in urban
communities as well and why.
VA Response:
These partnerships are being explored as an alternative to
traditional care defined as administered solely in a VA medical
facility setting. By utilizing the community partners, not only will
care be delivered closer to Veterans but potentially in a more familiar
and comfortable setting within the Veteran's own community. Bringing
care to a closer, familiar setting has been a successful model rolled
out in other areas of VA including: campus outreach Vet Centers, and
previous mental health programs partnership in particular the North
Shore-Long Island Jewish Health System. Additional care modalities are
also being explored through these pilot programs to determine their
feasibility as alternative methods of delivering care. Telemental
health will be evaluated at a number of sites and in various
representations through the pilots. Some pilots will include video
equipment being placed in community centers, with primary mental health
care provided by a clinician at the supporting VAMC. The community
provider will assist with administrative and crisis support. This will
be a closely monitored collaborative approach to the Veterans'
recovery.
Pilot programs are being explored in both rural and urban
communities. A shortage of providers is not limited to rural areas, and
returning Veterans will go back to all geographic areas. It is
important to determine the validity of community partnerships in both
settings to give all Veterans the opportunity for the quality care in
the setting they desire. Urban pilots may face their own set of
challenges. For example, urban pilots may be located in larger, busier,
louder areas that may require a different model of collaboration and
oversight. In one urban pilot, VA is placing liaisons in the community
centers to assist in Veteran-centric issues and follow up.
7. In response to a question from Ranking Member Michaud regarding
veteran suicide data, Dr. Janet Kemp, the Director of VA's Suicide
Prevention and Community Engagement Program, stated that, ``[t)here
[are] a couple of states that we are still working with over privacy
issues and how we are going to share data and I run confident that we
will get those soon.''
Please name the states referenced above.
Please describe any and all barriers, including privacy issues, to
the states referenced above providing VA with the requested data on
veteran suicide rates.
When does the Department expect that complete veteran suicide rate
data will be received from all 50 states?
VA Response:
We are continuing to receive information from the states. We have
attached the latest worksheet we are using to collect this information.
There are concerns expressed from the states concerning how we will use
the information, how we will protect the privacy of the people listed
in their data bases, and if the information can legally be sent to us.
Over time, VA has been able to resolve these issues with each State.
See the attached sheet with the information as of March 7th, which is
the latest available. The States with ``R'' - requested but not
received are the States we are currently still working with. South
Carolina has refused the initial request but is currently processing a
second request which we anticipate will also be denied.
Updated State Data Availability (March 7)
----------------------------------------------------------------------------------------------------------------
State/
Area 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
----------------------------------------------------------------------------------------------------------------
Alabama I I I I I I I I I I I I P
----------------------------------------------------------------------------------------------------------------
Alaska I I I I I I I I I I I I P
----------------------------------------------------------------------------------------------------------------
American R R R R R R R R R R R R R
Samoa
----------------------------------------------------------------------------------------------------------------
Arizona R R R R R R R R R R R R R
----------------------------------------------------------------------------------------------------------------
Arkansas A A A A A A A A A A A A A
----------------------------------------------------------------------------------------------------------------
Californ P P P P P P P P P P P P P
ia
----------------------------------------------------------------------------------------------------------------
Commonwe R R R R R R R R R R R R R
alth N.
Mariana
Islands
----------------------------------------------------------------------------------------------------------------
Colorado A A A A A A A A A A A A P
----------------------------------------------------------------------------------------------------------------
Connecti R R A A A A A A A A A R R
cut
----------------------------------------------------------------------------------------------------------------
Delaware P P P P P P P P P P P P P
----------------------------------------------------------------------------------------------------------------
Florida I I I I I I I I I I I I I
----------------------------------------------------------------------------------------------------------------
Georgia P P P P P I I I I I I P P
----------------------------------------------------------------------------------------------------------------
Guam R R R R R R R R R R R R R
----------------------------------------------------------------------------------------------------------------
Hawaii A A A A A A A A A A A A P
----------------------------------------------------------------------------------------------------------------
Idaho I I I I I I I I I I I I A
----------------------------------------------------------------------------------------------------------------
Illinois R R R R R R R R R R R R R
----------------------------------------------------------------------------------------------------------------
Indiana R R R R R R R R R R R R R
----------------------------------------------------------------------------------------------------------------
Iowa A A A A A A A A A A A A A
----------------------------------------------------------------------------------------------------------------
Kansas I I I I I I I I I I I I P
----------------------------------------------------------------------------------------------------------------
Kentucky R R R R R R R R R R R R R
----------------------------------------------------------------------------------------------------------------
Louisian A A A A A A A A A A A A P
a
----------------------------------------------------------------------------------------------------------------
Maine I I I I I I I I I I I P P
----------------------------------------------------------------------------------------------------------------
Maryland R R R R R R R R R R R R R
----------------------------------------------------------------------------------------------------------------
Massachu I I I I I I I I I I I P P
setts
----------------------------------------------------------------------------------------------------------------
Michigan I I I I I I I I I I I I P
----------------------------------------------------------------------------------------------------------------
Minnesot I I I I I I I I I I I I P
a
----------------------------------------------------------------------------------------------------------------
Mississi P P P P P P P P P P P P P
ppi
----------------------------------------------------------------------------------------------------------------
Missouri I I I I I I I I I I I P P
----------------------------------------------------------------------------------------------------------------
Montana A A A A A A A A A A A A P
----------------------------------------------------------------------------------------------------------------
Nebraska I I I I I I I I I I I I P
----------------------------------------------------------------------------------------------------------------
Nevada I I I I I I I I I I I I P
----------------------------------------------------------------------------------------------------------------
New A A A A A A A A A A A A A
Hampshi
re
----------------------------------------------------------------------------------------------------------------
New I I I I I I I I I I I I P
Jersey
----------------------------------------------------------------------------------------------------------------
New P P P P P P P P P P P P P
Mexico
----------------------------------------------------------------------------------------------------------------
New York I I I I I I I I I I I I P
----------------------------------------------------------------------------------------------------------------
New York I I I I I I I I I I I I P
City
----------------------------------------------------------------------------------------------------------------
North I I I I I I I I I I I I I
Carolin
a
----------------------------------------------------------------------------------------------------------------
North A A A A A A A A A A A A A
Dakota
----------------------------------------------------------------------------------------------------------------
Ohio A A A A A A A A A A A A A
----------------------------------------------------------------------------------------------------------------
Oklahoma I I I I I I I I I I I A P
----------------------------------------------------------------------------------------------------------------
Oregon A A A A A A A A A A A A P
----------------------------------------------------------------------------------------------------------------
Pennsylv A A A A A A A A A A A A P
ania
----------------------------------------------------------------------------------------------------------------
Philippi R R R R R R R R R R R R R
nes
----------------------------------------------------------------------------------------------------------------
Puerto R R R R R R R R R R R R R
Rico
----------------------------------------------------------------------------------------------------------------
Rhode A A A A A A A A A A A A A
Island
----------------------------------------------------------------------------------------------------------------
South C C C C C C C C C C C C C
Carolin
a
----------------------------------------------------------------------------------------------------------------
South P P P P P P P P P P P P P
Dakota
----------------------------------------------------------------------------------------------------------------
State R R R R R R R R R R R R R
Departm
ent
----------------------------------------------------------------------------------------------------------------
Tennesse A A A A A A A A A A A A A
e
----------------------------------------------------------------------------------------------------------------
Texas A A A A A A A A A A A A A
----------------------------------------------------------------------------------------------------------------
Utah A A A A A A A A A A A A A
----------------------------------------------------------------------------------------------------------------
Vermont I I I I I I I I I I I P P
----------------------------------------------------------------------------------------------------------------
Virgin R R R R R R R R R R R R R
Islands
----------------------------------------------------------------------------------------------------------------
Virginia I I I I I I I I I I I I I
----------------------------------------------------------------------------------------------------------------
Washingt I I I I I I I I I I I I I
on
----------------------------------------------------------------------------------------------------------------
Washingt P P P P P P P P P P P P P
on D.C.
----------------------------------------------------------------------------------------------------------------
West I I I I I I I I I I I I P
Virgini
a
----------------------------------------------------------------------------------------------------------------
Wisconsi A A A A A A A A A A A A P
n
----------------------------------------------------------------------------------------------------------------
Wyoming A A A A A A A A A A A A A
----------------------------------------------------------------------------------------------------------------
I = data included in initial report,
A = available for future analysis,
P = pending state approval/processing,
R = requested but not received,
C = being processed
8. In response to a question from Ranking Member Michaud regarding
performance requirements for VA mental health providers, you stated
that, ``....it is important to have performance measures, and I think
it is incumbent upon us as the leaders to make sure that there is the
proper balance between time available to do clinical care, and the
necessity of meeting performance measures.''
Please name each of the current performance measures (including any
and all clinical reminders) currently in place for VA mental health
care providers, to include the justification for using each measure and
how long it has been in place.
VA Response:
There are 4 mental health performance measures in VHA's FY 2013
Performance Plan:
Percent of new mental health appointments completed
within 14 days of the create date for the appointment - New as a
performance measure in FY 2013.
Percent of established mental health patients with a
scheduled appointment within 14 days of the desired date for the
appointment - New as a performance measure in FY 2013.
Percent of patients discharged from an inpatient mental
health unit who receive outpatient mental health follow-up within seven
days of discharge - Started in FY 2009.
Percent of targeted population of OEF/OIF/OND Veterans
with a primary diagnosis of PTSD who receive a minimum of eight
psychotherapy sessions within a 14-week period - Started in FY 2012.
Clinical reminders are not considered performance measures. The
clinical reminder system helps providers deliver higher quality care to
patients for both preventive health care and management of chronic
conditions, and helps ensure that timely clinical interventions are
initiated. Reminders assist clinical decision-making and also improve
documentation and follow up, by allowing providers to easily view when
certain tests or evaluations were performed and to track and document
when care has been delivered. They can direct providers to perform
certain tests or other evaluations that will enhance the quality of
care for specific conditions. The clinicians can then respond to the
reminders by placing relevant orders or recording clinical activities
on patients' progress notes.
Clinical reminders may be used for both clinical and administrative
purposes. However, the primary goal is to provide relevant information
to providers at the point of care, for improving care for Veterans.
Clinical reminders support clinicians by providing pertinent data for
clinical decision-making, reducing duplicate documenting activities,
assisting in targeting patients with particular diagnoses and
procedures or site-defined criteria, and assisting in compliance with
VHA performance measures and with health promotion and disease
prevention guidelines.
While some clinical reminders are national, facilities/VISNs also
develop clinical specific reminders to support quality improvement
efforts. Responsibility for completing clinical reminders is also left
to the discretion of facilities/ VISNs.
The national mental health clinical reminders, deployed throughout
the system, include:
Primary care screens: Primary care providers complete most of these
reminders but are supported by mental health. These reminders are
conducted annually to ensure all primary care patients are assessed for
common mental health diagnoses. If the screen is positive for the first
three measures below, additional follow up is required. The Military
Sexual Trauma (MST) screen is completed one time to assess for a
history of MST during military service. All Veterans who respond
positively to the screen are offered a referral for mental health
services. VA medical centers are expected to refer the Veteran to
appropriate services in the event the Veteran tests positive from the
homeless screener. If homelessness screen is positive for actual
homelessness, the Veteran is immediately referred to the local VA
facility homeless services team and if the homelessness screen is
positive for being at risk for homelessness, the Veteran is referred to
social work services.
Alcohol Use Screen
I Alcohol Use Positive follow-up evaluation
Depression Screen
I Depression Positive follow-up evaluation
PTSD Screen
I PTSD Positive follow-up evaluation
Military Sexual Trauma (MST) Screening
Homelessness Screening
Specialty mental health reminders:
PTSD Reassessment - to support administration of the PTSD
checklist for patients receiving treatment for PTSD
Mental health high risk no show follow up - to support
tracking high risk patients that have missed an appointment
Please describe how you, as the Under Secretary for Health, ensure
a ``proper balance'' between measuring provider performance and
ensuring sufficient clinical care.
VA Response:
VHA's performance measurement system was developed to improve
quality of care and to support strategic planning. The key aspects of
the Performance Measurement Program are to:
Demonstrate an integrated health system consistently
using the best scientific evidence in clinical practice to reliably and
efficiently achieve the highest quality health outcomes
Set national benchmarks for the quality of preventive and
therapeutic healthcare services that exceed private sector performance
Facilitate provision of care to a larger Veteran
population without increasing health care expenditures
Align resources to support strategic initiatives
While strategic directions are codified by VHA leadership,
performance measures typically require review and input from front line
providers, subject matter experts, external stakeholders, health care
policy experts, regulators, and others as they are developed and
implemented. In the past, these measures frequently were also used as
part of employee performance plans to support implementation. In the
last few years, VHA has been reducing its use of the performance
measurement system in reviewing individual performance and has sought
to achieve system compliance with the measures without inclusion in
performance plans.
9. In response to a question from Representative Runyan regarding
the need to be proactive in addressing veterans' mental health needs,
you discussed the need to develop close, trusting relationships between
veteran patients and VA mental health providers. You stated that VA
needed to focus on, ``...developing the relationships where [veteran
patients] will tell us where there are things that may be antecedents
to suicide that are bothering them,'' and, ``[i]t is getting the
information, and the contact with the individual before they have the
difficulty as you have pointed is the problem.'' In response to a
similar question from Representative Brownley, you stated that,'' ...we
have a newly organized task force that Dr. Kemp is chairing that is
going to look at how we can develop a different paradigm if you will
for the way we deliver care to people that have chronic pain, sleep
disorders, depression, etc., the things that have the greatest impact
on suicide.''
How does VA foster such relationships between VA providers and
veteran patients?
VA Response:
Establishment of healing relationships between providers and
Veterans is fundamental to care. This includes not only the individual
provider but the healthcare team as a whole. Mental health providers
are trained to reach out to Veterans and develop relationships based
upon trust, including the ethical principles of respect for autonomy,
beneficence, non-malfeasance, justice, and integrity. VA providers and
Veterans jointly develop goals for treatment (VHA Strategic Plan, FY
2013) based on Veteran preferences. The VA mental health provider is
charged with providing a full breadth of information about mental
health services available to assist the Veteran in collaboratively
establishing the plan of care and ensuring that the Veteran receives
any needed care. In VA, mental health providers are embedded in
multiple settings including the Patient Aligned Care Team (PACT),
Geriatric and Extended Care settings, as well as in specialty mental
health to support both individualized outreach and coordination of
care. The VHA Strategic Plan emphasizes personalized, proactive,
patient-driven healthcare with the sub-goals of effective communication
and convenient access to information, advice and support.
What different paradigms is the taskforce referenced above looking
at regarding the delivery of mental health care and when is that work
expected to be complete?
VA Response:
The VA's Mental Health Innovations Task Force is embarking on a
groundbreaking proactive, population-based approach that is designed to
address antecedents to suicidal behavior, by creating strategies to
reach Veterans before they are in crisis and establishing a sustained
relationship that connects all aspects of their life with an emphasis
on mental health and wellbeing. This holistic approach to addressing
suicide prevention will build on our understanding of diagnoses known
to increase risk and effective evidence-based treatments and will
expand our approaches to proactive strategies which are often not a
part of our current treatment plans, moving beyond simple
identification and treatment of specific diseases. Our goal is to focus
on the Veteran (whole person), the community where he or she lives, and
the inclusion of proactive health strategies and approaches to optimize
mental health and wellbeing. This will require a culture change, which
takes time in any organization along with a communications strategy and
the development of tools providers can use to assist them in creating
this climate of personalized care. The initial strategic plan for the
taskforce includes a series of action steps with delivery dates that
began in February 2013 and extend into 2014, and beyond that there will
be an on-going process of implementing the lessons learned through this
initiative.
10) In response to a question from Representative Coffman regarding
VA mental health care providers, you stated that, ``...this spring [we
have] implemented our performance criteria for timeliness, the
intention is to go out and do three things. One, look at the measures.
Two, survey veterans as to whether or not they were- had timely access
as well as other satisfaction related questions. And three, to survey
the staff. Are they able to provide timely access for their patients,
are they adequately staffed, do they have enough people to do the work
that they are being required. So, yes, we are going to do it. And we
will be doing that on a regular basis''
Please provide the timeliness performance criteria referenced
above.
VA Response:
VHA has two measure of timeliness for mental health:
Percent of new mental health appointments completed
within 14 days of the create date for the appointment - new as a
performance measure in FY 2013.
Percent of established mental health patients with a
scheduled appointment within 14 days of the desired date for the
appointment - new as a performance measure in FY 2013.
Please provide information regarding the survey of veteran patients
referenced above, to include the number of veteran patients expected to
be surveyed, the questions expected to be included on the survey, the
method expected to be used to conduct the survey (i.e., in person,
electronic, via telephone, etc.), the expected survey results, the
expected total cost of the survey, and any and all follow-up actions
expected to result from the survey.
VA Response:
The Veteran survey is attached below, and VHA plans to distribute
the survey to 10,000 Veterans. VHA is still developing the method of
distribution; cost of distribution will be related to the actual method
used. VHA will use the information in two ways: 1) as an overall
measure of Veteran perceptions of care that can be trended over time;
2) as feedback to assist individual facilities in developing action
plans to address barriers to access perceived by Veterans at their
sites.
OFFICE OF MENTAL HEALTH VETERAN SATISFACTION SURVEY
The Paperwork Reduction Act of 1995 requires us to notify you that
this information collection is in accordance with the clearance
requirements of section 3507 of this Act. Accordingly, we may not
conduct or sponsor and you are not required to respond to a collection
of information unless it displays a valid OMB number. We anticipate
that the time expended by all individuals who complete this survey will
average 15 minutes. This includes the time it will take to read
information provided and gather the necessary facts to fill out the
form. Submission of this form is voluntary and failure to respond will
have no impact on benefits to which you may be entitled. Responses to
the survey will be reported in aggregate form and will be anonymous.
For each item identified below, circle the number to the right that best
fits your judgment of its occurence at your facility. Use the scale
above to select the frequency number
------------------------------------------------------------------------
Neither
Survey Strongly Disagree Disagree Agree Strongly NA or
Item Disagree or Agree Agree Unknown
------------------------------------------------------------------------
1. I get 1 2 3 4 5 NA
appoint
ments
with my
mental
health
provide
r on
the day
that I
want or
within
two
weeks
of the
day
that I
want
------------------------------------------------------------------------
2. I can 1 2 3 4 5 NA
see my
mental
health
provide
r who
prescri
bes my
medicat
ions as
frequen
tly as
needed
------------------------------------------------------------------------
3. If I 1 2 3 4 5 NA
have a
questio
n about
my
psychia
tric
medicat
ions, I
can get
in
touch
with a
mental
health
provide
r or
pharmac
ist by
phone
to get
my
questio
n
answere
d
------------------------------------------------------------------------
4. I 1 2 3 4 5 NA
talk to
the
person
who
prescri
bes my
mental
health
medicat
ion by
Telemen
tal
health
(V-Tel)
------------------------------------------------------------------------
5. I 1 2 3 4 5 NA
talk to
my
counsel
or/
therapi
st by
Telemen
tal
health
(V-Tel)
------------------------------------------------------------------------
6. There 1 2 3 4 5 NA
are
problem
s
getting
the
Telemen
tal
health
(V-Tel)
equipme
nt to
work
------------------------------------------------------------------------
7. 1 2 3 4 5 NA
Mental
health
treatme
nt has
been
helpful
in my
life
------------------------------------------------------------------------
8. I was 1 2 3 4 5 NA
able to
choose
which
of the
psychot
herapie
s I
wanted
to try
after
good
discuss
ion
with my
mental
health
provide
r about
the
options
------------------------------------------------------------------------
9. I 1 2 3 4 5 NA
believe
it is
necessa
ry for
me to
stay in
mental
health
treatme
nt to
keep my
service
connect
ed
disabil
ity
------------------------------------------------------------------------
10. I 1 2 3 4 5 NA
would
like to
schedul
e
mental
health
appoint
ments
during
extende
d hours
(early
morning
s,
evening
s, or
on
weekend
s)
------------------------------------------------------------------------
11. It 1 2 3 4 5 NA
is hard
to get
to my
mental
health
appoint
ments
because
of
transpo
rtation
problem
s
------------------------------------------------------------------------
12. 1 2 3 4 5 NA
Parking
is a
problem
at my
facilit
y
------------------------------------------------------------------------
13. My 1 2 3 4 5 NA
mental
health
appoint
ments
are
schedul
ed by
VA
without
any
input
from me
------------------------------------------------------------------------
14. I 1 2 3 4 5 NA
get a
reminde
r call
or
letter
about
my
mental
health
appoint
ments
------------------------------------------------------------------------
15. I 1 2 3 4 5 NA
attend
group
mental
health
treatme
nt, and
the
room
comfort
ably
fits
all the
group
partici
pants
------------------------------------------------------------------------
16. When 1 2 3 4 5 NA
I have
an
individ
ual
mental
health
session
with my
provide
r, we
meet in
a room
that is
private
------------------------------------------------------------------------
17. I 1 2 3 4 5 NA
know
that I
will
get a
call
back if
I leave
a
message
for my
mental
health
provide
r
------------------------------------------------------------------------
18. My 1 2 3 4 5 NA
mental
health
provide
r and I
agree
on how
often I
should
have
appoint
ments
------------------------------------------------------------------------
19. I 1 2 3 4 5 NA
can't
see my
mental
health
provide
r as
much as
I
should
because
the
provide
r does
not
have
time to
see me
------------------------------------------------------------------------
20. I am 1 2 3 4 5 NA
comfort
able in
the
waiting
area
for
mental
healthc
are
------------------------------------------------------------------------
21. The 1 2 3 4 5 NA
staff
is open
to my
suggest
ions
regardi
ng
improve
ments
to
mental
health
service
s
------------------------------------------------------------------------
22. I am 1 2 3 4 5 NA
treated
with
respect
and
kindnes
s at
the
mental
health
program
s
------------------------------------------------------------------------
23. 1 2 3 4 5 NA
During
our
appoint
ments,
my
mental
health
provide
r
focuses
on the
compute
r
rather
than
engagin
g with
me in
face-to-
face
eye
contact
------------------------------------------------------------------------
24. I 1 2 3 4 5 NA
know
that
there
are
mental
health
provide
rs
availab
le
right
in
Primary
Care
------------------------------------------------------------------------
25. My 1 2 3 4 5 NA
primary
care
provide
r
prescri
bes my
psychia
tric
medicat
ions,
such as
medicin
e to
help
with
depress
ion or
nervous
ness
------------------------------------------------------------------------
26. My 1 2 3 4 5 NA
family
has
been
involve
d in
mental
health
treatme
nt with
me as
much as
I would
like
them to
be
involve
d
------------------------------------------------------------------------
WRITE IN SECTION:
27. My Mental Health Treatment Coordinator is:
28. The biggest problem or concern I have about Mental Health
Treatment is:
29. The biggest compliment or positive I have about Mental Health
Treatment is:
If you wish to discuss your experience, please feel free to contact
your Mental Health Treatment Coordinator, facility Mental Health Chief,
Local Recovery Coordinator, or other Mental Health staff.
Please provide information regarding the survey of VA mental health
care providers referenced above, to include the number of VA mental
health providers expected to be surveyed, the questions expected to be
included on the survey, the method expected to be used to conduct the
survey (i.e., in person, electronic, via telephone, etc.), the expected
survey results, the expected total cost of the survey, and any and all
follow-up actions expected to result from the survey.
When does the Department expect all three of the above actions to
be completed?
VA Response:
VA has completed the implementation of the new performance measures
although we will be rolling out new processes to support the
implementation of these measures throughout FY 2013, notably the use of
the ``Agreed upon Date'' for documenting the desired date. VA has
administered the Mental Health Provider Survey in September 2012 to
collect baseline data, although additional data was collected from non-
responding facilities in January 2013. VHA will re-administer this
survey in September 2013. VHA will implement the Veteran Survey in the
summer 2013.
How often does the Department expect to conduct follow-up surveys
of veteran patients accessing VA mental health care?
VA Response:
Annually.
How often does VA expect to conduct follow-up surveys of VA mental
health providers?
VA Response:
Annually.
Department of Veterans Affairs Responses to Questions from Congressman
Jeff Denham
1. As we have heard the hearing, the conflicts in Afghanistan and
Iraq have created extraordinary demands for care as veterans return
from theater. For those with PTSD or other mental health issues, long
waits for treatment can put them at risk for suicide or other
behavioral problems.
Has VA considered short-term solutions to address the immediate
mental health need while it recruits and hires the staff it needs long
term?
VA Response:
VA has been expanding the use of technology to improve access to
care especially in rural areas or areas where it is difficult to hire
staff. VA has increased the use of telemental health to allow VA to use
provider resources from areas with capacity to deliver services to
areas that have limited provider resources. VA has expanded this
service to begin implementation of telemental health home based care
ensuring further improvements in accessibility. In addition, VA
continues to develop Mobile Applications such as the PTSD Coach to
support clinical service delivery.
VA recognizes that not all access issues can be resolved through
staffing. In some instances, access issues may be the result of
inefficient care delivery processes or difficulties in implementation
of specialty programs. VA has been conducting site visits at all of its
health care systems to review mental health program implementation and
to provide consultation on areas needing improvement.
Also, VA is utilizing community providers to provide mental health
services through the Non-VA Medical Care Program. Also, as part of the
President's Executive Order, VA has established 15 pilot programs to
support improving access to care. In addition, VA will continue to
monitor access and wait times to ensure continual improvement in access
going forward.
2. I understand that VA has been conducting pilot programs designed
to provide veterans with access to community-based mental health
services in several rural communities like mine. For veterans that are
able to get into one of these programs, they provide needed care closer
to the veteran's home. However, I understand that use of these pilots
by VA facilities has been very low.
What are you doing to encourage use of these programs in rural
communities?
VA Response:
The first pilots, initiated under the direction of the Executive
Order, were brought on line during the last week of February 2013.
These pilots include a number of rural community sites. There has been
a positive response not only from the medical center staff and the
community partners but among the Veterans. VA management, from the
Under Secretary of Health to network directors to center directors, has
made this a priority to implement and oversee these pilots. By early
inclusion of both sides of the partnership and allowing the sites the
leeway to define their programs based on local needs, we have achieved
early buy in from facilities and staff. To preserve the initial
enthusiasm about these pilots regular calls are conducted not only with
each local site but with the nationwide group to encourage information
sharing and lessons learned. Veterans are encouraged to participate in
a number of ways. The sites are using email and local announcements to
ensure staff are aware of the pilot program and the potential for
inclusion of Veterans the pilot. Veteran case files must be reviewed
for Veterans that match the treatment types and locations being offered
through the pilot. VA staff contact the Veteran and explain the program
and offer the opportunity to participate. One key to working towards a
successful outcome and continued participation by all parties will be
continued communication and coordination between the VA, the community
partner, and the Veteran. Community partners are also reviewing their
case files for Veterans that may not be enrolled with the VA, and
working with their pilot contacts at the medical centers to contact and
enroll these Veterans.
Are there any plans to expand these rural pilot programs, to other
rural communities across the country?
VA Response:
Although only 15 pilots were required in the Executive Order, as of
May 31, 2013, the Department of Veterans Affairs (VA) has established
pilot projects with 24 community-based mental health and substance
abuse providers across nine states and seven Veterans Integrated
Service Networks (VISNs). The twenty-four pilots have been established
across Georgia, Tennessee, Wisconsin, Mississippi, Alaska, South
Dakota, Nebraska, Indiana and Iowa. VA plans to allow these pilots to
move forward for one year and then evaluate whether further expansion
is recommended.
Department of Veterans Affairs Responses to Questions from
Congresswoman Jackie Walorski
1. During the hearing, we heard how veterans are discouraged with
long wait times in-between appointments and consequently drop out of
treatment.
What is VA doing to improve mental health wait times for veteran
patients accessing VA mental health care?
VA Response:
VA has the responsibility to meet and anticipate the needs of
returning Veterans. VA has a multipronged strategy for improving mental
health wait times for Veterans accessing VA mental health including:
Hiring and staffing initiatives;
Expansion of the use of technology;
Quality improvement initiatives; and
Development of community contracts.
In FY 2012, VA began the development and implementation of a
general outpatient mental health staffing model to provide guidance to
VA facilities and VISNs to ensure a consistent level of mental
staffing. To support the implementation of the model, VA initiated an
aggressive hiring plan to hire 1,600 mental health clinicians and 300
clerical support staff, as well as to ensure that vacancies are filled
in a timely fashion. VA is also enhancing the training programs for
mental health professionals over the next few years to increase the
number of psychiatrists, psychologists, nurses, social workers, and
pharmacists. In addition, as part of the President's Executive Order,
VA is hiring 800 peer specialists to provide additional coverage for
mental health treatment teams.
VA has been expanding the use of technology to improve access to
care especially in rural areas or areas where it is difficult to hire
staff. VA has increased the use of telemental health to allow VA to use
provider resources from areas with capacity to deliver services to
areas that have limited provider resources. VA has expanded this
service to begin implementation of telemental health home-based care
ensuring further improvements in accessibility. In addition, VA
continues to develop mobile applications such as the PTSD Coach to
support clinical service delivery.
VA recognizes that not all access issues can be resolved through
staffing. In some instances, access issues may be the result of
inefficient care delivery processes or difficulties in implementation
of specialty programs. VA has been conducting site visits at all of its
health care systems to review mental health program implementation and
to provide consultation on areas needing improvement.
Also, VA is utilizing community providers to provide mental health
services through the non-VA Medical Care Program. As part of the
President's Executive Order, VA is in the process of establishing 15
pilot programs to support improving access to care. In addition, VA
will continue to monitor access and wait times to ensure continual
improvement in access going forward.
2. How is VA working to better accommodate veterans who have
transitioned into the civilian world and all the new responsibilities
they must deal with while trying to seek the health care?
VA Response:
In order to expand the number of providers available beyond
traditional business hours, VHA released a directive on January 9,
2013, on ``Extended Hours Access for Veterans Requiring Primary Care
Including Women's Health and Mental Health Services at Department of
Veterans Affairs (VA) Medical Centers and Selected Community-Based
Outpatient Clinics.'' This increases VA's commitment to offering
appointments during evenings or weekends. Benchmarks are currently
being set to ensure implementation of this directive across the VA
system.
Integrating mental health care into primary care settings is a
critical element of increasing the availability of mental health care
for Veterans. VA's Primary Care-Mental Health Integration programs
combine co-located collaborative care and care management (often by
telephone) to support primary care providers in treating common mental
health conditions within the primary care setting. Through the first
quarter of FY 2013, 88 percent of VA medical centers and COBCs
classified as large and very large have integrated behavioral health
programs, and 6.3 percent of all primary care patients at these sites
were directly served by these programs.
As part of the Department of Defense (DoD)/VA Integrated Mental
Health Strategy, VA and DoD are collaborating on the development of
Web-based self-help resources for common issues experienced by Veterans
after they have transitioned into the civilian world. These programs
allow for 24-hour, anonymous, self-paced access and can be used by
Veterans on their own or in conjunction with mental health treatment.
In November 2012, the Moving Forward program was launched online
(www.startmovingforward.org). Moving Forward is an educational, life-
coaching program for individuals who are having problems, but are not
yet in need of or willing to engage in mental health treatment. The
program is based on the principles of Problem Solving Therapy, an
evidenced-based cognitive behavioral treatment for depression and other
distress. The Moving Forward Web course uses highly interactive, multi-
media presentations to teach problem-solving skills through text,
videos, exercises and games. The second course, Parenting for
Servicemembers and Veterans, is in the final stages of development and
will be launched in FY 2013. It is a free online course that will
provide Military and Veteran parents with tools to help them reconnect
with their families and build closer relationships with their children.
Using stories from real Veteran and Military families, videos,
interactive activities, and original curriculum developed by leading
experts, this Web-based course is intended to help parents learn how to
address both everyday parenting problems and family issues unique to
their military experience.
In addition to innovative Web-based approaches, VA and DoD are
collaborating on mobile applications for smartphones and tablet
computers to enhance access to mental health information and care for
Veterans and Servicemembers. For example, VA and DoD jointly launched
the PTSD Coach smartphone application in April 2011. As of March 1,
2013, the PTSD Coach application has been downloaded more than 100,000
times in 74 countries. PTSD Coach helps users track their PTSD
symptoms, links them with public and personalized sources of support,
provides accurate information about PTSD, and teaches helpful
strategies for managing PTSD symptoms. PE Coach, another joint VA/DoD
mobile application, guides and facilitates evidence-based PE treatment
for PTSD. The application is designed to be installed onto a patient's
personal phone, brought into therapy sessions, and used during and
between treatment sessions. The application includes the ability to
audio record the therapy session (as required by the treatment
protocol) directly onto the patient's phone, removing the typical
logistical challenges associated with audio recording in the past. The
application also delivers text-based psychoeducational handouts as
multi-media experiences; provides all patient homework in a digital
format; utilizes an interactive breathing retraining tool to improve
learning and rehearsal of the PE relaxation skill; provides clinicians
with the ability to review compliance with PE protocol homework based
on patient's actual use of the various components of the PE Coach
application; integrates phone calendar functionality with the PE Coach
application to increase the likelihood of patient recall and attendance
of PE therapy sessions; tracks a patient's self-reported symptoms and
subjective distress over time; and, display outcomes for convenient
review of progress. These technological approaches are designed to
ensure availability of mental health information and facilitate
meaningful participation in mental health interventions in ways that
are more convenient and accessible to the Veteran.
Questions From: Hon. Michael Michaud, Ranking Minority Member, To:
Department of Veterans Affairs
1. As you heard in my opening statement, mental health is a
significant problem that faces the nation, not just veterans or the VA.
We have been told that shortages in mental health clinicians are
affecting health care systems across the nation. I imagine that
difficulty in finding qualified providers is most acute in the rural
and highly rural areas.
a. What have you done to work on a more collaborative basis with
other Federal agencies to implement programs that will grow the numbers
of qualified mental health providers?
2. The President's Executive Order required VA and HHS to work
together to establish 15 pilot projects with community based providers,
such as community mental health clinics, health centers, substance
abuse treatment facilities and rural health clinics.
a. Have these pilot sites been established?
b. Where are they located?
c. How were the locations of the pilot sites determined?
3. The President's Executive Order required VA to hire and train
800 peer to peer counselors by December 31, 2013.
a. Please provide us with an update on how many you have hired,
where they have been placed, and a brief description of the training
that VA will be providing to these new counselors.
4. Considerable concern has been voiced about the lack of
transitional services between the Department of Defense and VA,
especially as it relates to mental health and those on active duty who
are evidencing heightened risk of mental health issues. In testimony,
Dr. Rudd from the first panel stated that he is convinced that the bulk
of the problem is not a clinical one. He said we have to do a better
job of managing those at risk, providing easy and frequent access to
care, and convincing veterans to stay in care.
a. What are VA and DoD doing to work together to ensure that those
transitioning with mental health issues are not falling through the
cracks? Are we getting communities involved early in the process?
b. Is there something similar to a ``warm handoff'' that
servicemembers who are severely disabled experience?
c. If not, are we working toward that goal?
5. It is my understanding that VA now has Memorandums of
Understanding with all 50 States to share suicide data and that the
Suicide Data Report recently released by VA now includes State veteran
data which is a big step forward. However in this report many States
are not included, which limits the report somewhat. Could you please
tell the Committee:
a. What States are not included in the data?
b. What are the barriers or reasons why some States did not
participate?
c. Has VA reached out and made a good faith effort to get these
States to participate?
d. Moving forward how is VA planning to improve data collection?
6. I understand that since March VA has an additional 1150 mental
health clinical providers on board. I also understand that in addition
to the new hires of 1600 clinical and 300 administrative, VA continues
to fill existing and projected mental health vacancies within the VA
system.
a. What is VA's combined goal of new and existing vacancy hires?
b. Do you have a projected number of mental health clinicians that
will be on board and providng services to veterans?
c. Please provide an update on the total number of additional
mental health staff hired to-date, broken down by occupation, status
(whether full-time, part-time, clinical, administrative, other, or a
combination), Veterans Integrated Service Network (VISN) and veteran
status.
7. VA has reported that they need to substantially increase the
number of mental health trainees exposed to VA in their training years
by increasing the number of clinical training positions in mental
health to include nursing, pharmacy, psychology, psychiatry, and social
work for the 2013-14 academic year.
a. How is VA progressing with this increase in training positions?
b. What are the difficulties VA encounters when trying to recruit
residents who have not been exposed to VA?
c. Please provide a breakdown by discipline and number of positions
of the increase.
d. Have these positions been allocated throughout the VA health
care system?
8. There is concern in the community that veterans may not be
getting the kind of mental health care they need or the appropriate
intensity of care. Wounded Warrior Project conducted a survey of over
13,000 alumni, over a third of respondents reported difficulties in
accessing effective mental health care. Reasons given were inconsistent
treatments (e.g. canceled appointments, switch of providers, lapses in
between sessions, etc..) and not being comfortable with existing
resources.
a. Please provide a copy of the survey.
9. VHA policy requires all first-time patients referred to or
requesting mental health services receive an initial evaluation within
24 hours and a more comprehensive diagnostic and treatment planning
evaluation within 14 days. The primary goal of the initial 24 hour
evaluation is to identify patients with urgent care needs and to
trigger hospitalization or the immediate initiation of outpatient care
when needed.
a. Can you tell us what percentage of first-time patients are
actually identified as needing urgent care or hospitalization?
10. Please provide a copy of the mental health performance
requirements for all mental health settings.
Questions From: Congresswoman Julia Brownley, Ranking Minority Member,
Subcommittee on Health, Veterans Affairs, and Congressman Waxman, To:
the Department of Veterans Affairs
1. Mental Health Staffing
a. How many full-time mental health professionals have been hired
at each of the following facilities since January 1, 2012: the Oxnard
CBOC, Ventura Vet Center, and West LA VA?
b. How many part-time mental health professionals have been hired
at the Oxnard CBOC, Ventura Vet Center, and West LA VA over that time
period?
c. Please identify the program to which each full time and part
time mental health professional has been assigned.
2. Mental Health Funding
a. Please identify the funding levels for mental health services at
the Oxnard CBOC, Ventura Vet Center, and West LA VA for FY12 and FY 13.
b. Please include a detailed description of how those funds are
allocated across the Oxnard CBOC, Ventura Vet Center, and West LA VA
programs.
3. Social Worker Staffing
a. How many social workers have been hired at the Oxnard CBOC,
Ventura Vet Center, and West LA VA HUD-VASH programs since January 1,
2012?
b. Has the VA met its set goal for the ratio between social workers
and veterans?
c. How many additional social workers need to be hired to meet the
ratio the VA set as a goal?
4. Waiting Times
a. What is the current average waiting time for veterans to receive
mental health screenings and services at the Oxnard CBOC, Ventura Vet
Center, and West LA VA?
b. What is the average waiting time over the past 6 months?
c. What the median waiting time over that period?
d. What is the range of waiting times over that period?
e. If the Oxnard CBOC, Ventura Vet Center, and West LA VA do not
track this data on waiting times please provide an explanation of why
they do not.
5. What changes in the treatment of mental health does the VA plan
to implement at the Oxnard CBOC, Ventura Vet Center, and West LA VA
during FY13?
6. What transportation options are available for veterans traveling
from Ventura County, and outlying areas of LA County, to the West LA VA
for medical treatment?
a. Does the VA provide door-to-door bus or vanpool service for
veterans?
b. Are veterans expected to find their own means of transportation?
c. If so, does the VA reimburse veterans for the cost of private or
public transportation?
7. Does the Department of Veterans Affairs have in place a pipeline
system for identifying and recruiting qualified mental health
professionals from colleges and universities across the country?
a. How does the VA conduct outreach to mental health professionals
for recruiting purposes?